計畫編號： DOH94-NH-1001

計畫名稱：糖尿病相關研究 -3年計畫(第1年)

執行機構：台灣醫學會

研究人員：賴教授美淑

執行期間： 94年05月01日至97年04月30日

中文摘要

一般臨床效果(clinical effectiveness)受很多因素影響，其中以使用藥物為重要因素之一。本研究的目的，是由健保申報資料庫產生的糖尿病追蹤族群、建立藥物利用的指標，探討其與藥物管理(pharmacological management)的相關性。主要研究內容為：1.藥物使用型態(drug utilization pattern’s)，分析目前常用的口服藥物有磺醯尿素(Sulfonylurea)、雙胍類(Metformin)、α-葡萄糖??抑制劑(α-glucosidase inhibitor)…等，多種口服降血糖藥物的使用型態。並探討初次使用口服降血糖藥物的順適性(Adherence)、持續性(Persistence)、斷藥( Discontinuation)…等，多種指標。並就影響順適性的因子與藥費分析，探討醫療照護品質之關係做回顧性分析。2. 針對台灣糖尿病人世代中，使用降血壓用藥、降血脂用藥，及降血糖用藥，三種用藥組合使用型態，以及進一步對糖尿病世代併有腎臟病變的病人，降血壓用藥組合是否符合實證醫學的建議？ 3.以預防保健觀點，探討使用阿斯匹靈預防性用藥（aspirin chemoprophylaxis）分析及其影響因子分析。本研究資料庫是源自於校正後之台灣糖尿病病人實證追蹤的研究族群，以89年糖尿病世代追蹤族群資料檔640,173人為資料來源，與世界衛生組織藥物資料ATC_DDD。藥物代碼ATC_7 Code與我國健保醫令檔案之藥物代碼drug_no作聯結，進行89年糖尿病世代追蹤族群用藥分析及90年糖尿病世代追蹤族群用藥分析以及90年西醫門診初次使用口服降血糖族群之藥物分析。 糖尿病用藥指標之定義有:順適性（Adherence）；持續性（Persistence）；停藥（Discontinuation）等。aspirin用藥定義以台灣目前上市低劑量（81-165 mg）的aspirin共取57種，來分析病人有無使用aspirin(包括低劑量的aspirin35種，Ticlopidine 21種與Clopidogrel 1種)。只要90年度有一次開藥的紀錄，並大於30天的藥量，就認定病人有使用aspirin類的藥物。年齡>40歲、高血壓、血脂異常與蛋白尿，符合以上四種危險因子的病人應列為aspirin初級預防對象。腦中風、暫時性腦缺血、心肌梗塞、心絞痛、冠狀動脈氣球擴張術後、末梢血管病變與跛行的診斷病人為次級預防對象。研究結果顯示，90年西醫門診初次使用口服降血糖藥物病人有8,950人，77.0％使用Sulfanyurea類，52.0％使用Biguanides類。其中以Biguanides類順適性最好、達83.3％，次為Sulfonylurea 82.4%。此兩種用藥持續性約為66-67％，斷藥比率約為 35-36％。影響糖尿病口服用藥順從性的最主要的因子、就醫分局別（高屏分局較差）；無併發症以及醫院評鑑為地區醫院較差。降血壓藥物分析：台灣糖尿病病患使用降血壓藥物主要是以CCB為主，ACEI或ARB次之，此項與國內高血壓患者用藥型態很像，也都是以CCB為主。使用降血壓藥物，以三種降血壓藥物以上治療為主，佔46.82%，幾乎將近一半。，有合併腎病變的組雖然比無合併腎病變有較高的用藥比率（72.6％，54.5％）。但比較實證醫學建議的用藥比率為低。降血脂藥物研究發現台灣糖尿病病人使用降血脂藥物的比率不會因為有併發症而增加，無併發症使用降血脂藥物的比率反而較多。Aspirin藥物研究結果顯示台灣糖尿病病人使用aspirin的比率有27.05%，比在美國報告醫院糖尿病病人使用aspirin的人已到54-85%為低。本研究符合初級預防，有使用aspirin為9.6％，符合次級預防使用aspirin為47.7％。糖尿病病人有CVD病變且有使用aspirin的比率只有40.42%。這與國外的結果還有很大的差距。在評估順適性與影響因子分析時發現，年齡多寡與順適性好壞未達顯相關，推論可能為全民健保創造之醫療可近性及台灣的高醫療水準，提供了對等的高醫療品質。

英文摘要
There are many factors related to the clinical effectiveness and drug utilization is one of the important factors. The purpose of this study is to analysis the DM patients?? drug utilization pattern to see the pharmacological management. Three major parts are included in the report: 1. DM oral hypoglycemic agent drug utilization pattern. The adherence, persistence and discontinuation are the indicators to see the drug use pattern. Further analysis to see the impact factors related to the drug adherence. 2. Hypertension control drugs and lipid lowering drugs utilization analysis especially focus on proportion of the DM with renal disease patients using the ACEI or ARB. 3. Low dose aspirin usage for primary and secondary prevention. The study data base was from the Taiwan 2000 DM cohort (640,173) that was adjusted by previous DM accuracy adjusted model. Select the 2001 newly hypoglycemic agent user as the study subjects ( 8,950). The adherence, persistence and discontinuation are the indicators to see the drug use pattern. Further analysis to see the impact factors related to the drug adherence. The drug code is using the WHO ATC_7 Code for oral hypoglycemic agent, hypertension lowering agent and lipid lowering agents further analysis. 57 kind of brands of low dose Aspirin ( 81-165mg) are searched from the NHI drug lists. The primary chemoprophylaxis targets is define as those DM patients with age greater than 40, hypertension, high blood cholesterol and protein urea. The secondary chemoprophylaxis targets are defined for those DM patents with CVA, TIC, AMI, PTCA procedure and peripheral vessel diseases. The result showed: Among the 8,950 newly oral hypoglycemic agents in the year of 2001 , the usages rate for the Sulfanyuea and Biguanides are 77.0% and 52.0%. The adherence rate are 83.3% and 82.4% separately. The persistence rate is around 66%-67% and the discontinuation is around 35-36% for those two drugs. The patients without complication are prone to how adherence. The community hospitals and the hospitals belong to the Southern BNHI branch show low adherence rate. The rank of most frequent hypertension lowering drug are CCB then follow by ACEI/ ARB. 46.8% of the study subjects are using 3 kinds of drug combination . Those who also have renal complication, only 72.6% are getting the ACEI/ARB that are suggested by evidence-based medicine. Among the recommended for the primary aspirin chemoprophylaxis group and secondary prevention group, 9.6% and 27.5% are found to get the drugs. The adherence rate to the oral hypoglycemic agents are rather high in our study. To use the appropriateness hypertension lowering drugs for the DM with renal disease in our study is less then 80 %. The aspirin chemoprophylaxis usage is quite low in primary prevention and reach near 50 % in secondary prevention. The cohort panel data was followed for consequent 3 years to detect theirs complication and mortality; medical utilization and quality related indicators. Analyze the factors which associated with better professional DM care accountability index. The 2000 DM cohort contained 620+ thousand DM Patients were the target group whose medical utilization complications disease codes and mortality were identified. Using Multinomial logic Model and Logistic Regression Model to detect the important impact factors associated with DM care accountable indexes (No. of OPD visits, No. of blood sugar, no. of HbA1C, No. of eye ground check per year). The complication rate included acute complication, chronic disease and severe chronic disease were high among the study target: 62% with any one complication. The incidence of chronic complication was 468 per thousand person year. The mortality among the groups with any complication is high as 65 per thousand per