目的：分析不同类型脑梗死病人就医行为及医生诊疗行为的差异，并探寻主要的影响因素，为医疗质量、医药政策的评估及医疗服务的日常监测提供证据支持。方法：应用首都医科大学宣武医院脑梗死住院病人医疗信息数据库，分析年龄、性别、付费方式、疾病程度、治疗方法、科室、医生等因素对脑梗死病人就医行为及医生诊疗行为，以及医疗服务质量、水平、费用及药物使用等的影响。（1）通过病案管理数据库，收集首都医科大学宣武医院2004年1月1日至2008年12月31日出院的全部脑梗死病人（共6850人）信息，包括：Variable name Variable name病案号 主要手术名称姓名 主要手术医师性别 主要手术ICD年龄 主要手术日期入院日期 其它手术1名称出院日期 主要诊断出院情况付费方式 住院费总计入院科室 西药费出院科室 中成药费主要诊断 中草药费ICD9 放射费其它诊断1-5 治疗费ICD9 手术费主治医师 （2）通过医院信息系统数据库（HIS），收集全部脑梗死病人药物治疗明细，包括：Variable name Variable name病案号 药品规格姓名 剂量医嘱名称 单位开始时间 数量结束时间 单价医嘱频率 （3）数据处理：应用Microsoft-Excel 2003, 创建pivot tables和pivot chart，整理及分析数据。 结果：1. 不同类型脑梗死病人其就医行为存在明显差异，针对不同类型脑梗死病人，医生的诊疗行为也存在明显差异。宣武医院脑梗死住院男性患者就医人数比女性患者多1倍，人均住院费用比女性患者显著增高，而疗效基本一致。脑梗死患者随年龄增长费用显著增高、而治疗效果降低。严重脑梗死及手术治疗的患者，费用显著增高、但预后不佳。不同付费方式对患者就医行为、医疗质量、医疗费用和药物治疗的影响尤其显著。公费支付的患者总费用、药费、住院天数等几乎比医保患者高一倍。整个医疗费用构成及药物治疗也存在许多不合理的情况。不同科室及不同主治医生的诊疗行为差异明显，对医疗费用、医疗质量及药物使用影响显著。2. 不同付费方式对脑梗死病人药物治疗及医生处方行为影响显著。公费支付的患者药费明显增高，而疗效下降。脑梗死治疗用量排名前四位的注射剂为奥扎格雷钠（丹奥），马来酸桂哌齐特（克林澳），舒血宁和依达拉奉（必存），几乎占所有药费金额的一半。但这四种药物使用量、使用频次、使用时间及金额在不同付费方式的脑梗死病人组，差异极大，不同付费方式是影响医生处方行为的最主要因素。结论：不同类型脑梗死病人的就医行为及医生的诊疗行为存在明显差异，其影响因素各不相同。针对不同的影响因素，必须区别对待，应用不同的手段进行干预。年龄、性别、疾病程度是不可改变的因素，在实行新的医药政策（如医保今后实行DRG-疾病诊断相关组付费）时，应考虑以上因素区别定价。是否实行手术治疗、不同科室及不同主治医生的治疗行为是医院及医疗管理部门可以进行干预的因素，应采取有效的措施促进医疗质量的提高和费用的降低。不同付费方式的医疗支付政策，是长期困扰我国医疗卫生发展的难题，针对这一特殊情况，医保管理部门应从政策层面进行付费方式的改革，才能彻底解决影响医疗质量及医疗费用的关键问题。通过我们的系统分析和数据支持，将为科学、正确的政策制定提供强有力的证据支持；并且为加强医疗服务的日常监测、提高医疗管理水平、促进医疗质量提高，提供客观、有效的手段。

Objective To analyze the patient’s medical behavior and physician’s prescription behavior in different type stroke therapy, figure out the difference and the main influence factors among them, therefore, provide evidence-based support to improve the medical cost, medical care quality, routine monitoring and policy making in stroke patient treatment.Methods Using the stroke inpatient data base from Xuan-wu hospital of capital medical university, assess care cost, quality, outcome, drug use by age, gender, payer, severity of illness, treatment, department and individual physician Data base 1:Data dictionary of XW stroke inpatient claim data (from 2004-2008)Variable (c) Variable (e) Variable Description (Medical Record)病案号 PID Patient ID, Number of observations, n=6850 from 2004-08性别 SEX gender(number), 1- male, 2- female年龄 AGE Age(number)入院日期 ADMISSION Admission date(Date)出院日期 DISCHARGE Discharge date(Date,2004-1-1—2008.12.31)付费方式 PAYER Payment way, 1-BPHI, 3- OOP, 4-government, 6- others主要诊断 DIAGNOSIS Major Diagnosis (Chinese characters)主要手术名称 PROCEDURE Major Procedure (Chinese characters)主要诊断出院情况 OUTCOME Outcome in discharge (number)1- heal, 2-mend, 3- un-heal, 4- dead住院费总计 CHARGE Total charge (number)西药费 W-DRUG Western drug cost (number)中成药费 C-DRUG Chinese drug cost (number)中草药费 H-DRUG Traditional Chinese herb cost (number)放射费 RADICATION-C Radiation fee (number)治疗费 TREATMENT-C Treatment fee (number)手术费 OPERATION-C Operation fee (number)Data base 2:Data dictionary of XW stroke inpatient medication data (from 2004-2008)Variable name Pharmacy record病案号 Patient ID, Number of observations, n=65377 in 2006，similar amount in other years姓名 Patient name (Chinese characters)医嘱名称 Prescription of each drug (Chinese characters)开始时间 Starting time of medication (Date)结束时间 Ending time (Date)医嘱频率 Medication frequency (English abbreviation, BID)药品规格 Strength (combination of N, E, C)剂量 Dosage (number)单位 Unit (English)数量 Volume (number)单价 Unit priceUsing Microsoft-Excel 2003, create pivot tables and pivot chart to analyze the data. Results （1） The different type stroke therapy varies in Patient’s medical behavior and Physician’s prescription behavior.  The cost of hospitalization of male patients is higher than Female with the similar outcome. Along with the increase of age, the cost of hospitalization is higher but the outcome of treatment is worse.  The severe stroke patient and the patient with the operation showed higher cost and worse outcome.  Physician’s prescription behavior varies in the different departments and in the individual as well.  The payer is the most effective factor to influence both the Patient’s medical behavior and Physician’s prescription behavior.（2） Medication and Physician’s prescription behavior to stroke inpatient is influenced significantly by payers. Cost and stays of government paid patient is much higher than that of other payer patients Cost of BPHI paid patient reduced from 2006 and became the least costly even compared with the expense of OOP patients.  Total cost of different payer patients dramatically drop from 2007 to 2008, especially for the government paid patient. Regardless of payers, drug cost accounts for half of total cost and drops from 2007 to 2008 in a consistent pattern with total cost. Edaravone, CinepazideMaleate, Ozagrel and Ginkgo leaf injection are the top 4 costly medications in Stroke inpatients in XW; and Maleate, Ginkgo and Ozagrel are also the top 3 drugs by volume.For Government and BPHI paid patients, Ozagrel is least used among reimbursed drugs, medications may not follow STGs Overuse of drugs covered by insurance Drugs not reimbursed might be underused The more expensive, the more use of medication, especially in government-paid patients. Financial incentive is the most factor to influence the prescription behavior of Physician. For OOP patients, Sensitive to the cost of medication  Persuaded medication and financial incentive also exit.  Easy access to new/better medications Follow the STGs, proportion of Ozagrel use is pretty high.  But underuse of overall medications might exist In 2008, intervention for stroke medication in XW Overuse of drugs covered by insurance still exists Use of Maleate, the most expensive drug, reduces Improve the compliance to STGs, Ozagrel use increasesConclusions Patient’s medical behavior and Physician’s prescription behavior are influenced by age, gender, payer, severity of illness, procedure, department and individual physician.  Payers is the most important (strongest) influence factor Financial incentive might induce irrational medication Intervention within the hospital might work, but the effect is limited In order to promote rational use of drugs, it is necessary to indentify the influence factors in Patient’s medical behavior and Physician’s prescription behavior and promote the proper behavior accordingly.  Evidence-based research is necessary to improve the medical cost, medical care quality, routine monitoring and policy making in stroke patient treatment. Key words Cerebral infarction, Patient’s medical behavior, Physician’s prescription behavior, Hospitalization, Medical cost, Medical insurance; Medication; rational use of drugs