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研究生:林金潭
研究生(外文):Lin, Chin-Tan
論文名稱:比較血管收縮素轉換酵素抑制劑與血管張力素受體阻斷劑控制高血壓病患併發其他疾病機率及醫療資源利用之相關性探討
論文名稱(外文):A comparison study of the association of risk to develop other comorbid diseases, medical resource use between angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker drugs for patients with hypertension
指導教授:李金德李金德引用關係
指導教授(外文):King-Teh Lee
學位類別:碩士
校院名稱:高雄醫學大學
系所名稱:醫務管理暨醫療資訊學系碩士在職專班
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2013
畢業學年度:101
語文別:中文
中文關鍵詞:服藥遵從性血管收縮素轉換酵素抑制劑(angiotensin-converting enzyme inhibitorACEI)血管張力素受體阻斷劑(angiotensin II receptor blocker drugsARB)資源利用率
外文關鍵詞:drug complianceangiotensin-converting enzyme inhibitor (ACEI)angiotensin II receptor blockers (ARB)medical use
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研究目的
在台灣十大死因中高血壓及相關疾病致死率遠高於惡性腫瘤。高血壓是罹患心血管疾病(CVD)的主要風險因子,高血壓患者藥物遵從性不佳,使得罹患其他疾病機率和醫療成本增加。學者指出,降血壓藥使血壓降低與降低心血管疾病的罹病率和致死率有關。有鑑於此,本研究目的有三,分別為了解各年齡層高血壓病患醫療資源利用、後續診斷出罹患心血管疾病等疾病的比率;了解罹患上述疾病與藥物遵從性的關聯性;了解年齡、地區是否影響高血壓患者藥物遵從性。
研究方法
本研究係採次級資料分析法,以回溯性橫斷(retrospective cross-sectional)法進行研究,參考相關文獻設計出本研究架構,以「2000年全民健康保險研究資料庫百萬抽樣歸人檔」分析自1997年起至2005年底前第一次使用降血壓藥物、服用藥物期間五年以上之高血壓病患,共10,745人為研究對象。比較降血藥物血管收縮素轉換酵素抑制劑(angiotensin-converting enzyme inhibitor, ACEI)與血管張力素受體阻斷劑(angiotensin II receptor blocker drugs, ARB)類為目前廣泛使用的藥物,兩組平均每人五年以上的總醫療支出、藥費支出以及服藥順從性,探討ACEI類與ARB類藥物的使用與各項醫療支出的關係。
研究結果
醫療資源利用的部分可分為藥費部分和總費用(含住院費用)。其中在藥費的部分,使用ARB類藥物病患平均五年以上的藥費支出高於ACEI類藥物患者之藥物費用(p<0.001)。總費用部份,使用ARB類藥物病患的費用較ACEI類藥物患者低,具有顯著性的差異(p<0.001)。
以χ²檢定比較兩組患者出現中風、心肌梗塞、心衰竭、糖尿病的比率。就中風罹病率,ACEI組罹患中風者高於ARB組者,兩組有顯著差異(p<0.001),在糖尿病的罹病率部分,兩組達統計顯著性(P<0.05)。在藥物遵從性方面,ARB的服藥遵從性較ACEI組佳,兩組也達統計顯著差異(P<0.001)。
結論與建議
單純在藥費支出上,ARB的藥費較高。但總費用上卻明顯較ACEI藥物類組低,次分析發現ACEI組住院人數比率、醫療資源利用率皆高於ARB組,顯示評估用藥類別和考慮整體醫療支出時,ARB是較好的選擇;本研究在服藥遵從性的結果也顯示ARB組的遵從性高於ACEI組。對於控制血壓和延緩罹患其他心血管疾病上,ARB的療效確實較佳。但是,本研究發現,在初次診斷出為高血壓後五年以上,無論是ARB組或ACEI組,兩組罹患糖尿病的比率皆高於三成,且高於其他心血管疾病的罹病率。在此建議臨床醫師在診治高血壓患者時,除了提醒病患在血壓控制部分,血糖控制亦相當重要。


The mortality of hypertension and its related diseases is higher than the one in the carcinogens tumors among the top ten causes of death in Taiwan. Hypertension is the major risk factor for development of cardiovascular disease (CVD). The poor drug compliance of the hypertension patients causes the increasing likelihood to develop other diseases and medical cost. Researchers pointed out antihypertensive drugs that lower the hypertension is associated with the lowering the morbidity and mortality of CVD. In light of these facts, the study aimed to understand the ratio of medical use by hypertensive patients with different age group, the following morbidity of CVD, the relationship between development of said diseases and drug compliance, and how age, gender and location of patients would influence their drug compliance.

Research method
The secondary data analysis was used with the retrospective cross-sectional design. The study structure was developed based upon the relevant literature. The samples were drawn from The National Health Insurance (NHI) database between 1997 and 2010 representing one million sampling from the whole population. The inclusion criteria were first time use of antihypertensive medication between 1997 and 2005, continuing for more than 5 years. The excluded criteria were that the history of stroke, myocardial infraction (MI), heart failure (HF) and diabetes mellitus (DM) at the time of first diagnosed with hypertension. There are different types of antihypertensive medications, widely use are angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor blockers (ARB). A total of 10,745 subjects were included in the present study. The included participants were taking either former or later drug, and categorized into ACEI cohort and ARB cohort. The comparison was made to understand their total medical spending, drug spending, and drug compliance, further exploring relationship between the use of each of medication and medical spending.

Results
The present study separated the medical use into the medication fee and total medical spending (including the hospitalization). Regarding medication fee, amount in ARB cohort was higher than the that in ACEI cohort (p<0.001). As for total medical fee, the amount from ARB cohort was significantly lower than from ACEI cohort (p<0.001).
The χ² test was used to reveal the morbidity of stroke, MI, HF and DM. The morbidity of stroke and DM between ACEI cohort and ARB cohort reached statistically significant (p<0.001). When it came to the drug compliance, the compliance in ARB cohort was better than that in ACEI cohort, statistically significant was found.

Conclusion and suggestion
Considering the medication fee only, the study found amount of ARB cohort was higher; however, the overall medical fee was considered, the medical expenditure resulted from ACEI cohort was obviously higher than the one from ARB cohort. It pinpointed that ARB type medication is a better choice when intending to lower the overall medical expenditure. As abovementioned, the drug compliance in ARB was better than that in ACEI, and other results supported that the efficacy was better in the controlling blood pressure and delaying the development of other CVD. Interestingly, the study found that 5 years after first taking antihypertensive medication, the morbidity of DM is over 30% in both groups, and such morbidity was also higher than the morbidity of other CVD. With such results, we herein suggested clinicians should remind the hypertensive patients to control both their blood pressure together with the blood sugar when interviewing with such patients.


目錄
第一章
緒論……………………………………………………………01

第一節
背景和動機………………………………………………01

第二節
研究目的…………………………………………………04

第三節
高血壓藥物種類…………………………………………05

第四節
名詞定義…………………………………………………06
第二章
文獻探討………………………………………………………07

第一節
高血壓盛行率……………………………………………07

第二節
高血壓治療準則…………………………………………09

第三節
服藥遵從性………………………………………………16
第四節
血管收縮素轉換酵素抑制劑和血管張力素受體阻斷劑的作用機轉………….………...……………………………20
第三章
研究材料與方法………………………………………………31

第一節
研究架構和研究假說……………………………………31

第二節
研究設計和研究樣本……………………………………34

第三節
研究材料…………………………………………………35

第四節
研究變項………….…………………………...…………38

第五節 統計方法………………………………………...……….41
第四章
研究結果………………………………………………………43

第一節
樣本人口學資料…………………………………………43
第二節
研究結果…………………………………………………50
第五章
討論與結論……………………………………………………64
第一節
討論………………………………………………………64
第二節 結論………………………………………………………69
第三節 研究限制…………………………………………………71
參考文獻…………………………………………………………………72

表次
表2-1 成人血壓分類標準及定義……………………………………12
表2-2 血管收縮素轉換酵素抑制劑與血管張力素受體阻斷劑控制高血壓病患併發其他疾病機率及醫療資源利用之相關研究....27
表4-1 樣本人口學資料………………………………………………45
表4-2 樣本人口特性及醫療層級差異性分析………………………46
表4-3 各地樣本年齡分布……………………………………………49
表4-4 各年齡層罹患高血壓分布情形………………………………52
表4-5 ACEI與ARB組罹患相關疾病的人數/比率…………………53
表4-6 ACEI與ARB組各地區罹患相關疾病的人數/比率…………55
表4-7 性別與藥物遵從性的關係……………………………………57
表4-8 以藥物類別看藥物遵從性……………………………………58
表4-9 比較性別與服用ACEI、ARB藥物類型的遵從性……….…58
表4-10 各年齡服用藥物的遵從性……….………….………….…….59
表4-11 以地區看藥物遵從性…………………………………………60
表4-12 ACEI與ARB兩組在五年以上藥費、五年以上住院醫療費用及五年以上總醫療用……….………...….………….………..61
表4-13 以年齡區隔服用ACEI藥物高血壓患者平均總醫療費用…62
表4-14 以年齡區隔服用ARB藥物高血壓患者之平均總醫療費用..63
表4-15 ACEI與ARB組之住院人數/比率……………………………63



圖次
圖 2-1 高血壓治療指引……………..……………………………13
圖 2-2 單一類藥物治療和結合兩類以上藥物治療的選擇……...19
圖 3-1 研究架構圖……………………………..…………………32
圖 3-2 研究流程表…………..……………………………………34
圖 4-1 各地樣本人數分布………………………………………..47


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