健保放寬降血脂藥物給付範圍對心血管疾病發生率及費用之影響

Abstract

背景：近年來心血管疾病在各國造成龐大的疾病負擔，其中一個重要的危險因子即為高血脂，迄今已有許多臨床證據顯示降血脂藥物對於疾病初級及次級預防的效益，而國際相關準則也更正治療指引。台灣於2013年8月1日正式修正降血脂藥物的給付規定，放寬對於高危險族群，心血管病史或糖尿病患者的藥物給付的治療血脂起始值。然而，目前國內外尚未有研究針對降血脂藥物的放寬給付政策對健康結果及花費效益之影響做評估。

目的：本研究主要探討台灣於2013年更改給付規定後，對於影響族群糖尿病患者之降血脂藥物的開立、降血脂藥物延伸對於疾病的發生率、醫療花費之影響。

方法：使用全民健康保險全人口資料庫進行分析，選取2010年無心血管疾病史的糖尿病患者作為政策介入組，無心血管疾病史、無糖尿病史的高血壓患者為政策對照組。以2010年8月1日為追蹤起始時間，追蹤至2016年7月31日。採用差異中的差異法，分析政策實施前後，介入組與對照組的降血脂藥物開立趨勢、心血管疾病的發生率、降血脂藥費差異、心血管疾病醫療費用差異。

結果：研究發現在政策實施後，介入及對照組的降血脂藥物開立人數皆上升，介入組上升較為明顯，且差異達統計上顯著，因此政策影響介入組較大。心血管疾病發生率部分，發現介入組的缺血性腦中風發生率於政策實施後第三年趨緩，疾病花費也有趨緩，但未達統計上顯著差異，而藥費相對於對照組則是沒有上升太多，未達統計上顯著差異。

結論：2013年的放寬給付政策讓高風險族群之一的糖尿病患者的開藥人數上升，相對於對照組，藥費沒有明顯的上升，而心血管疾病中的缺血性腦中風發生率及花費漸趨緩但未達統計上顯著差異，建議相關單位再做更長的觀察評估。

Background：Recently, cardiovascular diseases (CVD) has been causing heavier disease burdens globally. Dyslipidemia is one crucial risk factor, and many clinical studies have proven the primary and secondary CVD prevention benefits of hypolipidemic drugs. Furthermore, the international guideline was changed to provide new advice for medication. On 2013 August 1st, 2013, Taiwan National Health Insurance (NHI) expanded the hypolipidemic drugs reimbursement criteria for high-risk patients, including patients with CVD history or diabetes. However, few studies have explored the impact and the benefits of expansion drug policy.

Objective：This study aims to evaluate the impact of expanding the hypolipidemic drugs reimbursement criteria on medication usage, CVDs incidence, and the health care expenditure for diabetic patients.

Methods：We considered the diabetic patients without CVD history as the intervention group, and the hypertensive patients without CVD and diabetes as the control group. Using August 1, 2013, as the transition point between the pre- and post-policy periods, we performed a difference-in-differences analysis to estimate the effect of hypolipidemic drugs reimbursement criteria expansion. Outcomes included patient numbers under medication, CVDs incidence, and the health care expenditure. The data was extracted from Applied Health Research Data Integration Service from National Health Insurance Administration.

Results：After the expansion, patient numbers under medication in the intervention group significantly increased compared to the control group. The rate of increase for the incidence and health care cost of ischaemic stroke slowed after three years of policy implementation, albeit with only marginal significance. The medication expenditure of intervention group did not show any significant increase compared with the control group.

Conclusion：The expanded coverage of hypolipidemic drugs significantly increased the number of medications for diabetic patients, but did not increase medication expenditure. The CVDs outcomes, restricted to ischaemic stroke, showed marginally significant decrease in incidence. The policy may have changed high-risk patients’ medication behaviors. However, more data and analysis are needed to evaluate the CVDs outcomes.