跳到主要內容

臺灣博碩士論文加值系統

(44.192.22.242) 您好!臺灣時間:2021/08/03 18:49
字體大小: 字級放大   字級縮小   預設字形  
回查詢結果 :::

詳目顯示

我願授權國圖
: 
twitterline
研究生:林銅祿
研究生(外文):Tong-Lu Lin
論文名稱:台灣1997至2002年高血壓藥物的用藥型態評估及當AIIA導入市場對臨床使用之影響
論文名稱(外文):An evaluation on the pharmaceutical expenditure of antihypertensive agents during 1997 to 2002 andImpact of introduction of Angiotensin II Antagonist on the antihypertensive drug utilization in Taiwan
指導教授:鄭慧文鄭慧文引用關係高雅慧高雅慧引用關係
指導教授(外文):Hui-wen ChengYea-huei Kao
學位類別:博士
校院名稱:臺北醫學大學
系所名稱:藥學研究所
學門:醫藥衛生學門
學類:藥學學類
論文種類:學術論文
論文出版年:2007
畢業學年度:95
語文別:中文
論文頁數:145
中文關鍵詞:藥物經濟學藥物使用量殘餘值每日劑量血管張力素II 拮抗劑市場佔有率
外文關鍵詞:Antihypertensive agentDefined daily dose (DDD)Drug utilizationPharmaceutical expenditureAngiotensin II antagonist (AIIA)Angiotensin converting enzyme inhibitor (ACEI)ß- blocker (BB)Calcium channel blocker (CCB)Market share
相關次數:
  • 被引用被引用:3
  • 點閱點閱:210
  • 評分評分:
  • 下載下載:0
  • 收藏至我的研究室書目清單書目收藏:3
利用健保局學術研究資料庫(National Health Insurance Academic Research Database;NHIARD),探討從1997年至2002年台灣高血壓藥物的用藥支付費用及型態,並評估當新的高血壓藥物類別血管張力素II 拮抗劑(Angiotensin II Antagonist;AIIA)導入市場後,對原有高血壓藥物使用行為所造成的影響;特別是針對台灣市場佔有率最高的血管收縮素轉換酶抑制劑(Angiotensin Converting Enzyme Inhibitors;ACEI)、乙型腎上腺素阻斷劑(β- Blockers;BB)、鈣離子阻斷劑(Calcium Channel Blockers;CCB)及其他類別Miscellaneous agents(MIS)等,四大類高血壓藥物。
從健保資料庫(NHIARD)取得1997年至2002年高血壓用藥資料,包括門診病例記錄及用藥處方資料,藥物支付費用可分成5個部份,包括相關的藥物價格、病患人數、每位病患的就醫平均數、每位醫師看診病歷處方中的每日劑量及殘餘值;同時並取得病患的病歷檔案(Medication profile)、醫院看診記錄(Hospital visit record)及藥品申報資料(Drug claim data),執行評估高血壓用藥的申報金額、臨床使用量、處方情形與病患市場佔有率分析等等,藉以瞭解當AIIA導入市場後,對高血壓藥物ACEI、BB和CCB及MIS等類別所造成的影響,本研究將以市場佔有率表示各類別高血壓藥物間的市場相對強度,包括:支付金額市場佔有率、臨床市場佔有率、處方數量市場佔有率、病患人數市場佔有率,同時並探討AIIA對不同層級醫院用藥的滲透時間。
1997年至2002年總高血壓用藥增加102%,主要的成因是混合效應-從病患人數增加34%,醫師看診病歷處方中每位病患的每日劑量增加33%,而高血壓用藥總殘餘值因素僅有7%的影響。此結果與瑞典、西班牙兩國經驗有所不同,其藥物支付費用之增加主要是來自於殘餘值。詳細的殘餘值分析顯示:原廠品牌的類別產品有11%的成長,但一般學名藥卻減少12%。至於醫院的殘餘值:醫學中心成長13%、區域醫院成長17%、地區醫院成長10%,但基層醫療診所卻下降14%。此結果顯示,各層級醫院醫師有不同的處方用藥行為,醫院層級醫師的用藥行為偏向新藥或原開發廠品牌藥,基層醫療醫師則傾向使用一般學名藥。至於,高血壓藥物各類別於支付金額市場佔有率、臨床市場佔有率、處方數市場佔有率、病患人數市場佔有率的分析上,當AIIA導入市場後,對其他高血壓藥物ACEI、BB、CCB和MIS所造成的影響。研究結果顯示,AIIA對ACEI影響最大,這是由於藥理性質相類似所造成的結果,AIIA對BB僅有小部份的影響,對CCB無影響且有正面加分作用,MIS則漸被淡忘。AIIA市場上的成長,最主要的原因是來自於取代ACEI及與其他高血壓藥物一起服用的併服療法,尤其是與CCB和BB併服後讓CCB維持成長BB流失不多。AIIA於各層級醫院以臨床市場佔有率及處方數量市場佔有率的成長強度分析依:醫學中心、區域醫院、地區醫院、基層醫療依序為:4.95:3.77:2.77:1及5.28:4.17:2.94:1。可知,醫學中心>區域醫院>地區醫院>基層醫療。
高血壓藥物支付費用成長的重要原因是病患人數及醫師門診處方中DDDS值的增加所致,各層級醫師有不同的處方用藥行為,醫院層級醫師的用藥行為偏向新藥或原開發產的品牌藥,基層醫療醫醫師則傾向使用一般學名藥。CCB是目前高血壓用藥的主流雖有小成長但再成長有限,AIIA呈現持續成長的趨勢,BB雖微下滑但維持平穩,ACEI有被AIIA取代現象僅以大量價格低廉之學名藥維持其數量上之優勢,MIS已漸被淡忘。由於醫院層級醫師用藥行為偏向新藥及品牌藥,所以醫學中心對AIIA的利用與擴散具有關鍵性之角色。
Background and Purpose
Antihypertensive medications have represented a tremendous financial burden to the health care plan globally. This study examined the utilization pattern of the antihypertensive agents to analyze the underlying reasons responsible for the pharmaceutical expenditure in Taiwan during 1997 to 2002 as well as to evaluate the long term impact of a new pharmacological class antihypertensive medicine- angiotensin II antagonist (AIIA) to the clinical utilization of the existing antihypertensive medications in Taiwan.
Methods
The claims data during 1997 to 2002 were obtained from National Health Insurance Academic Research Database (NHIARD), which include ambulatory service record and prescription data of the entire population. Drug expenditure was decomposed into 5 components: relative drug price, number of patients treated, average physician visit per patient, Defined Daily Dose (DDD) per physician visit and a residual. Gross growth of DDD and prescription numbers, market share analysis including monetary market share (MMS), clinical market share (CMS), prescription market share (PrMS) and patient market share (PtMS), market penetration time and DDDs/ prescription were used to assess AIIA''s impact on the angiotensin converting enzyme inhibitors (ACEI), β- Blockers (BB), calcium channel blockers (CCB) and other miscellaneous antihypertensive agents (MIS).
Result
Total antihypertensive drug spending increased 102% during this period, mainly due to the compounding effect from the increment of patients treated (34%) and DDD per physician visit (33%). Residual analysis revealed that the aggregate residual for antihypertensive agents only had a 7% effect; the brand- name product had 11% increment and the generic product had a 12% decrement. It also showed that while hospital sector had a positive 11% residual, primary care clinics had an 11% decrement. Detailed analysis on each sub- group revealed that CCB had the most significant gross growth of DDDs and prescription at 117.1 and 3.4 million increments, respectively. CMS results revealed that the introduction of AIIA had the most significant impact to the clinical utilization of MIS (-5.5%) and a moderate impact to both BB (-4.5%) and ACEI (-4.1%). Whereas PMS demonstrated the most significant impact to MIS (-6.5%), a moderate impact to ACEI (-2.3%) and a very minor impact to BB (-0.9%). AIIA, however, had a positive CMS (+3.9%) and PMS (+2.4%) correlation with CCB. AIIA utilization implicated by relative growth strength for the CMS and PMS at Medical Center, Regional Hospital, District Hospital and Primary Care Clinic were 4.95 : 3.77 : 2.77 : 1 and 5.28 : 4.17 : 2.94 : 1, respectively.
Conclusion
The most important factors that contribute to the expenditure surge of antihypertensive agents are number of treated patients and DDD per physician visit. While physicians at the hospital sector adopted more new and innovative medications, their counterpart at the primary care clinics tended to switch some off- patent products to the generics. The introduction of AIIA did not affect the negative clinical utilization drift of MIS and BB since this depressing trend started before AIIA introduction. On the other hand, the preference of using CCB and AIIA to control hypertension among the physicians in Taiwan was on the ascending side. Medial center was the early leading adaptor for AIIA and furthermore played an important role in the utilization diffusion of AIIA.
中文摘要……………………………………………………………1
英文摘要……………………………………………………………3
誌 謝……………………………………………………………5
目 錄……………………………………………………………6
表 目 錄……………………………………………………………8
圖 目 錄……………………………………………………………10
第一章 緒論
第一節 研究背景…………………………………………………12
第二節 研究目的…………………………………………………15
第三節 專有名詞縮寫表…………………………………………16
第二章 文獻探討
第一節 前言………………………………………………………18
第二節 處理高血壓之藥物經濟學分析…………………………19
第三節 高血壓藥物使用基準……………………………………22
第四節 高血壓藥物使用型態及趨勢……………………………31
第五節 影響高血壓處方型態及用藥因素之探討………………32
第三章 研究材料與方法
第一節 研究架構…………………………………………………34
第二節 研究對象及期間…………………………………………35
第三節 研究變項…………………………………………………37
第四節 研究流程…………………………………………………40
第五節 資料整理流程……………………………………………44
第六節 統計分析…………………………………………………45
第四章 以藥物經濟學理論評估台灣1997年至2002年高血壓藥物的用藥型態
第一節 前言………………………………………………………51
第二節 分析方法…………………………………………………53
第三節 研究結果…………………………………………………54
第四節 討論………………………………………………………63
第五章 當AIIA導入市場後對高血壓藥物臨床使用上之影響
第一節 前言………………………………………………………88
第二節 分析方法…………………………………………………90
第三節 研究結果…………………………………………………92
第四節 討論………………………………………………………97
第六章 綜合討論
第一節 年與季之異同……………………………………………112
第二節 高血壓藥物單獨或併服療法的處方型態………………113
第三節 高血壓用藥國內外趨勢之比較…………………………115
第四節 本研究的限制條件………………………………………117
第七章 結論………………………………………………………121
第八章 建議
第一節 對中央主管機關之建議…………………………………123
第二節 對未來研究者之建議……………………………………124
參考文獻……………………………………………………………125
投稿論文……………………………………………………………133

附錄一 門診處方及治療明細檔CD檔……………………………134
附錄二 門診處方醫令明細檔OO檔………………………………139
附錄三 醫事機構基本資料檔HOSB檔……………………………140
1. Alderman M.H., et al. Antihypertensive drug therapy. The effects of JNC criteria on prescribing patterns and patient status through the first year. AM J Hypertens 1996; 9: 413-8.
2. Ambrosioni E. Pharmacoeconomics of Hypertension Management: The Place of Combination Therapy. Pharmacoeconomics 2001; 19: 337-347.
3. Ambrosioni E. Pharmacoeconomic challenges in disease management of hypertension. J Hypertens Suppl 2001 Sep; 19 Sullp 3: S33-40.
4.Ariga K., Ohkusa Y. Determinants of Individual-Firm Markup in Japan: Market Concentration, Market Share, and FTC Regulations, Journal of the Japanese and International Economies 1999; 13: 424–450.
5. Arnold R.J.G. Disease Management and Pharmacoeconomics as Tools for Mass Prevention of Hypertensive Complications. Heart Disease 2001; 3: 152-156.
6. Avorn J. Balancing the Cost and Value of Medications: The Dilemma Facing Clinician. Pharmacoeconomics 2002; 20: 67-72.
7.Bradley T.G. Market Share and Rate of Return, Review of Economics and Statistic 1972; 54 (4): 412-423.
8. Bureau of National Health Insurance, Department of Health, Executive Yuan, Taiwan [online]. Updated June 2005. Available at: http://www.nhi.gov.tw/00english/e_index.htm/. Accessed June 20, 2005

9. Bureau of National Health Insurance, Department of Health, Executive Yuan, Taiwan [online]. Available from URL: http://www.nhi.gov.tw/00english/e_index. htm/ [Accessed 2007 April 5]
10.Buzzle R.D., Bradley T.G., Sultan R.G.M. Market Share-A Key to Profitability. Harvard Business Review 1975; 53(1): 99-102.
11.Cheng C., Hsieh C.R. Economic Analysis of NHI Pharmaceutical Policies and Drug Expenditures. Socioeconomic Law Review 2005; 35: 1-42.
12.Cheng S.F., Hsu H.H., Lee H.S., Lin C.S., Chou H.C., Tien J.H. Rational Pharmacotherapy in the Diabetic Hypertension: Analysis-prescribing Patterns in a General Hospital in Taiwan. J Clin Pharm Therapeutics 2004; 29: 547–558.
13.Consumer Product Index, Taipei, Taiwan: Directorate General of Budget, Accounting and Statistics (DGBAS) of Executive Yuan, Taiwan [database online]. Updated June 2005. Available at: http://www.stat.gov.tw/public/data/dgbas03/bs3/inquire/cpispl.xls/. Accessed June 20, 2005.
14.Croom K.F., et al. Irbesartan a review of its use in hypertension and in the management of diabetic nephropathy Drugs. 2004; 64: 999.
15.Darba J. Pharmaceutical Expenditure and Therapeutic Value of New Medicines in Spain. Pharmacoeconomics 2003; 21: 1211-1212.
16.Dicpinigaitis P.V. Antiotensin-converting enzyme inhibitor-induced cough: ACCP evidence- based clinical practice guidelines. Chest 2006; 129: 169S-173S.

17.Dunn E.C., Small R.E. Economics of antihypertensive therapy in the elderly. Drugs Aging 2001; 18(7): 515-25.
18.Esposti L.D., Di Martino M., Saragoni S., et al. Pharmacoeconomics of Antihypertensive Drug Treatment: An Analysis of How Long Patients Remain on Various Antihypertensive Therapies. J. Clin. Hypertension 2004; 6: 76-82.
19.Ess S.M., Schneeweiss S., Szucs T.D. European Healthcare Policies for Controlling Drug Expenditure. Pharmacoeconomics 2003; 21: 89-103.
20.Foreign Exchange Rate, Taipei, Taiwan: Central Bank of China (Taiwan) [database online]. Updated June 20, 2005. Available at: http://www.cbc.gov.tw/economic/statistics/total_index.asp/. Accessed June 20, 2005.
21.Gerdtham U.G., Johannesson M., Gunnarsson B., et al. Price Indices of Drugs and the Swithing to New Drugs. Pharmacoeconomics 1998; 13: 71-80.
22.Gerdtham U.G., Johannesson M., Gunnarsson B., et al. The Effect of Changes in Treatment Patterns on Drug Expenditure. Pharmacoeconomics 1998; 13: 127-134.
23.Gerdtham U.G., Lundin D. Why Did Drug Spending Increase During the 1990s: A Decomposition Based on Swedish Data. Pharmacoeconomics 2004; 22: 29-42.
24.Gianfrancesco F., Wang R.H., Mahmoud R., et al. Methods for Claims-Based Pharmacoeconomic Studies in Psychosis. Pharmacoeconomics 2002; 20: 499-511.
25.Goldberg Arnold R.J. Disease management and pharmacoeconomics as tools for mass prevention of hypertensive complications. Heart Disease 2001 May-Jun; 3(3): 152-6.
26.Gu Q., Paulose-Ram R., Dillon C., Burt V., Antihypertensive Medication Use Among US Adults with Hypertension, Circulation 2006; 113: 213-221.
27.Ikegami N., Ikeda S., Kawai H. Why Medical Care Costs in Japan Have Increased Despite Declining Prices for Pharmaceuticals. Pharmacoeconomics 1998; 14: 97-105.
28.Israili Z.H. & Hall W.D. Cough and angioneurotic edema associated with angiotensin- converting enzyme inhibitor therapy. Ann Int Med 1992; 117: 234-242.
29.Kaplan N.M., Rose B.D. Choice of therapy in essential hypertension: Recommedations. In UpToDate Onilin 10.1. Available from URL http://www.utdol.com/utd/content/ Accessed May 14.2007].
30.Liao W.P.,Yeh M.K., Ke C.H., et al. Pattern of Pharmacologic Treatment of Hypertension in Taiwan- Analysis of antihypertensive prescriptions in 1998. Taiwan J. Fam Med 2004; 14: 121-132.
31.Liu S.Z., Romeis J. Assessing the Effect of Taiwan''s Outpatient Prescription Drug Copayment Policy in the Elderly. Medical Care 2003; 41: 1331-1342.
32.Liu S.Z., Romeis J. Changes in Drug Utilization Following the Outpatient Prescription Drug Cost- sharing Program- Evidence from Taiwan''s Elderly. Health Policy 2004; 68: 277-287.
33.Lopez J., Meier J., Cunningham F., Siegel D.Antihypertensive medication use in the department of veterans affairs: a nationsl analysis of prescribing patterns from 2000 to 2002. Am J Hypertens. 2004 Dec; 17(12Pt 1): 1095-9.
34.Lyles A., Palumbo F.B. The Effect of Managed Care on Prescription Drug Costs and Benefits. Pharmacoeconomics 1999; 15: 129-140.
35.Lloyd A., Schmieder C., Marchant N. Financial and Health Costs of Uncontrolled Blood Pressure in the United Kingdom. Pharmacoeconomics 2003; 21 Suppl. 1: 33-41.
36.Malhotra S., Karan R.S., Pandhi P., et al. Pattern of Use and Pharmacoeconomic Impact of Antihypertensive Drugs in a North Indian Referral Hospital. Eur J. Clin Pharmacol 2001; 57: 535-540.
37.Mixon F., Hsing Y. The Determinants of Market Share for the “Dominant Firm” in Telecommunication, Information Econ. Policy 1997; 9: 309-318.
38.Nordmann A.J., Krahn M., Logan A.G., et al. The Cost Effectiveness of ACE Inhibitors as First- Line Antihypertensive Therapy. Pharmacoeconomics 2003; 21: 573-585.
39.Norman R.C., et al. The impact of the Canadian hypertension education program on antihypertensive Prescribing trends. Hyperthension 2006; 47: 22-28.
40.Okano GP, et al. A comparison of antihypertensive medication utilization before and after guideline changes using the department of defense prescription database. The annals of pharmacotherapy 1999; 33: 548-553.
41.Pardell H., Tresserras R., Armario P., Hernandez del Rey R. Relate Pharmacoeconomic considerations in the management of hypertension. Drugs 2000; 59 Suppl 2: 13-20; discussion 39-40.
42.Penna P., Cox E., Joseph T., Lehman L., Morrow T., Richter A., Sowers J., Tepper D. Roundtable discussion: Part III—Hypertension management in health plans. Manag Care Interface 2000; Suppl C: 24-31.
43.Penna P., Cox E., Joseph T., Lehman L., Morrow T., Richter A., Sowers J., Tepper D. Roundtable discussion: Part II—Development of a pharmacoeconomic model in hypertension. Manag Care Interface 2000; Suppl C: 17-23.
44.Penna P., Cox E., Joseph T., Lehman L., Morrow T., Richter A., Sowers J., Tepper D. Roundtable discussion: Part I—Epidemiologic, demographic, and treatment challenges in hypertension. Manag Care Interface 2000; Suppl C: 10-6.
45.Siegel D., Lopez J., Meier J. Pharmacologic treatment of hypertension if the Department of Veterans Affairs during 1995 and 1996. Am J Hypertens 1998 Nov; 11(11 Pt 1): 1271-8.
46.Saseen J.J., et al. Treatment of uncomplicated hypertension. Jam Borad Fam pract. 2003; 16(2): 156-164.
47.Sasess J.J., Carter B.L. Hypertension. In DiPiro J.T., Talbert R.L., Yee G.C., Matzke G.R., Wells B.G., Posey L.M., editors. Pharmacotherapy: A pathophysiologic approach. 6th ed. New York: The McGraw Hill Company.
48.Siegel D., Lopez J. Trends in antihypertensive drug use in the United States. JAMA 1997; 278: 1745-1748.
49.Siegel D., Lopez J., Cunningham F. Changes in the phamacologic treatment of hypertension in the Department of Veterans Affairs 1997-1999: decreased use of calcium antagonists and increased use of beta-blockers and thiazide diuretics. Am J Hypertens. 2001 Sep; 14(9 Pt 1): 957-62.
50.Simons W.R. Comparative Cost Effectiveness of Angiotensin II Receptor Blockers in a US Managed Care Setting: Olmesartan Medoxomil Compared with Losartan, Valsatan, and Irbesartan. Pharmacoeconomics 2003; 21: 61-74.
51.Singh H., Johnson M.L. Prescribing patterns of diuretics in multidrug antihypertensive regimens. J Clin hypertens. 2005,7(2): 81-87.
52.StatisticNet, Taipei, Taiwan: Department of Statistics, Ministry of Interior, Executive Yuan, Taiwan [database online]. Updated June 2005. Available at: http://www.ris.gov.tw/ch4/static/st20-0.html/. Accessed June 20, 2005
53.Szucs T.D. Pharmacoeconomics of Angiotensin Converting Enzyme lnhibitors in Heart Failure. Am J. Hypertension 1997; 10(10): 272S-279S.
54.The seventh report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure: the JNC 7 peport. Jama. 2003; 289: 2560-2572.
55.Thomas M., Cleland J., Price D. Database Studies in Asthma Pharmacoeconomics: Uses, Limitations and Quality Markers. Expert Opin.Pharmacother. 2003; 4: 351-358.
56.Williams E., wilkins. 2003 world health organization (WHO) / international society of hypertension ( ISH) statement on management of hypertension. Journal of hypertension 2003; Vol 21 No11: 1983-1992.
57.YangKao Y.H., Kuo C.W., Hung H.J., Jia S.W. Classification of pharmaceutical products reimbursed by National Health Insurance by the ATC system. Chinese Pharm J 2002; 54: 283-90.
58.Yeh M.K., Chou C.C., Loh C.H., et al. The Ambulatory Hypertension Patients of Taipei Area Hospital Prescription Trend Analysis. Chinese J. Occup Med 2004; 11: 71-78.
59.Windmeijer F., de Laat E., Douven R., Mot E. Pharmaceutical promotion and GP prescription behaviour. Health Econ. 2006; 15(1): 5-18.
60.黃文鴻:藥品支付價格調整對藥品利用型態之影響。中央健保局委託研究計畫,計畫編號:DOH91-NH-1023。民92. 10。
61.曾毓秋。保障民眾醫療照護及用藥品質—徹底解決藥價黑洞問題。全民健康保險; 40: 15-17, 民91. 11。
62.吳台莉、李建立、毛志民、林純貞。利用藥物經濟學方式研究醫師處方型態。行政院國軍退除役官兵輔導委員會研究計畫(計畫編號 VAC90683),民90. 12。
63.李惠玲、高雅慧以ATC分類探討全民健保藥品之利用與分配。行政院衛生署研究計畫,計畫編號DOH89-NH-018,民90. 03。
QRCODE
 
 
 
 
 
                                                                                                                                                                                                                                                                                                                                                                                                               
第一頁 上一頁 下一頁 最後一頁 top