台灣住院處方優化與其影響因素之初探

Abstract

研究背景與目的 近年來，隨著多重慢性疾病患者增加，罹患慢性疾病患者時常需就診於多位專科醫師並接受多種藥物治療，時常衍伸出多重用藥的問題。在台灣全民健保制度下，民眾享有高度就醫自由，沒有特定的專業醫事人員協助藥物整合。除了病患自身求醫行為，健保支付制度也產生誘因使醫師開立處方，導致有過度處方的可能性。為了解決多重用藥的問題，國際上提出透過處方優化改善病患用藥情形，尤其是藉由住院的機會進行處方優化能有效減少不必要的用藥，然而，台灣目前尚缺少處方優化相關研究，亟待研究投入。因此，本研究目的為檢測住院是否有處方優化之功能；及檢視住院期間有被處方優化者，其影響因素。 研究方法 本研究使用全民健康保險資料庫兩百萬歸人抽樣檔，以2017-2018年住院病患作為研究對象，檢測住院是否有處方優化的功能，當出院後30日平均每日用藥種類數少於入院前30日的用藥種類數，代表有處方優化。以羅吉斯迴歸分析入院前的用藥種類數、就診醫師數與就診醫療院所數對是否處方優化之影響，最後以是否有多重慢性病和年齡進行分層分析，探討被處方優化的影響因素。 研究結果 本研究對象共178,562人，住院期間被處方優化的比例為48.32%，有被處方優化的患者平均減少2.27種藥品。在多變項迴歸中，相較於沒有多重用藥者，多重用藥者被處方優化的機率較高 (OR值: 3.92)；入院前就診醫師數和就診醫療院所數越多，處方優化的機率越高，相較於就診於0-1位醫師，就診於2-3位與4位以上的OR值分別為1.71和2.26；入院前就診醫療院所數為1-2間和3間以上，相較於0間，OR值分別為3.95和4.97，且皆達到統計上顯著差異 (p <.0001)。 研究結論 本研究結果發現住院處方優化的比例為48.32%，整體研究對象平均減少0.30種用藥，沒有明確顯示台灣住院有處方優化的功能，而入院前有多重用藥、就診醫師數和就診醫療院所數越多，被處方優化的機率較高。為了改善用藥相關問題，需針對多重用藥者提供整體用藥評估，並改善健保支付制度中的經濟誘因，建議可強化醫師檢視雲端資訊的誘因以增進照護協調性，進而減少非必要藥品的使用。

Background As the population ages and the occurrence of multiple chronic conditions (MCC) increases, so does the use of multiple medications to manage treatment regimens, which derives the issue of polypharmacy. In Taiwan, the absence of a primary care system and referral requirements allows patients to select physicians based on their preferences, leading to excessive of outpatient visits. Beyond patients’ behaviors, the fee-for-service system and global budget payments create a strong incentive for healthcare providers to boost profits by increasing the prescription of medications. These aspects of Taiwan's health insurance system raise concerns about over-prescription and its associated consequences. To address the problem of polypharmacy, previous studies state that deprescribing can effectively manage polypharmacy and improve health outcomes, especially conducting deprescribing in hospitalization. However, little is known about the extent of in-hospital deprescribing in Taiwan and its associated factors. Therefore, this study aims to fill the knowledge gap by exploring whether hospitalization presents an opportunity for deprescribing and investigating the relationship between the number of medications, care coordination, and deprescribing. Methods This study used the National Health Insurance Research Database in Taiwan and identified subjects had been hospitalized with complete inpatient records during 2017-2018. Deprescribing was defined as having a lower average daily number of medications in the 30 days post-discharge compared to the pre-admission period. Logistic regression was used to examine the association between polypharmacy, care of coordination and deprescribing. In addition, this study conducted subgroup analysis to explore deprescribing associated factors: one based on age stratification, and the other based on the number of chronic conditions. Results The rate of deprescribing is 48.32% with an average withdrawal or decrease of 2.27 medications during hospitalization. This study indicated that using more medication (OR: 3.92), visiting more physicians (OR: 1.71/2.26) and hospitals (OR: 3.95/4.97) before admission have higher probability of deprescribing. Conclusion Having greater number of medications and healthcare provider visits are associated with higher probability of deprescribing. Reducing economic incentive for prescription and initiating medication reconciliation for polypharmacy patients may result in reducing unnecessary and non-benefit medications.