- 學位論文
台灣地區三大降血壓藥物使用趨勢及藥價調降之關係
The Trends In Use and Effect of Price Adjustment of Three Major Antihypertensive Agents in Taiwan
摘要
目的 高血壓是國人普遍且資源耗用最頻繁的慢性疾病。國內、外相關研究較少有利用行政資料庫，針對降血壓藥物使用做系統性長期趨勢的研究。也少有就健保藥價調降後，對於藥品市場是否有增加學名藥處方的趨勢。因此，本研究目的在於(1)探討1997∼2008年ACEI、ARB及CCB處方量與處方金額的長期趨勢; (2)探討1997∼2008年ACEI與ARB替代使用的趨勢變化; (3)預測三大降血壓藥處方量與處方金額之影響因子。; (4)探討健保藥價調降對原廠藥與學名藥使用的趨勢變化。 研究方法 本研究採次級資料分析法，以回溯性橫斷性方式(Retrospective cross-sectional study)進行研究，分析「全民健康保險研究資料庫」1997年1月至2008年12月，分類為處方心血管藥物，共計1,202,027筆研究筆數。選取ATC code前5碼為C08CA、C09CA與C09AA，再取得各項ATC對應之DDD量依據藥品規格量與成分量將藥品含量進行轉換，將處方量單位轉換為DDD，再將處方金額以消費者物價指數做校正。以SPSS 14.0統計軟體，利用獨立樣本T檢定、單因子變異數分析、卡方分析、複迴歸分析及Logistic迴歸分析，進行資料的分析及驗證研究假說。 研究結果 研究結果發現，ACEI、ARB及CCB處方量及處方金額呈現逐年增加，其中以ARB成長最快，該類藥物處方量自1998年第一個ARB品牌上市後，12年間共增加10.4倍。在三大降血壓藥的市占率中ARB由1999年占5.1%增加至2008年占25.1%，而處方金額則由1998年7.1%上升至2008年的34.5%。在不同醫院層級在三大降血壓藥處方量及處方金額依序為:醫學中心、區域醫院、基層院所、地區醫院。ACEI與ARB呈現替代效應，不同層級的醫院有不同的替代時間，醫學中心的替代時間早於區域醫院，但基層院所在處方量上並無發現替代效應。控制其他相關因子後，ACEI學名藥的使用會隨藥價調降逐次上升，而ACEI處方金額，隨每次藥價調降而減少，在2005年後CCB原廠藥的使用會隨藥價調降逐次下滑，但使用上仍以原廠藥為大宗。 結論和建議 本研究發現，1997∼2008年台灣地區在降血壓藥物的使用上，除ACEI處方金額外，ACEI處方量、ARB或CCB在處方量及處方金額上，都呈現逐年增加的趨勢。其中以CCB處方量為大宗。ACEI與ARB呈現替代效應。此外，控制其他相關因子後，發現層級別、就醫科別、就醫分局、藥價調降、原廠藥與學名藥皆為ACEI、ARB及CCB處方量與處方金額的顯著預測因子。影響高血壓病患的處方用藥因子很多，建議未來可結合問卷，詢問醫院醫師及病患在降血壓藥上的使用習慣，並探討其影響因子。
並列摘要
Objective : Hypertension is a common disease but the control rate remain low in Taiwan. The hypertension-related comorbidities, such as stroke, coronary heart dis-ease, and renal failure commonly lead to death or disability. There are rare domestic and foreign researches using the administrative databases for exploring the systemic long-term trend of antihypertensive agents and for investigating the consumption trend in the drug market after lowering the price by the requrirments of the National Health Insurance institute. Therefore, the purposes of this study were (1) to explore the long-term trend in drug consumption and cost in three major antihypertensive agents from 1997 to 2008. (2) to examine the trend of drug switches from ACEI and ARB antihypertensive agents between 1997 and 2008. (3) to detect the factors affect-ing the drug consumption and cost in three major antihypertensive agents. (4) to study the trend of the use of the original agents and the generic agents after lowering the price by the requrirments of the National Health Insurance institute. Methods : We conducted a cross-sectional retrospective study. We used the National Health Insurance Research Database(NHIRD) to perform the analysis between Janu-ary , 1997 and December , 2008 (12 years) with prescription cardiovascular agents, to produce a study sample of 1,202,027. All sataistical analysis were performed using the SPSS 14.0 statistical package.We used independent samples T-test, single factor ANOVA, chi-square analysis, multiple regression analysis and logistic regression analysis for statistical analysis and verify hypotheses. Results : The results showed that the overall consumption and cost in the three major antihypertensive drugs raised year by year. Among these three drugs, the fastest in-crease in prescriptions of the ARB was found. The amount of the ARB’s prescriptions amplified 10.4 times in the 12-year survey as compared with that in 1998 when the first ARB was clinically used. In addition, the prescriptions of the ARB gradually in-creased annually. The percentage of the ARB’ prescriptions in all three major drugs displayed 5.1% in 1999 and 25.1% in 2008. Moreover, their cost occupied 7.1% in 1998 and 34.5% in 2008 among these three drugs. However, the annual listing of the antihypertensive drugs items was not increased. Considering the different rank of our medical system, the consumption and cost of these three drugs was shown in order from the largest to the smallest as medical centers, regional hospitals, area hospitals and the clinics. The substitution effect in ACEI and ARB was found to be different in the medical system. Time to replace the ACEI with ARB appeared shorter in the medical centers than the regional hospitals. Interestingly, such effect regarding pre-scription volume did not exist in the clinics. Controlling for other relevant factors, the data depicted CCB were prescribed as the original drugs, but ACEI as the generic drugs after the drug prices were requested to be lowered. Conclusion and Suggestion : The study disclosed that there was a rising trend in the prescriptions of three major antihypertensive drugs as well as the cost in ARB and CCB from 1997 to 2008 in Taiwan, with the exclusion of the cost in ACEI. The pre-scriptions of CCB appeared the largest among these drugs. Remarkably, the substitu-tion effect existed in ACEI and ARB. In addition, the independent predictors for the drug consumptions and costs were medical divisions, medical levels, branch catego-ries, price adjustments and generics. Controlling for other variables, overall, the cost of antihypertensive drugs decreased as the drug prices were lowered in the last 12 years, but the consumption remained a insignficant rise.There are many factors af-fecting the determination and prescription of the antihypertensive agents. In the future, we suggest that these possible factors can be seeked using the questionnaires for phy-sicians and patients on their habits and explore their role.