以健保資料庫論氣喘的處方型態與費用兼論氣喘急性發作的危險因子

The study of prescribing patterns and cost of asthma via Nation Health Insurance Research Database and risk factors of asthma exacerbation

孫海倫(Hai-Lun Sun)

指導教授 ： 周明智

中山醫學大學/醫學院/醫學研究所/博士(2006年)

https://doi.org/10.6834/CSMU.2006.00009

摘要

自從1993年GINA (Global Initiative For Asthma)依病人的日、夜間症狀、發作頻率、尖峰吐氣流速等。將氣喘分成輕度間歇性、輕度持續性、中度持續性及重度持續性等四級。並依此分級而有不同的用藥。但這所有的用藥中，不外乎有幾大類。口服或吸入劑型的乙型支氣管擴張劑、口服或吸入劑型類固醇、茶鹼、白三烯受體拮抗劑等。本研究是採用健保局2002年1月份到3月份所有申報資料，共有5,474,067次處方箋。陳述性的研究此六大類抗氣喘藥物在有氣喘診斷及在非氣喘診斷下的醫師處方型態。同時探討不同科別的醫師 (兒科、家醫科及其他) ，對氣喘病童的用藥組合。更進一步研究，吸入劑型的氣喘藥物在不同科別醫師的使用情形。
氣喘的醫療費用及資源使用情形，在世界各國都有探討，而且也顯示佔所有病童醫療資源中不小的份量，但台灣目前的資料仍少見，因此我們比較氣喘病童及非氣喘病童在門診、急診及住院費用是否有所不同。
環境中避免接觸過敏原是治療氣喘中除藥物的使用外，最重要的一環，其中空氣污染是空氣中無法避免的過敏原之一，也是讓氣喘急性發作的誘因，因此最後我們探討空氣污染在氣喘急性發作的角色。
研究結果顯示，其中有氣喘診斷的處方共225,535次，非氣喘診斷的處方共5,248,532次。就單次處方僅使用一類抗氣喘藥物中以口服乙型支氣管擴張劑的使用頻率最高，不論是在氣喘診斷組或非氣喘診斷組或是在不同年齡層都是最高(77.6% - 52.6% Vs 84.8 % - 62.8%)。若是二類藥物合併使用則是以口服乙型支氣管擴張劑合併茶鹼或是乙型支氣管擴張劑合併口服類固醇是最常見的組合。至於在GINA準則中強調的控制型的吸入型類固醇則佔3.1~11.0 %。因此在有氣喘診斷及在非氣喘診斷下的醫師處方型態是類似的。
在不同科別醫師對氣喘病童的用藥組合上，在一次的處方簽中，只用一種氣喘用藥，口服乙型支氣管擴張劑在三個科別的醫師都佔最高比例，小兒科醫師佔70.4%，家醫科46.9%，其他科別佔58.0%。其次是茶鹼。一次處方簽有兩種氣喘用藥中，以口服類固醇合用乙型支氣管擴張劑或乙型支氣管擴張劑合用茶鹼是最常被三個不同科別的醫師所處方。但在單一使用吸入型類固醇中，小兒科佔7.8%，家醫科佔5.6%，其他科佔8.0%。而使用吸入型擴張劑，則以家醫科佔最多(14.9%)，其次是其他科別醫師(7.2%)，而小兒科醫師只佔(3.1%)。
對吸入型劑型而言，在16歲以下，2002年1月1日至3月31日，在所有氣喘病童處方簽中，曾用過吸入型支氣管擴張劑，小兒科醫師佔16.2%，家醫科醫師佔12.6%，其他科醫師佔22.7%。而曾經開立吸入型類固醇的處方中，小兒科醫師佔13.9%，家醫科醫師佔6%，其他科醫師佔12.9%。2歲以下的病童在所有年齡層中，最少使用。在小兒科及其他科醫師，使用越多種氣喘用藥，越容易開立吸入型劑型，而家醫科醫師較常使用吸入型支氣管擴張劑，較少使用吸入型類固醇。
至於氣喘的費用，我們共評估33,461位3-17歲病童，在2002年1月1日至12月31日期間的就診情形。當年的氣喘發生率為6.0%，在所有急、門診及住院的就診平均次數，氣喘病童都比非氣喘病童為高。氣喘病童在醫院中門診及其所有費用，是非氣喘病童的2.2倍。在所有氣喘病童的花費中，真正因氣喘求診的費用佔20%，其餘80%費用則非因氣喘求診。在因氣喘求診中，門診(診所及醫院)的費用佔3/4，急診及住院則佔1/4。
在空氣污染與氣喘的急性發作而言，我們測量二氧化硫、二氧化氮、臭氧、一氧化硫及微塵浮粒等五種污染物，其中，二氧化氮、一氧化硫及微塵浮粒與氣喘病童的急性發作有顯著正相關，在大人空氣污染與氣喘的急性發作則僅呈現正相關，並沒有統計學上的意義。

關鍵字

健保資料庫 ； 氣喘 ； 處方型態 ； 費用 ； 空氣污染

並列摘要

Guidelines from the Global Initiative for Asthma (GINA) mention several medications for the treatment of asthma. These medications include oral and inhaled beta-2 agonists, oral and inhaled corticosteroids, xanthines, leukotriene receptor antagonists, and their combinations. In addition to asthma, these drugs are commonly prescribed to treat other respiratory diseases, such as acute bronchitis, chronic cough, lower respiratory infection, or even bronchopneumonia. We analyzed differences in prescribing patterns between pediatric patients with and those without asthma, as coded in the claim records from the National Health Insurance Research Database. In addition, we analyzed the prescribing patterns of anti-asthma drugs by pediatricians, family physicians and other practitioners in asthmatic patients. Furthermore, we also analyzed between-group differences in the prescribing patterns of anti-asthma drugs, focusing on inhaled therapy as administered by pediatricians, family physicians and other practitioners.
In many countries, the burden of asthma is sufficient to warrant its recognition as a high-priority disorder in governmental health strategies. Cost is another major economic impact on asthma. So health-care utilization and costs, including those related to office, outpatient hospital, emergency department, and inpatient hospital visits were compared between pediatric patients with and those without asthma.
To improve the control of asthma and reduce medication needs, patients should avoid exposure to risk factors (allergens and irritants that make asthma worse). Air pollution is one of the common risk factor of asthma. The last purpose of this study was to evaluate the relationship between air pollution and asthma exacerbation in children and adults.
For prescribing patterns in asthma and non-asthma patients group, oral beta-2 agonists were the most frequently monotherapy in both groups of patients (52.6-77.6% vs 62.8-84.8%). Oral beta-2 agonists combined with xanthines or oral corticosteroids combined with an oral beta-2 agonist were the most frequent combination therapies in both groups. Inhaled corticosteroids were used in 3.1-11.0% of patients with asthma; the rate varied by patient age. In conclusion, prescribing patterns were similar in pediatric patients with and those without asthma.
For prescribing patterns by general pediatricians, family physicians and physicians in different disciplines groups, data for a total of 225,537 anti-asthma prescriptions were collected from the National Health Insurance Research Database for the period from January 1, 2002 to March 31, 2002. Oral beta 2-agonist was the most commonly prescribed drug used as monotherapy, with prescription rates of 70.4%, 46.9% and 58.0% by pediatricians, family physicians and other physicians respectively. A xanthine derivative was the next most commonly prescribed monotherapy. Oral corticosteroids combined with oral beta 2-agonist followed by oral beta 2-agonist combined with a xanthine derivative were the two most commonly prescribed dual agent combined therapies by all three categories of physicians. The prescription rate for inhaled corticosteroid monotherapy was 7.8% by pediatricians, 5.6% by family physicians and 8.0% by other care providers. The prescription rate for inhaled adrenergic was the highest in family physicians (14.9%), followed by the other care providers (7.2%) and was lowest in pediatricians (3.1%).
In summary, pediatricians and family physicians appeared to share similar opinions about the medical management of children with asthma, in that both most commonly prescribed oral beta 2-agonists and xanthine derivatives, either alone or in combined therapy. Family physicians were least like to prescribe inhaled corticosteroid and most likely to prescribe inhaled adrenergic agent.
Focusing on inhaled therapy as administered by pediatricians, family physicians and other physicians, the study consisted of all prescriptions for outpatients under 16 years of age from 1 January 2002 to 31 March 2002. Medications were grouped into two categories: inhaled bronchodilators, and inhaled corticosteroids. Inhaled bronchodilators were prescribed by 16.2% of pediatricians, 12.6% of family physicians and 22.7% of other physicians, with rates for inhaled corticosteroids of 13.9%, 6% and 12.9%, respectively. The prescribing frequency for inhaled therapy was lowest for patients under 2 years of age for all provider subgroups. In pediatrician and other physician subgroups, the more anti-asthma medications were prescribed, the more frequently inhaled medications were prescribed. Such trend was not observed in family physician subgroup. In conclusion, our cross-sectional retrospective descriptive study of asthma care provided by Taiwanese medical professionals showed that the family physicians prescribed inhaled bronchodilators and corticosteroids less frequently than pediatricians and other physicians. The lowest prescription rate for inhaled medication was for the subgroup of patients under 2 years of age, irrespective of professional category. Family physicians tended to prescribe inhaled therapy without combining other anti-asthma medications regardless of age subgroup.
For health utilization and cost, we evaluated 33,461 patients aged 3–17 years who were enrolled in the National Health Insurance Research database from January 1 to December 31, 2002. The period prevalence of treated asthma was 6.0%. Pediatric patients with asthma used substantially more services than did those without asthma in all categories. Hospital outpatient visits and overall health-care expenditures for patients with asthma were 2.2-fold higher than those of patients without asthma. Asthma care represented 20% of all health-care services that patients with asthma received, while the remaining 80% were for nonasthma care. Almost three-fourths of all asthma-related costs were attributable to office and hospital outpatient visits; one-fourth was attributable to urgent care and hospitalizations. These findings may serve as baseline data for future evaluations of changes in health care utilization and expenditures among pediatric patients with asthma.
The last purpose of this study was to evaluate the relationship between air pollution and asthma exacerbation in children and adults. Pearson’s analysis was used to establish correlations between air pollutants –SO2, NO2, ozone, CO, and PM10 –and emergency department visits for asthma in 2004. Among children, there were significant positive correlations between NO2 (r = 0.72), CO (r = 0.65) and PM10 (r = 0.63) and emergency department visits for asthma. Among adults, only weakly positive, non-significant correlations between all air pollution measures and emergency department visits for asthma were found. This study suggests that air pollution plays a role in acute exacerbation of asthma in children, but not in adults.

並列關鍵字

claim database ； asthma ； prescribing patterns ； cost ； air pollution

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