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研究生:林維安
研究生(外文):Lin, Weian
論文名稱:台灣地區氣喘病人醫療資源耗用分析及藥物流行病學之研究
論文名稱(外文):The medical resource use and pharmaco-epidemiology research of asthma patients in Taiwan
指導教授:譚延輝譚延輝引用關係
指導教授(外文):Tarn, Yen-Huei
學位類別:博士
校院名稱:國防醫學院
系所名稱:生命科學研究所
學門:生命科學學門
學類:生物學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
中文關鍵詞:氣喘就醫盛行率醫療資源利用處方型態禁忌用藥
外文關鍵詞:Asthma prevalencemedical resource usageprescription patternscontraindication drugs
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研究目的:本研究之主要目的在以資料庫分析之方式,分析台灣地區氣喘病人之盛行率,整體醫療資源利用以及處方型態。比較有氣喘病史之病患使用到NSAID 或non-selective beta-blockers前後的醫療資源利用情形。
研究方法:向國家衛生研究院申請有氣喘病史之病患1998-2002年之氣喘就醫資料,描述此一族群病人之氣喘就醫盛行率、醫療資源利用、歸人一年總醫療花費、並比較性別上氣喘治療的醫療資源差異。針對0-6、7-12、13-18以及65歲以上老人等族群進行處方型態、處方組合的分析。分析所有氣喘病患接受NSAID 或non-selective beta-blockers之處方箋數;以前後比較方式分析所有年齡層接受禁忌用藥後30天和90天的總醫療花費增減狀況;以cox regression分析接受禁忌處方後住院事件的發生比率。以logist regression分析醫師特性對接受禁忌處方的影響,以探討如何避免病患接受到禁忌用藥。
主要發現:本研究發現在1998-2002年之間,有氣喘病史之病患總人數逐年降低,從2000年的480,135人到2002年的469,177人。同時盛行率亦逐年降低,2000年氣喘盛行率為2.24%至2002年略降至2.15%。氣喘病患當中,65歲以上的病患人數佔總氣喘病患人數的20%,18歲以下的病患佔38%。盛行率以65歲以上老人較高,尤其是85歲以上的老人,約為10%。總醫療資源利用則呈現逐年增加的趨勢,以主診斷為氣喘的就醫紀錄分析,氣喘醫療總花費從2000年的19億成長至2002年的22億,平均一人一年總醫療花費從2000年的8,326元到2002年已經為13,943元。總藥物費用(含門診、住院、急診之藥費)約佔治療總花費的45%。性別之間對於氣喘醫療資源的利用確實存在差異,女性因氣喘所使用的醫療資源,如門診次數、歸人一年總花費等都較男性為低。在門診氣喘藥物使用方面,以口服beta-agonist最常見,所有年齡層都大量使用該類藥品。且在兒童及老年人族群,吸入劑使用的比例較低。老年人族群在門診最常使用到口服口服theophyllin、口服beta-agonist、口服類固醇。整體而言,急診之用藥較符合治療指南所要求,最常使用的是吸入性短效beta-agonist。含禁忌藥物的處方箋約佔總處方數的12%,接受到至少一次禁忌用藥的病人佔整體總氣喘病人的20%。使用最多的禁忌藥物在NSAID方面是diclofenic,beta-blocker則為propranolol。接受禁忌用藥後之醫療資源利用皆較未接受前高,平均約多出5000元。以cox regression分析接受禁忌處方後住院事件的發生比率時發現,接受到禁忌藥物後90天住院的機率是未接受禁忌藥物的病患的1.5倍。以邏輯氏迴歸分析發現,最常開立禁忌藥物給氣喘病患之醫師科別為骨科、神經科、心臟專科;醫師執業年數越多,越不容易開立禁忌藥物給病患;男性醫師較女性醫師容易開立禁忌藥物。
結論與建議:台灣地區氣喘病人1998-2002年的氣喘盛行率有逐年降低的現象,但是氣喘醫療資源利用則呈現逐年增加。藥物使用上,門診的藥物處方遵從診療指南建議的比例甚低。在急診用藥上則較符合診療指南的建議。醫師科別是影響處方禁忌藥物的主要因素。處方禁忌用藥給病人的確會增加醫療花費以及住院的機率。建議應加強對氣喘治療方面的資訊給予醫療人員,提供病患適當的藥物治療以協助氣喘病患控制症狀。醫藥人員應該注意氣喘病患的共同疾病,針對有可能使用到禁忌藥物的病患,應給予替代藥物,並避免開立禁忌用藥如beta-blocker或 NSAID給氣喘病患,以避免其他不必要之醫療資源利用,並能有效控制醫療花費的增加。
Purpose: The study contains three objectives. First, describe the asthma prevalence and the use of medical care resources for asthmatic patients in Taiwan during 1998-2002. Second, analyze the number of contraindicated drug prescriptions among patients with asthma. Third, compare the medical resource utilization before and after usage of these contraindicated prescriptions.
Methods: The claimed database was obtained from national health research institution, the data included OPD,ER, hospitalization, drug prescription record of asthma patients, from 1998-2002. This study described the prevalence of asthma in Taiwan and the use of medical resource by asthma patients from 1998-2002. And compare the difference of medical resource use between genders. Analyze the drug use and prescription patterns of 0-6, 7-12, 13-18,and over 65years old patients, from 2000-2002. The frequency of NSAID and non-selective beta-blockers precripted, the prevalence of these contraindication drugs among asthma patients were calculated. The difference of medical cost before and after 30 and 90 days, when received the contraindicated drugs was compared. Cox regression was used to analyze the odds ratio of hospitalization after receiving the contraindicated drugs of elderly patients. Logistic regression was used to analyze the relationship between contraindicated drug prescription and characteristics of doctors.
Main findings: The number of asthma patient is 480,135 at the year 2000, and decreased to 469,177 at 2002. The prevalence of asthma in Taiwan decreased during these three years, from 2.24 to 2.15%. The prevalence of elderly patients is higher than that of other age groups, and the prevalence of age 85 and older is 10%, highest among all the age groups. Among asthmatic patients, 20% is at age 65 and older, 38% is younger than 18 years old. Though the patient number decreased, the total medical resource use increased. The total medical expenditure for taking care of patients with asthma is NTD1.9 billion at 2000 and increased to NTD2.2 billion at 2002, increased 66%. And the total medical expenditure per patient per year increased from NTD 8,326 to 13,943 during 2000-2002. Total drug expenditure is about 45%of total medical expenditure. The difference of medical resources utilization between genders is significant. Female use less medical resource than male, less OPD, less ER, and less total cost. The major drug used in OPD is oral beta-agonist, all age groups get oral beta-agonist most of the time. Among children and elderly patients, the inhaler did not prescribed frequently. Most elderly patients received oral theophylline, oral beta-agonist, and oral corticosteroid. Children received oral beta-agonist most of the time at OPD. The asthmatic drugs used in ER follow the guideline appropriately. The drug most frequently used in ER is short-acting beta-agonist. Around 12% of prescriptions had contraindicated medications. In average, 20% of asthma patients received at least once contraindicated drug in one year period. The most frequent used contraindicated drug among NSAIDs is diclofenic, among beta-blockers is propranolol. The differences of medical care expenditure before and after receiving contraindicated drug is found to be significant different. After receiving the contraindicated drug; the patient’s total medical care expenditure in 30days and 90days are much higher than that of before. Compare to those who did not receive the contraindicated drugs, the odds ratio of hospitalization after 90days is 1.5. Using logistic regression, we found that female doctor prescribe less contraindicated drugs to asthma patients. The orthopedist, neurologist, and cardiologist prescribed contraindicated drugs more frequently. The more experienced doctor who practiced longer will prescribe less contraindicated drugs.

Conclusion and Suggestions: The prevalence of asthma in Taiwan decreased during 1998-2002, however, the medical care expenditure increased. Most of the OPD prescription patterns were not following the suggestions from asthma treatment guideline. Most of the ER prescription patterns do followed the treatment guideline. Doctor with different specialization is a factor to prescribe the contraindicated drugs. The use of contraindicated drugs did increased the medical care expenditure. We suggest that mechanism to provide more drug information to medical practitioners should be established in order to increase the quality of care provided to the patients with asthma, including appropriate use of drugs and self medications. Physician and pharmacist should avoid giving contraindicated drugs to asthma patients; especially to those who have multiple chronic diseases, such as hypertension, diabetes. With careful utilization of medications, we can avoid unnecessary medical resources utilization and effectively control the increase of medical care expenditures.
台灣地區氣喘病人醫療資源耗用分析及藥物流行病學之研究本文目錄 v
本文目錄 vi
圖目錄 viii
表目錄 x
中 文 摘 要 xvi
Abstract xix
第一章、 緒論 1
第一節、 研究背景和重要性 3
第二節、 研究動機 7
第三節、 研究問題及目的 11
第二章、 文獻回顧 14
第一節、 氣喘之疾病生理學 16
第二節、 氣喘的藥物治療策略 28
第三節、 禁忌用藥誘發氣喘之機轉 33
第四節、 資料庫分析與藥物流行病學 45
第三章、 研究方法 59
第一節、 資料庫獲得及內容 61
第二節、 分析及統計方法 70
第四章、 研究結果 80
第一節、 台灣地區氣喘盛行率及人數之描述 83
第二節、 各年齡層之醫療資源利用狀況 116
第三節、 台灣地區氣喘藥物治療處方型態 185
第四節、 接受禁忌藥物之分析 247
第五節、 氣喘禁忌藥物對醫療資源利用之影響 262
第五章、 討論 271
第一節、 研究設計及資料處理流程 275
第二節、 就醫盛行率和醫療資源利用分析 284
第三節、 治療處方型態分析 293
第四節、 禁忌用藥處方狀況以及對醫療資源利用的影響 303
第五節、 研究限制 308
第六章、 結論與建議 311
第一節、 結論 312
第二節、 建議 317
參考文獻 327
附錄 335
附錄一ISPOR發表的「回顧性資料庫研究品質檢查表」 336
附錄二、各年各年齡層主次診斷有氣喘之處方前十名統計表(含門診及急診) 349
附錄三、各年各年齡層主次診斷有氣喘之處方組合前十名統計表(含門診及急診) 440
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