健保醫療資訊雲端查詢與藥物使用及照護結果之相關性研究

人口老化、慢性病及多重慢性病病人日益增加為全球多數國家共同面臨的問題，藥物治療及疾病管理是被認為維持慢性病健康進展的有效手段，許多衛生部門運用醫療資訊交換系統(Health information exchange)促進協調性照護，期以提升病人醫療安全品質。衛生福利部中央健康保險署於2012年7月建置健保雲端藥歷系統，提供醫師查詢病人進期用藥資料，並於2016年擴充查詢資料項目，發展健保醫療資訊雲端查詢統。然而過去研究對HIEs是否可提高病人用藥安全尚未有一致性結果，且成效評估主要採用醫院”有無”使用HIEs系統的比較，鮮少針對查詢使用情形的高低進行研究。本研究主要主題如下：1.健保醫療資訊雲端查詢系統使用情形與不適當用藥相關分析，包含(1)探討系統查詢使用情形和門診處方重複用藥相關性，及(2) 探討系統查詢使用情形和門診藥物交互作用相關性；2.健保醫療資訊雲端查詢系統使用情形與照護結果之相關性分析，包含(1) 探討系統查詢使用情形和急診、住診次數相關性，及(2) 探討系統使用情形與照護結果間，是否透過減少不適當用藥的影響；3.健保醫療資訊雲端查詢系統使用情形與重複用藥管理方案外溢效果之相關性，探討系統使用情形與非六類藥品之門診處方重複用藥相關性。研究方法：本研究資料取自2013-2017年中央健康保險署全民健保資料庫資料，屬於次級資料分析，自2013年健保資料庫中擷取當年度50歲以上且至少有兩種慢性病之病人列為研究對象，並持續追蹤至2017年，樣本選樣條件為所有觀察期間(2013年到2017年)的原始檔案中均持續有門診就醫紀錄。採母群體20%隨機抽樣及排除2014年至2017年未有疾病就醫紀錄與相關變項極端個案後，納入本研究分析個案共有320,980人。研究設計為準實驗研究設計，採用Difference in Difference分析健保醫療資訊雲端查詢系統實施前後門診用藥、照護結果變化情形。以2014年推展醫療院所查詢健保醫療資訊雲端查詢系統為分界，2013年為前測期，實施後的第一年至第四年(2014~2017年)為後測期，並依本研究定義選取2014~2017年間至少3年系統被查詢率≧80%列為高查詢組，其餘列為低查詢組。運用統計檢定比較兩組的差異，並依照各研究目的不同採不同的分析方式，目的一及目的二:使用邏輯斯迴歸、負二項式迴歸模型探討雲端查詢系統使用情形與門診重複用藥、藥品交互作用、疾病急診次數、疾病住院次數等相關性，並採用廣義線性模型，探討門診重複用藥是否為雲端系統查詢使用及急診次數之中介因素，目的三分析多重慢性病病人系統查詢使用情形，在六類藥品管理方案及非管理方案藥品的差異。研究結果：目的一分析發現多重慢性病人於2014年到2017年具有高查詢率的多重慢性病病人，其被查詢率與年代交互作用顯著減少重複用藥的風險及重複用藥日數，但對藥品交互作用則無統計上顯著差異。目的二分析指出門診就醫時持續高度被查詢跨院就醫紀錄，降低疾病急診風險及平均急診次數，但僅2016~2017年較雲端查詢系統實施前(2013年)降低疾病住院風險及平均住院次數。控制門診重複用藥比率及相關干擾因子後，病人門診雲端系統查詢率對降低疾病急診比率的影響降低，且門診重複用藥的有無亦顯著影響疾病急診比率，推測門診雲端系統查詢率對疾病急診比率的影響，部分影響係透過門診重複用藥比率。目的三統計分析發現，非重複用藥管理方案之多重慢性病人門診就醫時，醫師仍會查詢病人健保醫療資訊雲端查詢系統資訊，且平均查詢率及查詢率≧80%相對比例較高。控制可能的干擾因子後，重複用藥管理方案組在系統查詢率與年代固定效果交互作用下，發生重複用藥的風險及重複用藥日數顯著下降，但非重複用藥管理方案組則無顯著差異。研究討論與結論：初步研究顯示，健保醫療資訊雲端查詢系統推展後，在健保署相關品質或管理方案下，多重慢性病人如門診就醫時，醫師持續高度查詢病人近期雲端系統就醫紀錄，其門診重複用藥及疾病急診的顯著降低，顯示雲端查詢系統搭配政策制度對多重慢性病人照護品質有正向影響。此外，醫師不會因為因健保署管理方案來挑選病人查詢雲端系統就醫紀錄，但在管理方案的疾病，高查詢組顯著下降重複用藥風險及重複用藥日數。建議未來可進一步以醫師或醫療院所為分析單位及相關研究設計，探討健保醫療資訊雲端查詢系統執行成效；並可結合其他資料庫，分析整體醫療資源使用情形。

關鍵字

健保醫療資訊雲端查詢系統；醫療資訊交換系統；重複用藥；藥品交互作用；疾病急診；疾病住院；重複用藥管理方案

並列摘要

The growing prevalence of chronic conditions in aging population is one of the major challenges to many nations around the world. In many western and Asian countries, fragmented ambulatory care and potential doctor-shopping behavior commonly exist. Sharing patients’ health information has been one of essential strategies adopted by health authorities in many countries for care coordination. Patient health information exchange (HIE) can improve care coordination and safety as well as health outcomes for medical care. This health information exchange program entitled “PharmaCloud” contains the diagnosis codes and prescription codes of each physician visit in the past 3 to 24 months for every NHI enrollee (which was expanded to include other medical information such as imaging files and renamed as “Medi-Cloud” system in 2016). With written consent from the patients, a physician working in clinics or hospitals can inquire the medication records for reference during a visit by simultaneously using the physician’s and patient’s NHI cards as a valid key to access to the NHI PharmaCloud system.The current study aimed to comprehensively evaluate the impacts of the NHI Medi-Cloud system, including: 1.Association between the inquery rate of NHI Medi-Cloud system and inappropriate drug usage (duplicating drug and drug-drug interaction) in outpatient with multiple chronic conditions. 2.Association between the inquery rate of NHI Medi-Cloud system, inappropriate drug usage and outcome (emergency and admission) in outpatients with multiple chronic conditions. 3.Spill-over effect of the NHI Medi-Cloud System and NHI administration. A retrospective pre-post design with a comparison group was conducted using nationwide health insurance claim data from 2013 to2017. Patients whose medication record inquiry rate fell within 80% in 3 years were classified as the high inquiry group, and the others as the low inquiry group. Generalized estimation equations with difference-in-difference analysis were calculated to examine the net effect of the NHI Medi-Cloud System inquiry rate for a matched sub-sample. In total, 320,980 subjects with multiple chronic conditions were randomly selected. This study examined the effects of the Taiwanese health information exchange program implemented in 2013 and found that the program had significantly decreased the likelihood of duplication medication and resulted in fewer days of overlapped medication in the subjects of high inquery rate. There was no effect between inquery rate and reduced risk of drug-drug interaction significantly. Subjects who had high inquery rate in outpatient had low risk of emergency, but there were no effects significantly betweet high inquery rate and risk of admission. This study also found inappropriate drug usage was a mediator between the inquery rate and outcome (emergency and admission) in outpatients with multiple chronic conditions. The high inquery rate were not limited to the six drug groups under NHI’s monitoring which implied the existence of spill-over effect. This study indicated that under a single-payer health system, the introduction of a centralized health information exchange program focused on medication records may lead to reductions in duplicated medication, overlapping medication days and emergency for patients with multiple chronic conditions. However, a higher inquiry rate of the medication information might not lead to a greater reduction in those variables because physicians did not review the available medication information in their clinical practice. The effects may due to the enhanced internal control via prescription alert system in hospitals, which is a positive unintended consequence of the intervention. Further investigation on broader patient groups and for longer observation time is recommended.

並列關鍵字

NHI Medi-Cloud System ； Health information exchange ； duplicated medication ； drug-drug interaction ； emergency ； adminission ； NHI administration

參考文獻

Chen, T. J., Chou, L. F., & Hwang, S. J. (2006). Patterns of ambulatory care utilization in Taiwan. BMC Health Serv Res, 6, 54. doi:10.1186/1472-6963-6-54

Chi, M. J., Lee, C. Y., & Wu, S. C. (2011). Multiple morbidity combinations impact on medical expenditures among older adults. Arch Gerontol Geriatr, 52(3), e210-214. doi:10.1016/j.archger.2010.11.013

Fortin, M., Bravo, G., Hudon, C., Vanasse, A., & Lapointe, L. (2005). Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med, 3(3), 223-228. doi:10.1370/afm.272

Fortin, M., Hudon, C., Haggerty, J., Akker, M., & Almirall, J. (2010). Prevalence estimates of multimorbidity: a comparative study of two sources. BMC Health Serv Res, 10, 111. doi:10.1186/1472-6963-10-111

Fu, S., Huang, N., & Chou, Y. J. (2014). Trends in the prevalence of multiple chronic conditions in Taiwan from 2000 to 2010: a population-based study. Prev Chronic Dis, 11, E187. doi:10.5888/pcd11.140205

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