利用全民健康保險研究資料庫探討臺灣慢性C型肝炎患者接受抗病毒藥物治療之利用分析

Abstract

目的： 使用全民健康保險研究資料庫分析臺灣地區慢性C型肝炎患者接受抗病毒藥物治療之利用分析，並預估未來治療之疾病負擔。 方法： 從國家衛生研究院之全民健康保險研究資料庫中，篩選於西元2004-2010年間曾經被診斷為慢性C型肝炎感染，且每年至少接受兩次丙胺酸轉胺酵素（Alanine Aminotransferase, ALT）檢測之患者，排除其中年齡小於20歲、性別不明以及合併慢性B型肝炎或慢性D型肝炎感染者，將此定義為研究族群，並探討下列四項研究內容：(1)慢性C型肝炎患者共病症與合併症之分析，並估算盛行率；(2)慢性C型肝炎患者接受抗病毒藥物治療之利用分析；(3)未來慢性C型肝炎患者治療疾病負擔之預估；(4)慢性C型肝炎患者接受抗病毒藥物治療之影響因素分析。 結果： 本研究使用國家衛生研究院之全民健康保險研究資料庫估算，在2004-2010年間診斷為慢性C型肝炎，且年齡大於20歲之患者共計229,407人，其盛行率約為1.28-1.66%。同一期間曾接受干擾素與雷巴威林合併治療共計27,194人，接受治療率約為14.52%，自2009年11月起我國健保改以個人化醫療模式（RGT）來治療C型肝炎患者，在個人化醫療施行後，接受C型肝炎治療的人數有遞增的趨勢，2009年之前平均每年為2919人到2009年之後平均為6301人，主要影響為患者需要接受再次治療的比例明顯降低。 然而，臺灣估計仍有13萬C型肝炎病患尚未接受抗病毒藥物治療，他們大多居住於臺灣西半部。另外，分析結果顯示有較高的機率接受C型肝炎抗病毒藥物治療之患者通常有下列特徵：男性、於肝膽腸胃科追蹤、定期接受超音波追蹤檢查、於南部就醫、帶有肝硬化或肝癌的患者。若是為高齡（≥70歲）、於東部就醫、在區域醫院及地區醫院接受照護、曾接受洗腎、合併感染腦中風或食道靜脈曲張這些特徵之一的患者，其接受C型肝炎抗病毒藥物治療的機率較低。 結論： 因我國目前全民健保納保率達99%以上，使得健保資料成為公共衛生相關領域研究中最具代表性之資料庫，透過分析其內容可作為國家醫藥衛生政策之參考。本研究發現臺灣尚未接受C型肝炎抗病毒藥物治療之患者達13萬人，而這些病患多為女性、高齡（>70歲）、未定期接受超音波追蹤檢查、非肝膽腸胃科追蹤、在區域醫院及地區醫院接受照護、於東部就醫以及曾接受洗腎、合併感染腦中風或食道靜脈曲張者。未接受C型肝炎抗病毒藥物治療患者將因病程惡化而造成更大的社會負擔，因此針對上述特徵病患制定公共衛生政策以提升其就醫警覺性與C型肝炎治療率為本研究可能之貢獻。

Aims： In this thesis, we conducted a retrospective cohort study to explore several important issues regarding chronic hepatitis C (CH-C) infection in Taiwan. Including the utility analyses for CH-C patients receiving the anti-HCV therapy and estimation for disease burden of CH-C. Methods： The cohort study was based on the National Health Insurance Research Database of Taiwan. The enrolled patients chosen from 2004 to 2010 had been diagnosed as CH-C and received at least twice alanine aminotransferase tests per year. The exclusion criteria included patient younger than 20 years or co-infected with chronic hepatitis B or chronic hepatitis D. We aim to (1) explore the comorbidity and complication of CH-C and to estimate the prevalence; (2) perform a utility analysis for CH-C patients receiving the anti-HCV therapy; (3) estimate the disease burden of CH-C and (4) analyze the factors affecting patients not receiving anti-HCV therapy. Results： A total of 229,407 CH-C patients were enrolled in the study and the corresponding prevalence was 1.28-1.66%. Moreover, 27,194 (14.52%) of overall CH-C patients had received pegylated interferon plus ribavirin therapy. The National Health Insurance (NHI) system has adopted response guided therapy (RGT) for CH-C patients since November 2009, and there was an upward trend for the number of patients receiving anti-HCV treatment. This fact implies that the number of patients who needed the second course of treatment decreases. However, we still have ~130,000 CH-C patients who do not receive anti-viral therapy at the time of this writing, and most of them are living in the western part of Taiwan. Further analysis showed that male gender, regular follow-up with abdominal ultrasonography at the gastroenterology department, living in southern part of Taiwan, or has liver cirrhosis or hepatocellular carcinoma were factors positively associated with receiving anti-HCV treatment. On the other hand, those who were older than 70 years, lived in eastern part of Taiwan, followed at district hospital or primary clinics, or had dialysis, cerebrovascular accident or esophageal varices had less inclination to receiving the treatment. Conclusion： Because the National Health Insurance (NHI) program covers 99.9% of Taiwan’s population, this advantage makes the NHI Database being the most representative for public health research in Taiwan. Therefore, a national medical and health policy should be constructed through analyses of NHI Database. On the basis of our data, around 130,000 chronic hepatitis C patients remain untreated. The characteristics included female gender, age above 70 years, without regular examination with abdominal ultrasonography, follow-up at district hospital or primary clinics, living in eastern part of Taiwan, or having dialysis, cerebrovascular accident or esophageal varices. These patients who do not receive anti-viral therapy may experience disease progression and thus increase the disease burden. To solve this emerging problem we should improve patient’s disease awareness and encourage eligible chronic hepatitis C patients to receive anti-viral therapy.