中老年糖尿病之門診處方型態分析

Prescription Patterns for The Middle-age and Older Diabetes Mellitus Patients in Ambulatory Care

李碧玉(Pi-Yu Lee)

指導教授 ： 楊哲銘

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2004年)

摘要

糖尿病為常見的慢性病之一，這類病患常有合併症，又以中老年病患居多，而需要使用多種藥物，所以在治療的藥費也相對增加，其花費在整體的醫療支出是值得注意。本研究目的是從門診糖尿病患的特性(性別、年齡、疾病複雜度)及就醫科別等變項來探討糖尿病的用藥處方型態及用藥費用差異情形。本研究以某區域醫院民國91年門診申報資料主診斷ICD-9-CM前三碼為250且年齡為40歲及以上之中老年為 研究對象，以SPSS11.0版進行除錯共計3,807人的申報資料加以分析，以t檢定、單因子變異數分析及Sheffe事後檢定來探討二變相間之差異，以逐步複回歸分析探討各變相間對用藥費用之解釋能力。 研究結果顯示，女性在用藥品項數及用藥費用高於男性，年齡愈大用藥品項數愈多，上述二點與許多研究結果結論是相同，從生命統計及相關研究中可得，女性平均壽命、病識感高於男性，所以會高於男性，年齡愈大之糖尿病患通常會因合併症而需使用多種用藥。在疾病複雜度中發現疾病數愈多者用藥費用愈高，且以高血壓及高血脂症之疾病診斷者居多，這與糖尿病比一般人多2-4倍的機率易患有心血管疾病有關，且合併症愈多者用藥費用相對會比較高。在不同之就醫科別，專門科「新陳代謝科」在用藥天數、用藥品項及用藥費用皆比一般科「家醫科」高，這與醫師所受的訓練及專科別之不同而有所差異。在糖尿病患相關之處方用藥分析結果，使用人次排名前三名依序為消化道與代謝(alimentary tract and metabolism)、心臟血管系統(cardiovascular system ) 、神經系統(nervous system)三類用藥居多，而藥費以心臟血管系統最高，其次為神經系統，再其次為消化道與代謝用藥，而在降血糖用藥處方型態組合中，採用兩類降血糖藥物者居多，其中以磺胺尿素類與雙胍類二者合併使用佔最高。 本研究之建議: 1. 健保局應積極提高門診慢性病處方箋之使用率，遏止重複看診領藥之機制。2. 建立標準處方模式，因年齡老化、慢性病患者增加及新藥陸續引進，藥費成長為必然之趨勢，應制定一套符合藥物經濟學的臨床使用指引，以達到疾病的控制與藥用費用的節制。3. 建議後續研究者可針對醫師個人特質來進一步分析或由病例紀錄更深入探討就醫科別用藥處方型態之差異。

關鍵字

糖尿病 ； 處方型態 ； 用藥費用 ； 降血糖藥

並列摘要

Diabetes mellitus is a very common chronic disease. The Diabetics are mostly middle-aged or older and suffer from comorbidities. Therefore, they need multiple medications and the expenses of treatment is relatively high. The cost in treating DM in terms of overall medical expenditure percentage needs our attention. The purpose of this research is to study the differences between Diabetes mellitus prescription patterns and drug expenditure from the perspective of diabetics’ characteristics, such as gender, age and complexity of diseases. The data comes from the outpatient services of a particular regional hospital in 2002. Patients with primary ICD-9-CM diagnosis code 250 and older than 40 years old are included. The data set contains 3,807 cases. We applied T-test, Oneway ANOVA, Scheffe test and regression in our analyses. SPSS 11.0 was the statistics package used in this study. The results indicate that drug expenditure is higher for female than male. And the older they are, the more items of medicine they got. These two findings are similar to those of many other researches. From life statistics and other related researches, we find that the female have longer life expectancy and are more aware of illnesses. This might explain why female diabetics cost more. Older people tend to have more comorbidities; thus they need more drugs. In the respect of severity of illnesses, the more comorbidities the patients have, the more money they will cost, especially for those combined with hypertension and hyperlipidemia. This finding probably has to do with the fact that diabetes patients are two to four times more at risk of suffering from cardiovascular diseases. In the respect of medical specialty, metabolism specialists tend to prescribe more days of medicine, more items of medicine and spend more in medications than family medicine doctors. It could be related to the trainings of the doctors and the specialties. The top three most prescribed drugs for the diabetics are those for alimentary tract and metabolism, for cardiovascular system, and for nervous system. The costs for these medications in descending order are cardiovascular system, nervous system, and alimentary tract and metabolism. Besides, most of prescriptions combine two types of hypoglycemic agents. Of them, sulfonylurea and biguanides are the two most frequently used together. In light our findings, we suggest the followings: 1. The Bureau of National Health Insurance should increase the utilization of chronic disease prescription in outpatient services so as to deter people from hospital shopping and getting basically the same prescriptions repeatedly. 2. Establish standard prescriptions. Owing to the increase of the elderly and patients with chronic diseases, and the advent of new medicine, the cost of medication will definitely increase and we should set up a clinical practice guideline based on pharmacoeconomic studies to control illness and medical cost at the same time. 3. Further studies should be done on the relationship between the prescription patterns and the characteristics of individual doctors. Besides, medical record reviews should shed more light on the distinction among medical specialties.

並列關鍵字

diabetes mellitus ； prescription pattern ； drug expenditure ； hypoglycemic agents

參考文獻

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