建構骨關節炎患者於不同用藥下 之健保資源耗用模式 -以NSAIDs與專一性COX-2抑制劑為例

A Study to Construct an NHI Resource Use Model for Osteoarthritis Patients Receiving Different Drugs -using NSAIDs and specific COX-2 inhibitors as examples

吳秀琴(WU HSIU CHIN)

指導教授 ： 胡雅涵

國立中正大學/管理學院/資訊管理學系/碩士(2013年)

摘要

骨關節炎(Osteoarthritis)是一種具有高流行率、高殘障率以及低死亡率的疾病，常見的口服治療藥物為非類固醇消炎止痛藥NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)及專一性COX-2(Cyclooxygenase 2)抑制劑。NSAIDs藥物使用普遍，但因其作用也破壞腸胃道黏膜而產生藥物副作用，從胃痛到出血、穿孔甚至死亡等併發症又衍生另外的醫療問題與治療費用。使用專一性COX-2抑制劑比傳統NSAIDs能提供更好的腸胃道安全性。然而，在台灣中央健保局制定的藥品政策對於高價藥物採取支付範圍的限制，專一性COX-2抑制劑的給付有諸多規定，形成醫師處方選擇受限，病人用藥普遍存在NSAIDs副作用風險。
本研究擷取2001-2010年最完整的醫療紀錄「健保資料庫」，發現NSAIDs用藥後造成比COX-2更多的潰瘍相關花費。並結合新興科技「資料探勘」(Data Mining)，應用決策樹(Decision Tree)J48與羅吉斯回歸(Logistic Regression)的分類技術，探勘研究變項對資源耗用的影響，研究結果顯示兩分類器績效相當，整體正確率(Overall Accuracy)為65%。決策樹在高資源耗用的分類下產生未列入COX-2給付範圍的新規則: (一)幽門螺旋桿菌感染者。(二)有高血壓及慢性腎衰竭合併症患者。(三)有高血壓及鬱血性心衰竭合併症患者。
研究過程中也發現COX-2使用量偏低(9.66%)，NSAIDs處方不當比率過高(0.37%-71.22%)，中央健保局政策制定以節約健保支出為主軸，對於病患藥品利用的效率、公平性和完整性未臻完善。因此，建議當局在抑制不當資源耗用之餘，應積極提升處方品質，將「醫院門診NSAIDs處方不當比率過高」列入醫療指標監測，照護更多的族群安全用藥，提高健保體系的價值。

關鍵字: NSAIDs、專一性COX-2抑制劑、決策樹、羅吉斯回歸

關鍵字

羅吉斯回歸 ； 專一性COX-2抑制劑 ； 決策樹

並列摘要

Osteoarthritis is a disease of high prevalence, high rate of disability, and low mortality rate. The commonly used oral medications for it include non-steroidal anti-inflammatory drugs (NSAIDs) and specific cyclooxygenase 2 (COX-2) inhibitors. Although NSAIDs are commonly used, it damages the gastric mucosa and produces side effects and complications ranging from gastric pain, to gastrorrhagia, gastrointestinal perforation, and even death, creating additional medical issues and costing more in extra treatment expenses. Specific COX-2 inhibitors are safer for the gastrointestinal tract compared with traditional NSAIDs. However, the drug policy developed by the Bureau of National Health Insurance Taiwan restricts the prescribing of expensive drugs and has resulted in various restrictions in the claims approval for specific COX-2 inhibitors. Doctors are faced with various restrictions when prescribing drugs and patients are commonly put on NSAIDs and exposed to their side effects.
This study has reviewed the complete medical records of the “NHI database” from 2001-2010 and found that medical expenses spent on ulcer-related treatment were much higher with NSAIDs than with COX-2. This study has also used a combination of emerging technologies such as data mining and classification techniques such as decision tree J48 and logistic regression to examine the effects of study variables on the depletion of resources. Results showed that both classification methods produced similar results and the overall accuracy was 65%. High resource depletion in decision tree produced new rules for the approval of COX-2 by the NHI: (1) patients with helicobacter pylori infection, (2) patients with concomitant high blood pressure and chronic renal failure, and (3) patients with concomitant high blood pressure and congestive heart failure.
The study also found that the prescribing rate for COX-2 was rather low (9.66%) while the inappropriate prescribing rate for NSAIDs was considerably high (0.37% - 71.22%). The Bureau of National Health Insurance formulates its policies centering round cutting expenses for the NHI and not the efficacy of drugs. The fairness and comprehensiveness of this policy are imperfect. Therefore, it is recommended that the bureau should proactively improve the quality of prescriptions in its effort to minimize inappropriate resource use. The “Improper over-prescription of NSAIDs in hospital outpatient department” should be listed as one of the medical indicators requiring monitoring to ensure that safe drug use is practiced in the larger population and value of the NHI system can be enhanced.

Keywords: NSAIDs, Specific COX-2 inhibitor, Decision tree, Logistic regression

並列關鍵字

Decision tree ； Specific COX-2 inhibitor ； NSAIDs ； Logistic regression

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