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標題: | 部分給付下varenicline與尼古丁貼片之比較效果 Comparative effectiveness of varenicline and nicotine patch reimbursed partially in health service |
作者: | Chih-Kuan Lai 賴志冠 |
指導教授: | 戴政 |
關鍵字: | 戒菸治療,戒必適,尼古丁貼片,尼古丁取代治療,比較效果,給付, smoking cessation,varenicline,nicotine patch,nicotine replacement therapy,comparative effectiveness,reimbursement, |
出版年 : | 2010 |
學位: | 碩士 |
摘要: | 背景:門診戒菸治療服務計畫自91年實施以來,為鼓勵並協助有意戒菸者接受治療,以部分給付模式提供各種不同戒菸藥物每週定額之費用補助,戒必適(varenicline)為近年新上市之戒菸輔助藥物,在隨機對照試驗中,其長期戒菸治療成功率優於既有藥物,但在現有國內給付制度下,實際推廣於臨床例行使用後之效果尚不清楚。
目的:(一)在現在部份給付(負擔)模式下,探討兩種不同戒菸輔助藥物—戒必適與克菸貼片之比較效果;(二) 在平常的臨床情境使用下,戒必適是否仍維持臨床試驗中較克菸貼片更佳之戒菸治療效果;(三) 探討任何可能的影響此兩種藥物在實際臨床情境治療成果之因素? 材料與方法:門診戒菸治療服務計畫中,自95年四月至98年十一月接受服務治療之個案,選取年齡介於20-70歲、接受戒必適或克菸貼片治療者,且其六個月後之抽樣電訪結果為合格者,合乎條件之個案戒必適組有1,117名、克菸貼片組1,211名。以開始接受治療後六個月之七日點戒菸成功率為主要結果指標,個案接受藥物處方週數為次要結果指標。 統計分析:以羅吉斯回歸進行模式進行相關因素分析。 結果:本研究六個月後之戒菸治療成功率主要受到所使用之藥物種類及其處方時間所影響,使用戒必適治療者之戒菸成功率相較於使用克菸貼片,其OR為1.48 (1.20–1.81),接受藥物處方≧4週者之戒菸成功率亦明顯高過處方<4週者甚多,其OR為2.18 (1.72–2.75),而接受服務個案之年齡較長者可略提高其戒菸成功率,年齡每增加一歲其OR為1.011 (1.002-1.020);有同住家人吸菸和尼古丁成癮度較高者,會降低戒菸成功率,其OR為分別為0.71 (0.56–0.88)與0.87(0.83–0.91)。目前門診戒菸治療服務計畫中,個案接受處方之時間戒必適為3.16±2.25週,高於克菸貼片之2.39±1.97週,兩者間具有顯著之差異 (P <0.0001),但皆遠低於臨床指引建議之標準。 討論與建議:在國內現行給付制度下,接受同等治療期間(開立處方藥物<4週或≧4週)之個案,使用戒必適之戒菸效果超出克菸貼片,其六個月後戒菸成功率之OR達1.48 (1.20–1.81),增加程度接近隨機對照試驗之結果,且使用戒必適者通常會持續接受更多週數之藥物處方,使其戒菸治療獲得加成效果。目前接受戒菸治療者普遍過早停止使用輔助藥物,而影響治療效果,在部分給付制度下,戒必適相對較為昂貴,其普及率與處方率偏低,戒菸治療服務計畫如能設法提高戒必適之使用率,應能有效提供戒菸治療成功率。 Background: National Smoking Cessation Service (NSCS), implemented since 2002, encourages and promotes motivated smokers to participate anti-smoking treatment by partially reimbursing related pharmacotherapy. Varenicline is a novel, recently launched adjuvant for treating tobacco dependence. Its long term cessation rate is superior to traditional treatment in randomized controlled trials (RCTs). However, whether its efficacy can be translated into daily practice with a partial coverage of drug expense remains unclear. Aim: The aim of this study is three folds: (1) To investigate the comparative effectiveness of varenicline and nicotine patch in a health care system with partial coverage; (2) To determine whether varenicline still maintain a better effectiveness than nicotine patch as it does in RCTs; (3) To identify any possible factors that influence or lead to the difference of the treatment outcome between varenicline and nicotine patch? Material and method: Eligible participants are: (1) aged 20 to 70 years; (2) those who received varenicline or nicotine patch (Nicotinell) between Apr 2006 and Nov 2009 in NSCS; and (3) qualified for the telephone follow-up made 6 months after their first visit of smoking cessation service. We recruited 1,117 participants in varenicline group and 1,211 in nicotine patch group. The primary outcome of analysis is 7-day point prevalent abstinence (PPA) at 6months. The secondary outcome is the duration of prescribed pharmacotherapy (in weeks). Statistic analysis: Logistic regression is used for association analysis to find the related factors. Result: The success of cessation at 6 months after initiating treatment is mainly determined by the type of pharmacotherapy and its duration of prescription in our study. The ORs are 1.48 (95% CI: 1.20–1.81) for varenicline group vs. Nicotinell patch group and 2.18 (95% CI: 1.72–2.75) for those with at least 4 weeks of prescribed pharmacotherapy vs. those less than 4 weeks. Older age is a modest but positive factor to enhance successful cessation. There are two negative factors to curb cessation attempt: smoker in the household (OR=0.71, 95% CI: 0.56–0.88) and higher FTND (Fagerstrom Tolerance of Nicotine Dependence) score (OR=0.87, 95% CI: 0.83–0.91). The durations of prescription are only 3.16±2.25 weeks and 2.39±1.97 weeks in varenicline and Nicotinell group respectively. Both are far below than guideline recommendation. Discussion and Suggestion: Varenicline is more effective in treating tobacco use as compared with Nicotinell patch no matter the duration of prescription is at least or less than 4 weeks in routine daily practice. The findings of this comparative effectiveness research are similar to those identified in previous RCTs. In addition, the participants who receive varenicline also tend to be more compliant than those treated with Nicotinell patch. The better compliance of varenicline will synergistically exaggerate its treatment effect. Under-treatment is a common problem in NSCS. Most participants terminate adjuvant therapy prematurely. Varenicline with partial coverage is relatively expensive and infrequently prescribed in NSCS. A new strategy to encourage the distribution and prescription of varenicline is imperative to improve the cessation rate of NSCS. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/23338 |
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