利用臺灣全民健保資料庫進行腎臟移植病患門診用藥型態及 照護費用之分析研究

Evaluation of the Ambulatory Care Costs and Drug Utilization of the Post-Renal Transplant Patients with the Taiwan NHI Claims Database

李建立(Eric Kin-Lap Lee)

指導教授 ： 詹道明

高雄醫學大學/藥學院/藥學研究所/博士(2011年)

摘要

研究目的：
由於病患進行器官移植手術後第一年的門診照護總費用及藥費是決定移植手術成功與否的一個關鍵指標，因此本論文針對國內腎臟移後第一年的病患門診醫療照護總費用與藥品使用情形作評估，所使用資料來源為台灣健保學術資料庫。

本研究主要係以藥物流行病學方式進行，分別探討以下列三個主題：
1. 分析台灣各級醫院進行腎臟移植手術之案件數及分佈情形，並比較各級醫院申報腎臟移植病患門診照護費用及用藥情形。
2. 比較國內腎臟移植與其他器官移植門診照護費用及用藥情形。
3. 比較國內外腎臟移植門診照護費用及用藥情形。

研究資料與處理：
針對本研究第一個主題所使用的資料來源為台灣全民健保資料庫1999至2003年系統抽樣檔包括住院醫療費用清單明細檔、住院醫療費用醫令清單明細檔、門診處方及治療明細檔及門診處方醫令明細檔；第二及第三主題所使用的資料來源則為台灣全民健保資料庫2001至2006年承保抽樣歸人檔。其他所使用之相關研究資料包括健保局提供之健保用藥基本資料檔，主要作為藥名及國際藥理分類之轉換，所有全民健保學術資料是以文字檔案格式釋出，因此資料轉檔及相關統計分析使用SPSS中文版14.0統計軟體進行。

結果：
在1999-2003年間，共有663位腎移植手術病患，在26所醫院進行手術，其中有90%在醫學中心進行。約有55% 病患在台北地區醫學中心進行而其他分佈在全國各地。申報費用最多次前12所照顧腎移值患者的醫院，所得到之給付佔總金額99%。根據ATC藥理分類，處方金額申報最高的免疫抑制劑為Sandimmum Neoral Cyclosporin佔(43%)，Mycophenolate 佔(30.8%) 以及Tacrolimus佔(21.3%)等。而前三名高申報率免疫抑制劑之每日使用量(DDD) 分別為137.5 mg、1187 mg 和5.54 mg，而前兩者之用量較世界衛生組織WHO公告的250 mg及2gm為低。

以2001至2006之資料分析腎臟、心臟、肺臟及其他器官移植的手術後第一年的門診照護總費用及藥費，發現藥物費用佔各總費用約80%，除了其他類的移植手術例如：骨髓移植約占60%。各類器官移植的醫療照護費用與藥物費用有明顯的差異，肝臟移植病患之照護費用最高。另外比較1999至2003階段之結果，處方金額申報最高的免疫抑制劑改變為Sandimmum Neoral Cyclosporin佔(36.8%)，Tacrolimus佔(30.17%)以及Mycophenolate 佔(21.46%)。於2005年Tacrolimus消耗總金額已超過為Sandimmum Neoral Cyclosporin總金額，成為主要的免疫抑制藥物。

最後，病患進行境外移植手術的年齡層較國內的年齡層要高，分別為44.44±13.11歲及39.43±13.11歲，而且有明顯的統計意義(p=0.012)。估計境外移植手術後的第一年門診照護總金額與藥物費用比國內為低，境外及境內移植藥費分別為NT$.277,178.76±106,832.99 及NT$.225,419.06±122,400.69，而境外及境內移植總費用則分別為 NT$.308,978.58±110,917.41 及NT$.247,564.93±124,711.06，且有明顯的統計意義，分別為(p=0.005 及 p=0.004)。但對於移植手術後第一年之用藥型態，醫生所選擇處方的免疫抑制劑仍以Sandimmum Neoral Cyclosporin為主並沒有明顯差異(p=0.495)。

關鍵字

健保資料庫 ； 腎臟移植 ； 用藥型態 ； 照護費用

並列摘要

OBJECTIVES：
Owing to the first-year ambulatory cost after transplantation generally considered as an indicator of the success of the transplantation surgery, in this thesis we attempted to evaluate the ambulatory care costs and drug utilization of the post-renal transplant patients with the Taiwan NHI claimed database.

Firstly we proposed to conduct a pharmacoepidemiology study to examine the utilization and the expenditure for immunosuppressants among renal transplant recipients in order to estimate the growth of future costs under the Taiwan global budget system.

Secondly, we will compare the total expenditure of the first year post-transplantation ambulatory health care and drugs used that attempted to provide evidence that the renal transplantation was less costly than hemodialysis.

Lastly, we hope to evaluate the differences of the ambulatory health care costs and drug utilization of the first year post-renal transplantation between the patients who have had domestic and foreign renal transplant surgery.

STUDY MATERIALS & DATA MANAGEMENT：
For the study data, we used the Taiwan Longitudinal Health Insurance Database (2005), which contained all of the claims data from 1,000,000 beneficiaries who were randomly sampled from the Registry for Beneficiaries of the National Health Insurance Research Database, which includes approximately 25.68 million individuals, namely, 98% of the population in Taiwan. This database contains all the ambulatory, emergency, and hospitalization claims information and costs tracked back to 1997 and carried to 2006. All of the NHRI data were delivered as text files and the SPSS Chinese version 13.0 statistical program was used to transcribe them into working files for further analysis.

MAJOR FINDINGS：
The first-year post-transplantation drug costs and total health care costs of the kidney, heart, lung, liver, and other organ transplantations were evaluated and the drug expenditures were about 80% of the total health care cost except for the other specified organ transplant, i.e., bone marrow, wherein they were 60%. The mean differences between drug expenditures and total costs of various organ transplants were significant differences (p<.01; ANOVA).

Compared with the first period covering 1999–2003, wherein the most frequently prescribed immunosuppressive agents were cyclosporine (43%), mycophenolate (30.8%), and tacrolimus (21.3%), the updated information showed cyclosporine (36.8%), tacrolimus (30.17%), and mycophenolate (21.46%). In 2005, the total drug expenditure for tacrolimus was higher than for cyclosporine which was the major immunosuppressive agent used previously.

There was a significant difference between the age group of the foreign renal transplant surgery cases (44.44±13.11) and the domestic cases age (39.43±9.19) with (p=0.012) using the independent T-TESTS. The estimated first year post-renal transplantation ambulatory drug costs and total costs of the domestic renal transplant surgery cases were significantly higher than the foreign cases (p=0.005 and p=0.004) respectively. However, there was no significant differences for the drug of choice used initially from the first-year after renal transplant surgeries (p=0.495).

並列關鍵字

ambulatory care costs ； drug utilization ； renal transplant ； claims database

參考文獻

REFERENCES

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