台灣高血壓患者併用中西藥的就醫型態分析： 全民健保資料庫2002~2007

Abstract

背景： 高血壓是心血管疾病重要的危險因子，根據衛生署公布台灣地區民國九十八年國人十大死亡主要原因統計資料結果顯示，與高血壓有關的心臟疾病、腦血管疾病、糖尿病、腎臟病變等疾病分別高居死因排行榜第二、三、五及十位。國民健康保險局進行「高血壓、高血糖、高血脂盛行率調查」結果發現15 歲以上高血壓盛行率是21.5 %，40 歲以上超過35%，60 歲以上更高達60%，可見高血壓對國人健康所造成的威脅與影響。雖然西方醫學科技進步，世界每年仍有30％以上的人口尋求輔助替代醫療，在華人的社會主要的輔助替代醫療是傳統中醫藥，而台灣中西醫醫療為雙軌並行，民眾極可能在非西醫師醫囑之情況下，同時使用中藥與西藥治療疾病。因此，除了可能的療效增加之外，中西藥合併使用引發的用藥安全也已引起醫藥界的重視。 目的： 本研究希望透過全民健保資料庫分析，達到以下研究目的： 1.了解健保高血壓患者使用西醫、中醫與中西醫併用的病患族群、醫師群族以及醫療機構屬性。 2.提供醫療機構面對同時併用中西醫的顧客族群，該有的決策考量。 3.提供政府醫療行政部門，對於未來若是要開放中西醫同時給付的專案或行政措施依據。 方法： 本研究採次級資料分析，資料來源為「全民健康保險學術研究資料庫」之承保抽樣歸人檔，以2005 年承保資料檔中「2005 年在保者」隨機抽取100萬人為分析資料對象，本研究擷取2002 至2007 年健保申報資料庫分析；將ICD-9-CM 前3 碼為401 至405 及A-code 為A26 之高血壓門診個案為研究對象；依描述性分析了解高血壓患者採用西醫、中醫與中西醫併用治療的族群屬性、醫師屬性與醫療機構特性；再依統計性分析了解高血壓患者對於西醫、中醫與中西醫併用的醫療利用情況分析。 結果： 病患人數隨著年齡的增加而增加，年齡低時男性多於女性，但是隨著年齡增加，女性則多於男性；高血壓患者曾使用中醫治療高血壓的人口比例約為2.8％；但是高血壓以西醫治療的患者，因不限高血壓疾病，尋求中醫治療的人口比例卻高達28.9％。另外，隨著高血壓患者年齡的降低，採用西醫治療高血壓(比不採用西醫治療高血壓)的機率是降低的，但是利用中醫治療高血壓(比不採用中醫治療高血壓)的機率卻是相對增加的。 在醫療機構特性方面，基層院所、私立醫院與高都市化的醫療機構，利用中醫治療高血壓（比不採用中醫治療高血壓）的機率是較其他特性類別為高。 此外，當患者併用中西醫治療時，若是因為高血壓疾病尋求中西藥合併治療者，則選擇中醫與西醫的醫療服務是在同一醫療院所的利用機率是高於不在同一醫療院所內(OR=0.26； 95％ C.I.：0.240-0.281； p<0.001)。由於在同一醫療院所，醫師較易掌握患者所併用的中藥或西藥，所以對於病人的用藥安全考量是有正面的意義。 結論： 本研究結果將有助於了解我國高血壓患者併用中西藥的就醫型態，雖然高血壓治療仍是以西醫為主，但是患者往往會合併中醫治療其他疾患。當中西藥併用時，除了療效有可能增加之外，但是隨之衍生的中西藥合併使用所引發的本草藥物交互作用風險也相對提升。所以當醫療院所可以同時提供中醫與西醫的醫療服務，對於高血壓患者欲利用中西醫治療高血壓或是其他合併病症時，可以提供病患較完整的服務，是有其競爭優勢。而對於政府醫療行政部門，基於病人安全的因素，未來若是要開放中西醫同時給付的專案計畫或是行政措施，應以同時可提供中醫與西醫醫療服務或是中西醫病歷可以匯通的醫療機構為優先考量。

Background: Hypertension is an important risk factor of cardiovascular disease. Heart diseases, cerebrovascular diseases, diabetes and nephritis/nephrotic syndrome/nephrosis, ranked 2nd, 3rd, 5th and 10th leading causes of deaths in Taiwan, are related to hypertension as stated in the report from Department of Health, Executive Yuan, R.O.C. in 2009 in Taiwan. The hypertension prevalence rate in our population in 2002 was 21.5% in those aged 15 years and elder, 35% in those aged over 40, or 60% with age ≧ 60. Although western medicine is the mainstream in the world, it is estimated that complementary and alternative medicines are still used by more than 30 % of people all over the world. Chinese medicine is the main therapy of complementary and alternative medicine in Chinese society. When combining with western medicine and Chinese medicine, it not only can enhance the effect of western medicine, but also can increase the risk of herb-drug interaction. Objective： In view of the preceding background, three aims of this research will be investigated: 1. To explore the characteristics of patients and physicians during utilization of western medicine, Chinese medicine and combination of two for hypertension control. 2. To understand the the characteristics of medical institutions during utilization of western medicine, Chinese medicine and combination of two for hypertension control. 3. To analyze the odds ratio of utilitation patterns among the patients, physicians and institutions’ characteristics. Method: Using the database of National Health Research Institutes, we analysised 2002-2007 Longitudinal Health Insurance Database 2005 (LHID2005) which contains all the original claim data of 1,000,000 beneficiaries, randomly sampled from the year 2005 Registry for Beneficiaries (ID) of the National Health Insurance Research Database (NHIRD). The study subjects will be identified using the first three digit ICD-9 codes as 401-405, and A26 (A-code) during 2002 to 2007. Utilization patterns are characterized by four features including: western medicine only, Chinese medicine only, combination of western and Chinese medicine for hypertension, and western medicine for hypertension combining with Chinese medicine for any conditions. Result： The proportion of utilization pattern of Chinese medicine is about 2.8%, but the proportion of western medicine for hypertension combining with Chinese medicine for any conditions increased to 28.9%. The younger group of patients is, the more odds ratio of utilization of Chinese medicine is. The odds ratio of utilization of Chinese medicine is higher in medical institutions’ characteristics of local medical department, private institute and higher urbanization level. Beside, the odds ratio of the same medical institution is higher in the group of combining with western medicine and Chinese medicine for hypertension than the group of western medicine for hypertension combining with Chinese medicine not for hypertension. Conclusion: The major therapy for hypertension is still western medicine, but the majority of Chinese medicine is used for treating or preventing other conditions. Maybe it can improve the efficiency of hypertension control when combining western medicine and Chinese medicine, but the risk of herb-drug interaction is increasing. So there is competitive advantage when medical institute can provide both of western medicine and Chinese medicine at the same time.