健保限縮骨質疏鬆藥物給付，是否影響醫師開立骨鬆藥?

Abstract

骨質疏鬆症是「一種因為骨骼強度減弱致使個人增加骨折危險性的疾病」，主要發生在老年人，通常沒有明顯症狀，因此常常在已經造成骨折時才被發現，最嚴重的是髖骨骨折，髖骨骨折急性期平均醫療費用約10萬元，骨折後續復健及生活照顧需要大量人力協助，骨折後一年內的死亡率女性為15%，男性為22%。 大型骨質疏鬆藥物的臨床研究都發現，規律服骨質疏鬆藥物可以有效降低骨折發生率，台灣健保局對骨質疏鬆藥物的給付是針對已經發生骨質疏鬆性骨折的病人，給予給付，預防再度骨折，但是2010/10/7之後規定：骨質疏鬆症藥物給付除原先的骨質疏鬆性骨折之外還須經DXA 檢測骨質密度，新規定可能會造成有些因骨質疏鬆症壓迫性骨折使骨質密度高估的患者無法使用骨質疏鬆的藥物。不同的醫師對於新政策可能有不同的因應方式，本研究想要了解健保給付條件改變之後，對醫師處方行為的影響?. 本文使用2010到2011年健保資料庫中年齡介於61至95歲之間，開立骨質疏鬆藥物的門診記錄中有骨質疏鬆相關診斷碼、或是曾經因為骨質疏鬆性骨折住院開刀的人，共有21870人符合條件(包含：16188位女性(74.02%)，5682位男性(25.98%))。使用變異數分析及線性複回歸(multiple linear regression) 分析政策宣布前後，骨鬆藥物處方機率是否有顯著差異，對醫師處方模式是否有影響？ 結果顯示，政策宣布後，每個月處方骨質疏鬆藥物的人次減少12%。政策造成醫療資源過剩及醫療資源不足區開藥的機率下降2%。區域醫院開藥的機率上升2%。骨科、神經外科及復健科開藥的機率分別下降6-8%。資歷<5年、資歷超過26年的醫師開藥的機率分別下降5-8%。 結論是，健保關於骨質疏鬆藥物給付的新規定，確實使每個月處方骨質疏鬆藥物的人次減少。主要影響原本開藥較多的科別，例如：骨科、神經外科及復健科。以及剛取得專科醫師執照資歷<5年的醫師、或是資歷超過26年的醫師。但是對不同層級的醫院以及醫療資源不同的區域，影響較小。

The definition of osteoporosis is a disease where decreased bone strength increases the risk of fracture. It often affects old people and usual lacks of symptoms. People don’t recognize it until they broke their bones. Among all kinds of fracture, hip fracture is the one with most serious consequence. The average medical cost in acute phage after hip fracture is about 100000NTD following with rehabilitation and dependant daily life. The 1 year mortality rate after hip fracture is 15% for female and 22% for male. Clinical trial for osteoporosis medication revealed positive impact on fracture rate reduction. In Taiwan, the National Health Insurance only reimburses medications for osteoporosis to those who had broken their hip or spine to prevent 2nd fracture. On 2010/10/7, there was a new imbursement policy being announced：to claim for the medications for osteoporosis must fulfill the following 2 criteria 1. History of fracture 2. Bone marrow density: T score ≦ -2.5 (with 1 fracture site) or -1~ -2.5 with 2 or more fracture site. This new policy may cause under use of osteoporosis medication because compression fracture of the spine may increase BMD. We are interested in the policy impact on prescription patterns of doctors. Method：The policy impact on prescription patterns of doctors was analyzed using a sample of one million individuals randomly selected from the National Health Insurance Research Database. Subjects who were age 61-95 and had osteoporosis related ICD-9CM code or who had admitted to hospital for osteoporotic fracture surgery during 2009-2011 were analyzed using Analysis of variance and multiple linear regression. RESULTS: We identified 21870 patients who were eligible. Among them, 74.02% (n=16188) were female and 25.98% (n=5682) were male. After the policy was announced, monthly prescriptions of osteoporosis medication was reduced by 12%. Policy related change as follow：In areas where medical resources too many and to little reduced by 2%. Regional hospital increase prescription by 2 %. (1749±2650 versus 2274±3159 US dollars, p<0.0001). Doctors of orthopedics, neurosurgery and rehabilitation division decrease prescriptions by 6-8%. Doctors who got their medical license less than 5 years or more than 26 years decrease prescriptions by 5-8% comparing with those who got their licenses 6-25 years. Conclusion：This policy do reduce monthly prescriptions of osteoporosis medication. Larger impact was observed in those departments where more prescriptions before the policy was announced.(orthopedics, neurosurgery and rehabilitation division). And in those who is too young or too old as a doctor.