醫師處方血管張力素受體阻斷劑固定劑量複方製劑與病患服藥相關順從性探討

The Study of Correlation between Physician’s Prescription of Angiotensin Receptor Blockers Single-Pill Combination and Patients’ Compliance

陳博儒(Po-Ju Chen)

指導教授 ： 張肇松

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2012年)

摘要

研究背景與目的
2003年JNC7報告中提到大部份病患需要兩種或以上的藥物來協助達到高血壓的控制目標(小於140/90 mmHg)，2003年世界衛生組織及國際高血壓學會認為單獨使用一種降血壓藥物治療沒有辦法達到理想的效果，必須要有理想的合併降血壓藥物治療，但是並沒有比較的隨機臨床試驗證實如何才是最佳的降血壓藥物組合。而在2010年臺灣高血壓治療準則上也提到在第二級或第三級高血壓，或是具有高風險性患者身上使用不同的藥物來合併治療常常是必需的。本研究係探討台灣地區不同層級醫院及病患使用ARB固定劑量複方製劑及使用非ARB固定劑量複方製劑在藥費、總費用的差異和順從性的比較。
研究方法
本研究採用次級資料分析法，以回溯性橫斷性方式(Retrospective cross-sectional study)進行研究，而研究架構乃參考有關之文獻並以「2000年全民健康保險研究資料庫百萬抽樣歸人檔」分析自2001年6月起第一次使用降血壓藥物之高血壓門診共116,364筆為研究對象。並以PDC分成ARB固定劑量複方製劑及非ARB固定劑量複方製劑，比較兩組平均每人三年的總醫療支出、藥費支出以及服藥順從性，探討ARB固定劑量複方製劑的使用與各項醫療支出的關係。
研究結果
本研究顯示，使用ARB固定劑量複方製劑的病人其平均每人三年的藥費支出比非ARB固定劑量複方製劑組多，而兩組在門診及藥局的藥費支出上都是呈現逐年遞減。總費用部份，不管是一年、二年或是三年都可以發現ARB固定劑量複方製劑組的病人總費用都比較低，具有顯著性的差異。順從性方面，ARB固定劑量複方製劑組高於非ARB固定劑量複方製劑組，具有顯著差異性(0.3978 vs.0.3509, P<0.001)。死亡率部份，ARB固定劑量複方製劑組無論在一年內(1.16% vs. 1.92%)，累計二年內(1.74% vs. 3.29%)及累計三年內(2.26% vs. 4.49%)均低於非ARB固定劑量複方製劑組，均具有顯著差異性。
結論與建議
在藥費中ARB固定劑量複方製劑的藥費較高。但是在總費用上卻明顯少於非ARB固定劑量複方製劑組，是不是因為使用這一類藥物對總費用有所幫忙，值得進一步探討。而ARB固定劑量複方製劑組的順從性比另一組高，但仍不到4成，另外兩組從各年度費用亦可看出順從性逐年下降，未來可以從衛教方面多多宣導服藥順從性的重要性。

關鍵字

血管張力受體阻斷劑固定劑量複方製劑 ； 藥品占率 ； 總醫療支出 ； 藥費支出 ； 藥品持有率

並列摘要

Background and Objective
JNC 7 reported in 2003 that most hypertension patients need to combine two or more drugs to control their blood pressure below 140/90 mmHg. Drug combination therapy reaches lasting effect better than single drug is recommended by WHO and International Society of Hypertension in 2003. Taiwan Hypertension Treatment Guidelines 2010 refers to the necessity of drug combination therapy on patients with grade 2, grade 3 or high risk hypertension. By using two or three different mechanism anti-hypertensive drugs, low or standard dose, will control blood pressure better than single one high dose . The purpose of this study is set to explore the difference of drug costs, total costs and compliance comparison in the different levels of hospitals and patients in Taiwan with ARB single-pill combination and non-ARB single-pill combination.
Methods
The research framework is determined by secondary data analysis, retrospective cross-sectional study, and reference to the relevant literature. The 116,364 subjects of study were quoted from Large Health Insurance Dataset of 2000 who were first-time antihypertensive drugs users since June 2001. To compare average three-years total cost, drug cost and compliance and explore the relationship between usages and medicine expense of ARB single-pill combination, we divide subjects into ARB single-pill combination group and non-ARB single-pill combination group by PDC.
Results
This research shows the average medicine expense in 3 years of an individual patient who uses ARB single-pill combination is higher than non-ARB single-pill combination. However, both patients groups show the decreasing trends in expense of outpatients and drugstores year by year. In the viewpoint of total expense, this research reveals ARB single-pill group total patients expense is statistically significant lower in one-year, two-year and three-year respects. In the viewpoint of compliance, ARB single-pill combination group is statistically significant higher than non-ARB single-pill combination group. (0.3978 vs. 0.3509, P<0.001). In the respect of death rate, ARB single-pill combination group is statistically lower than non-ARB fixed-dose combination group in one-year (1.16% vs. 1.92%), two-year (1.74% vs. 3.29%) and three-year (2.26% vs. 4.49%).
Conclusion and Suggestions
The drug cost of ARB single-pill combination is higher than non-ARB single-pill combination. But total cost for ARB single-pill combination is significant much less which needs further exploration whether ARB single-pill combination is helpful. Because ARB single-pill combination group compliance is higher but still less than 40% and compliance is decreasing year by year in two groups, the importance of compliance needs hygiene advocacy in the future.

並列關鍵字

Angiotensin receptor blocker fixed-dose combination ； Proportion of days covered (PDC) ； Total medicine expense ； Drug cost ； Medication possession ratio (MPR)

參考文獻

Andrade, S. E., Kahler, K. H., Frech, F., & Chan, K. A. (2006). Methods for evaluation of medication adherence and persistence using automated databases. Pharmacoepidemiol Drug Saf, 15(8), 565-574; discussion 575-567.

Bangalore, S., Kamalakkannan, G., Parkar, S., & Messerli, F. H. (2007). Fixed-dose combinations improve medication compliance: a meta-analysis. Am J Med, 120(8), 713-719.

Basile, J. N. (2007). Fixed-dose combination therapy in the treatment of hypertension: ready for prime time. South Med J, 100(4), 343-344.

Brenner, R., Waeber, B., & Allemann, Y. (2011). Medical treatment of hypertension in Switzerland. The 2009 Swiss Hypertension Survey (SWISSHYPE). Swiss Med Wkly, 141, w13169.

Burnier, M., & Zanchi, A. (2006). Blockade of the renin-angiotensin-aldosterone system: a key therapeutic strategy to reduce renal and cardiovascular events in patients with diabetes. J Hypertens, 24(1), 11-25.