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目的描述和分析不同健康保险计划中急诊费用分担对参保者急诊服务利用的直接影响以及药品费用分担对参保者急诊服务利用的间接影响。方法计算机检索18个数据库(包括循证类、卫生类、经济类及社会类等),2个灰色文献数据库和Google搜索引擎,检索时限均为2011年6月21日至9月19日。由2位研究者根据纳入标准独立筛选文献和提取资料,如遇分歧则讨论解决或交由第三人裁定。而后采用主题分析法,描述费用分担对急诊利用的直接和间接影响,并分析其副作用。结果①最终纳入22篇文献。其中13篇文献描述了急诊费用分担直接引起的参保者急诊利用变化,9篇文献描述了药品费用分担间接引起的参保者急诊利用变化,主要涉及5类健康保险计划。②急诊服务利用对保险费用分担具有反应性,共付比例增加时,急诊服务利用降低,反之亦然。药品共付增加会影响基本药物利用,引起急诊利用增加;而急诊共付增加,会降低急诊不合理利用,不会降低合理利用。结论对于参保者,药品共付增加,会导致急诊利用增加等不良事件;而急诊共付增加,急诊合理利用未降低,无不良事件产生。对于非参保者,费用分担影响尚有待研究。本系统评价结果提示,可根据地区经济水平、居民收入等,适当引入急诊自付,但药品自付比例的确定应慎重。
Objective To describe and analyze the direct impact of the sharing of emergency costs on the utilization of emergency services and the indirect impact of the sharing of drug costs on the utilization of emergency services by participants in different health insurance plans. Methods A total of 18 databases (including evidence-based, health, economic and social), 2 gray literature databases and Google search engine were searched by computer. The search time was from June 21 to September 19, 2011. Two researchers independently screened documents and extracted data according to the inclusion criteria, and discussed or settled the third party for disagreement. Then the thematic analysis is used to describe the direct and indirect impact of cost sharing on emergency utilization and to analyze its side effects. Results ① 22 papers were finally included. Thirteen of them described the changes in emergency use of insured persons as a direct result of emergency cost sharing. Nine articles described the changes in emergency utilization of insured persons indirectly caused by drug cost sharing, mainly involving five types of health insurance plans. (2) The utilization of emergency services is reactive to the sharing of insurance premiums. When the co-payment ratio increases, the utilization of emergency services is reduced, and vice versa. The increase in the co-payment of drugs will affect the utilization of essential drugs and cause an increase in the utilization of emergency services. The increase in emergency co-payment will reduce the improper use of emergency services and will not reduce the rational utilization of drugs. Conclusions For the insured, the co-payment of drugs will lead to the increase of emergency use and other adverse events; the emergency co-payment increases, the emergency use of rational use is not reduced, and no adverse events occur. For non-insured persons, the impact of cost sharing remains to be studied. The system evaluation results suggest that, according to regional economic level, income, etc., the appropriate introduction of emergency copay, but the proportion of drug co-payment should be carefully determined.