慢性腎臟病患用藥趨勢及費用之探討

研究背景與目的　　　慢性腎臟疾病(Chronic Kidney Disease, CKD) 是遍及全球的公共衛生問題，且與複雜的合併症有關，不論病因為何，部分患者會進展到「末期腎臟病(End-Stage Renal Disease, ESRD)的階段，ESRD的發生率和盛行率持續地增加，且是全球共同的趨勢。在台灣地區末期腎臟疾病粗發生率居世界之首，盛行率僅次於日本，高居世界第二；而中老年人口(≧45歲)無論盛行率或發生率皆高居世界之首，可知腎臟疾病確實盛行於台灣地區。 CKD患者若能即早控制高血壓、給予血管張力素轉換酵素抑制劑(Angiotensin-Converting Enzyme Inhibitors, ACEI)或第二血管張力素接受器斷劑(Angiotensin II Receptor Blockers , ARB)、控制血糖和限制蛋白質等，仍可改善腎功能，其中以降血壓藥品的角色最重要，因控制高血壓可減少心血管併發症。本研究將探討CKD病患開始接受替代治療前的藥費與藥物使用趨勢，以瞭解國內CKD患者藥品的使用情況和藥品費用的支出情形，期能將所收集之相關資訊提供給衛生政策單位作為施政的參考，進而節約醫療資源的使用。研究方法本研究採回溯性橫斷性研究(Retrospective cross-sectional study)，研究期間為2000年1月1日至2004年12月31日止。利用全民健康保險研究資料庫－承保抽樣歸人檔，建立國內CKD患者的用藥資料，研究樣本為2000~2004年健保資料庫中經定義為CKD的對象，分析CKD患者用藥費用的影響因素(年齡、性別、合併症)；研究利用ATC分類系統(Anatomical Therapeutic Chemical Classification System:ATC Classification System)探討藥品利用情形，此外依醫療院所層級別探討CKD患者於藥品使用和費用之變化。研究結果 2000~2004年CKD患者之門診費用與藥費，每人每年平均門診費用隨年度顯著上升；門診藥費同樣的也隨年度而顯著上升。不同年齡層、性別、合併不同疾病(糖尿病、高血壓、充血性心衰竭)之CKD患者其門診費用與門診藥費有顯著差異，且年齡、性別、合併症為門診藥費顯著的預測因子。CKD患者藥物使用頻次，在2000年排序前三名分別為：消化道與代謝用藥、呼吸道用藥、心臟血管系統，心臟血管系統用藥在五年間的使用頻次顯著的增加；藥品使用金額耗用金額前三名分別為心臟血管系統用藥、消化道與代謝用藥、血液與造血器官用藥。心血管用藥金額在2000年至2004年逐年成長，2002年之後Agents acting of the Renin-angiotensin system的藥品為CKD患者心血管用藥金額之冠。 ARB使用頻次逐年顯著上升，而ACEI則有下降的趨勢；各醫療機構層級開立ACEI或ARB之頻次佔各年該醫療機構層級所有處方頻次之比率，皆是醫學中心>區域醫院>地區醫院>基層診所。ARB有替代ACEI之趨勢，且替代速度隨醫療機構層級愈高而愈快。在ACEI的使用上隨著機構層級愈高，開立進口藥之比例也愈高。經由multinomial logistic regression發現CKD患者年齡愈大，且有糖尿病(OR值為2.25，95%信賴區間為2.02-2.51)，高血壓(OR值為8.58，95%信賴區間為7.64-9.60)、充血性心衰竭(OR值為1.60，95%信賴區間為1.36-1.87)之患者使用者ACEI和ARB的機會較高。結論 CKD患者在ACEI、ARB的使用頻次呈現逐年上升的趨勢，但醫療機構層級所有處方頻次之比率，皆是醫學中心>區域醫院>地區醫院>基層診所，建議未來可藉由醫師繼續教育訓練，讓醫師更能認識此藥物之效果與使用方式。藥費在五年間逐年上漲，衛生政策單位可對高價或高使用量的藥品作重點管制，以達到控制藥費之目的。

關鍵字

慢性腎臟病；血管張力素轉化媒抑制劑；血管張力素受體阻斷劑；藥物利用

並列摘要

Abstract Background The chronic kidney disease is a world-wild public health problem. It is also related to complex co-morbidities. No matter what are the causes of disease, partial of the patients will progress to the End-Stage Renal Disease in the end. The ESRD incidence and prevalence increases continually and it also becomes a global common tendency. The ESRD incidence in Taiwan is the highest of the world. The prevalence, which is inferior to Japan, takes second place in the world. Futhermore, the prevalence and incidence of the middle and old-aged population, people who is older than 45 years old, is the highest of the world. It can tell how the kidney disease prevails in Taiwan apprently. CKD patients can improve the kidney functions through controlling the hypertension earlier, taking the Angiotensin-Converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARB), and controlling the blood sugar and the limit protein. The antihypertensive drugs are the most important one since controlling hypertension can help reducing the cardiovascular complications. The goal of this study is proved through calculating the pharmaceutical expenditure of the CKD patients and analyzing the tendency of drug utilization. Hope the information and results can be a reference resource for health policies making department and also can help reducing the medical resources utilization. Method and Materials This study applies the Retrospective cross-sectional study to look into the influenced factors (age, sex, co-morbidity) in drugs expense, and also applies the Anatomical Therapeutic Chemical Classification system to analyze the tendency of drugs utilization of the sample, which are patients who defined by NHI Research Database from 2000/1/1 to 2004/12/31 in the CKD group. Moreover, it will discuss the fluctuation of drugs utilization and expense by hospital level. Results The average cost of CKD outpatient and drugs a year per patient from 2000 to 2004 is increasing apparently. Furthermore, the CKD patient will have distinct outpatient and drugs expense from different age or sex combining with different disease, such as diabetes, congestive heart failure, and hypertension. In addition, age, sex and co-mboridity are the most noticeable factors in forecasting the cost. The frequency of medicine utilization in alimentary tract and metabolism, respiratory system and cardiovascular system took the first three places in 2000. The cost of cardiovascular system drugs has been increased remarkably in the term of 2000-2004. The ARB utilized frequency is rising year by year; however, ACEI has been decreasing recently. There is significant difference between different levels of health care organizations. Moreover, ARB has kept replacing ACEI. The higher the hospital level is, the faster the replacing speed. By using the multinomial logistic regression, it also shows that CKD patients, who are elder or have diabetes, hypertension or congested heart failure, have more ACEI and ARB usage opportunities. Conclusion The frequency of CKD patient in ACEI, ARB usage has been higher year by year. Nevertheless, the investigation shows that medical centers have the highest prescription frequency. In order to increase the knowledge in the effects and the directions of drug usage, physicians should take education training continuously in the future. The cost of drugs has risen year by year during these five years. The health policy department could control the drugs charges by focusing on controlling those high price or high usage of drugs.