執行「保險對象特定醫療資訊查詢」對於安眠藥物開立的影響:以台灣中部某公立綜合醫院為例

Impact of Implementing“Prescription monitoring program”on Specific Hypnotics: an Example of Public Hospital in Central Taiwan

王奕翔(I-SHIANG WANG)

指導教授 ： 何清治

中臺科技大學/管理學院/醫療暨健康產業管理系碩士班/碩士(2017年)

摘要

背景
我國安眠藥濫用情形嚴重，因此健保署針對管制藥品用藥偏高病人列為執行「保險對象特定醫療資訊查詢」，希望藉此降低重複用藥或使用劑量過高等情形，以提升治療品質與病人用藥安全。
目的
本研究即在探討執行「保險對象特定醫療資訊查詢」前、後，安眠藥的處方箋及偏高劑量的開立量是否降低。
方法
本研究採取病歷回溯性研究，研究對象選定中部某地區醫院20~99歲門診病患，於2014年8月1日至2016年7月31日取得Flunitrazepam、Zolpidem、Midazolam、Estazolam、Zopiclone共五種安眠藥管制藥品的處方箋，共有14628張。描述性分析包含個別藥品處方箋數量、藥品總顆數變化、平均每日給藥劑量變化的趨勢以及處方箋所屬病患特質分布。推論性分析採簡單線性迴歸評估政策實施前、後，高劑量安眠藥處方比例的增減。
結果
本研究發現在「保險對象特定醫療資訊查詢」監督下，須查詢的2個藥品Flunitrazepam與Zolpidem開立量下降，但其他安眠藥開立量上升，整體來說，安眠藥總開立量還是有下降的。Flunitrazepam與Zolpidem偏高劑量的開立則有持續惡化現象。主診斷為物質成癮或濫用的病人在介入後開立處方箋比例增加。
結論與建議
執行「保險對象特定醫療資訊查詢」後Flunitrazepam、Zolpidem及安眠藥總量的開立量是降低，但其他3種安眠藥開立量是上升的，且Flunitrazepam、Zolpidem使用偏高劑量是惡化的；物質成癮或濫用的病人較不易被改變用安眠藥的習慣。本研究建議已在查詢名單者，請轉介至精神專科醫師評估處理，不開立慢性連續處方箋，並限定在特定醫療機構拿藥，且給予睡眠衛教與認知行為或成癮治療。
關鍵字: 保險對象特定醫療資訊查詢，高關懷名單，安眠藥

關鍵字

保險對象特定醫療資訊查詢 ； 高關懷名單 ； 安眠藥

並列摘要

Background
The abuse of hypnotics in our country is serious. National Health Insurance Administration, therefore, sets up the “Prescription monitoring program ”for those who use higher dosage of controlled drugs in order to cut down repeated prescription drugs or higher dosage of hypnotics so that patients can improve their quality of medical care and safety of medication use.
Method
The study uses retrospective study of medical record, selecting subjects from a public hospital in central Taiwan between 20~99 years old, from August 1st, 2014 to July 31st, 2016. Data collected included Flunitrazepam、Zolpidem、Midazolam、Estazolam and Zopiclone, total 5 kinds of hypnotics. There are about 14628 prescriptions in total. Descriptive analysis includes the number of prescriptions for individual drugs, total number changes of drugs, trends of the average daily dosage changes, and the patients' characteristics of taking those prescriptions. Inferential analysis uses simple linear regression to assess the fluctuation of the proportion of high-dose hypnotics "before" and "after" the implementation of the policy.
Result
This study indicates that under the supervision of “Prescription monitoring program ”,the amount of prescription of Flunitrazepam and Zolpidem, two important queried drugs, decreases, but amount of other hypnotics increases. Overall speaking, the amount of prescription of all hypnotics obviously decreases; however, the high-dose prescription of Flunitrazepam and Zolpidem is still worsening. The proportion of patients whose main diagnosis is substance dependence or abuse increases after intervention.
Conclusion and Recommendation
Implementing the policy of “Prescription monitoring program” can reduce the amount of prescription in Flunitrazepam and Zoplidem at the cost of increase the amount of prescription in other hypnotics. The total amount of all hypnotics is reduced. Moreover, for the patients who need the high-dose prescription, this policy cannot help them to reduce it effectively. Patients with substance dependence or abuse cannot be easily changed their habit of hypnotics. So if patients are on the list of "Prescription monitoring program”, this study suggests that they should be transferred to psychiatrists for evaluation and management and no being prescribed chronic continuous prescription. Also they should be limited in specific health facilities where sleep hygiene or cognitive behavioral therapy or addiction therapy can be provided.
Keywords: Prescription monitoring program, high care list, hypnotics

並列關鍵字

Prescription monitoring program ； high care list ； hypnotics

參考文獻

1.Bachhuber, M. A., Maughan, B. C., Mitra, N., Feingold, J., & Starrels, J. L. (2016). Prescription monitoring programs and emergency department visits involving benzodiazepine misuse: Early evidence from 11 United States metropolitan areas. Int J Drug Policy, 28, 120-123. doi: 10.1016/j.drugpo.2015.08.005

2.Billioti de Gage, S., Begaud, B., Bazin, F., Verdoux, H., Dartigues, J. F., Peres, K., . . . Pariente, A. (2012). Benzodiazepine use and risk of dementia: prospective population based study. BMJ, 345, e6231. doi: 10.1136/bmj.e6231

3.Cao, X. L., Wang, S. B., Zhong, B. L., Zhang, L., Ungvari, G. S., Ng, C. H., . . . Xiang, Y. T. (2017). The prevalence of insomnia in the general population in China: A meta-analysis. PLoS One, 12(2), e0170772. doi: 10.1371/journal.pone.0170772

4.de Vries, O. J., Peeters, G., Elders, P., Sonnenberg, C., Muller, M., Deeg, D. J., & Lips, P. (2013). The elimination half-life of benzodiazepines and fall risk: two prospective observational studies. Age Ageing, 42(6), 764-770. doi: 10.1093/ageing/aft089

5.Dormuth, C. R., Miller, T. A., Huang, A., Mamdani, M. M., & Juurlink, D. N. (2012). Effect of a centralized prescription network on inappropriate prescriptions for opioid analgesics and benzodiazepines. CMAJ, 184(16), E852-856. doi: 10.1503/cmaj.120465