台灣新發粥狀動脈硬化心血管病人statin使用分析及相關影響因子探討

黃詩婷

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台灣新發粥狀動脈硬化心血管病人statin使用分析及相關影響因子探討

Utilization pattern of statin among patients with newly onset atherosclerotic cardiovascular disease in Taiwan

黃詩婷 , Masters　　Advisor：賴美淑　　

繁體中文

粥狀動脈硬化心血管疾病；他汀類藥物；藥品使用；遵囑性；持續性；危險因子； ASCVD ； statin ； utilization ； adherence ； persistence ； risk factors

Abstract │ Reference (76) │ Altmetrics

Abstract 〈TOP〉

背景：
心血管疾病造成社會極大負擔，高血脂為其最主要危險因子。直至今日，利用statin藥品降血脂已有諸多臨床證據支持，且2013年ACC/AHA 準則建議在已發生心血管疾病的病人，應維持長期而有效的statin使用。然而，台灣新發心血管疾病族群中statin藥品的處方情況與遵囑性、持續性及其相關因子都仍未有相關證據。
目的：
本論文主要探討台灣新發粥狀動脈硬化心血管疾病族群statin藥品使用狀況及處方遵囑性、持續性隨時間變化情形，同時進一步分析影響處方遵囑性、持續性之相關因子。
材料與方法：
本論文以全民健康保險資料申報檔進行分析，選取2006到2012年新發粥狀動脈硬化心血管疾病且出院後90天內門診使用statin之病患做為研究族群，利用描述性分析statin藥品處方比例之年度趨勢，以及處方statin藥品後病人遵囑性、持續性隨時間改變情形，遵囑性以藥品覆蓋率及藥品持有率來定義、持續性以連續有處方天數不超過90天來定義。並利用廣義線性混合模型及cox proportional hazard model分別分析影響藥品遵囑性、持續性之相關因子。
結果：
第一部份、新發粥狀動脈硬化心血管疾病個案statin藥品使用分析
    在2006年至2012年新發粥狀動脈硬化心血管疾病且出院後90天內門診使用statin個案，共189,545人次(173,235人)，其中，年度別開方statin百分比自30%上升到43%。在statin種類的選擇上，以high potency的atorvastatin及rosuvastatin占大宗，從71%上升到83%；以處方劑量來看，雖然高劑量的statin藥品有逐年增加趨勢，但主要以處方中低劑量藥品為主，占總用藥的九成以上。
第二部份、statin藥品遵囑性、持續性及相關影響因子
    排除在門診初次處方statin前即再次發生粥狀動脈硬化心血管疾病病人後，共185,252人次(169,624人)。藥品遵囑性部份，總追蹤七年共十五段180天，追蹤人次從185,252下降至398人次，覆蓋率及持有率皆在處方一年內下降最快。藥品持續性部份，在開始用藥一年、兩年、三年後分別有三成、五成、六成病人發生用藥不持續，追蹤七年後剩下三成病人持續使用statin。
    進一步分析藥品遵囑性及藥品持續性的危險因子，跟藥品遵囑性相關的重要危險因子包括：年齡超過75歲、腎臟疾病、憂鬱症等病史、曾使用digitalis或胰島素等；保護因子包括：診斷為急性心肌梗塞 (有做CABG/PTCA處置)或穩定冠心症且接受CABG/PTCA處置、住院期間或住院前一年曾使用statin、高血脂病史、曾使用β-blocker, ARBs, antiplatelet、出院第一筆處方statin屬high potency、開方statin的醫療機構層級別高、處方科別為心臟科及內分泌科、處方年代較近等。
    和藥品持續性相關的危險因子與保護因子和遵囑性類似，但在危險因子部份住院期間曾做血脂檢查、曾使用CCBs或口服降血糖藥、有失智症病史之病患較易不持續用藥，保護因子部份曾使用anticoagulants較易持續用藥。
結論：
    雖然statin藥品在新發粥狀動脈硬化心血管疾病病人的使用近幾年有增加趨勢，但在處方比例上仍低，且病人使用statin藥品的遵囑性、持續性在用藥初期下降最快。建議未來可在用藥初期針對statin藥品的遵囑性、持續性高危險族群做介入，並評估相關措施的效益。

Parallel Abstract 〈TOP〉

Background：
Cardiovascular disease has caused great health burden, hyperlipidemia is the main risk factor. Clinical trials had demonstrated statin as the leading lipid-lowering drugs; moreover, ACC/AHA guideline also suggested long and effective statin use on known atherosclerotic cardiovascular disease (ASCVD) patients. However, statin prescription, utilization pattern, and risk factors associated with suboptimal utilization on newly onset ASCVD patients were unknown. 
Objective：
To identify statin utilization pattern and time trend in patients with newly onset ASCVD in Taiwan and to explore factors associated with statin adherence and persistence.
Material & Method：
Patients with newly onset ASCVD covering the period between 2006 and 2012 who had prescribed statin at the outpatient department within 90 days after discharged are our target population. We analyzed the statin prescription, patient adherence, and patient persistence pattern. Adherence pattern was defined by proportion of days covered (PDC) and medication possession ratio (MPR); Persistence was defined as the final day of the last prescription filled prior to a gap in therapy of 90 days. Generalized estimating equation and cox proportional hazard model were used separately to establish potential risk factors to suboptimal statin adherence and persistence.
Result：
Part 1. Statin utilization analysis among newly onset ASCVD patients
    A total of 189,545 newly onset ASCVD episodes (173,235 person) were identified. Prescription rate of statin increased from 30% to 43%. Atorvastatin and rosuvastatin were prescribed most frequently. Although the prescription rate of high dose statins increased, moderate to low dose were used most frequently, accounting for over 90% of all prescriptions.
Part 2. Statin adherence, persistence, and the associated factors
    We excluded those who had a second ASCVD event prior to the first statin prescription at the outpatient department after discharged, and ended up with 185,252 episodes (169,624 person). We followed these patients for seven years (segmented into fifteen 180-days intervals), and the follow-up episodes decreased from 185,252 to 398. Median PDC and MPR had decreased sharply within the first year of prescription. Regarding to the persistence, there were 30%, 50%, and 60% of patients turned out to be non-persistence after one, two and three year of statin use, and only 30% of patients remain persistence for the total seven years of follow up.
    Furthermore, we analyzed risk factors to suboptimal statin adherence and persistence. Main risk factors associated with suboptimal statin adherence including: age over 75 years old, history of renal disease, depression, medication history of digitalis or insulin; Protective factors including: diagnosis of acute myocardial infarction (with CABG/PTCA) or stable coronary artery disease receiving revascularization, statin use during or one year before ASCVD hospitalization, history of hyperlipidemia, medication history of β-blocker, ARBs, antiplatelet, high potency of the first statin prescription, higher level healthcare organization, prescription speciality of cardiology and endocrinology, more recent year of prescription.
    Factors associated with suboptimal statin persistence were almost the same as with suboptimal adherence. However, Patients with lipid examination during ASCVD hospitalization, medication history of CCBs or oral anti-diabetic drugs, and history of dementia were more likely to discontinue statin therapy, while those with anticoagulants history were more likely to be persistent.
Conclusion：
Although the prescription of statin agents on newly onset ASCVD population increased, the percentage of patients being treated remains low. Adherence and persistence to statin declined sharply within the first year of treatment. We suggest there should be some early interventions on high risk population as well as to evaluate the effect of such interventions in future study.

Reference ( 76 ) 〈TOP〉

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