某醫學中心高血壓病人慢性病連續處方箋藥物治療型態之研究

研究目的 本研究分析持高血壓慢性病連續處方箋病人的用藥型態與趨勢，另以現行高血壓藥物使用臨床指引，對高血壓之用藥品質進行評估，並對

處方異常個案進行追蹤，希望藉由此研究，對個案醫院現況提出品質促進方案，增進病人用藥安全。

研究方法 本研究採回溯性研究，以台灣北部某醫學中心民國九十四年三月門診健保申報檔中持有高血壓診斷並有用藥記錄的慢性病連續處方箋患者

為研究對象。將資料轉至 Microsoft EXCEL （ 2003 年版）工作表，利用該軟體進行除錯及各式組合條件篩選，再以 Statistical Package for Social Science （ SPSS ） 11.5 版套裝軟體對有效資料進行描述性與推論性統計分析。

研究結果 本研究共收載 5,753 名病人進入研究，降血壓藥物使用頻率以鈣離子阻斷劑使用頻率最高（ 68.23% ）其次依序為血管張力素接受器阻斷劑

（ 42.83% ）、乙型阻斷劑（ 38.86% ）、 thiazide 類利尿劑（ 15.44% ）、甲型和乙型阻斷劑（ 10.69% ）、甲型阻斷劑（ 10.17% ）、血管張力素轉換 ? 抑制劑（ 9.13% ）。平均每張處方中降血壓藥費 947.3 元，約佔總處方藥費支出的三分之二（ 66.5% ）。 採用單一種降血壓藥物治療的有 31.11% ，合併兩種或兩種以上藥物治療有的 68.89% 。合併治療型態中以鈣離子阻斷劑加上乙型阻斷劑的組合最多（ 30.40% ），鈣離子阻斷劑加上血管張力素接受器阻斷劑次之（ 22.91% ）。就處方型態而言，病人處方平均用藥品項為 3.54 ± 1.75 筆。降血壓藥使用平均項數為 1.99±0.85 項，平均處方用藥金額為 1425.46 ± 903.20 元。老年患者使用降壓藥的項數多於非老年患者（ 2.03 ± 0.89 vs. 1.96 ± 0.81 筆）；心臟內科處方降壓藥的項數多於非心臟內科（ 2.16 ± 0.88 vs. 1.77 ± 0.76 筆）。平均處方金額男性高於女性（ 1496.13 ± 927.38 vs.1363.87 ± 877.12 元），老年患者高於非老年患者（ 1502.95 ± 929.21vs.1353.56 ± 872.41 元），內分泌科（ 2248.99 ± 1253.96 元）平均費用最高，家庭醫學科（ 1028.64 ± 690.60 元）最低。研究期間非慢性病連續處方箋相較，慢性病連續處方箋總用藥項數較少（ 3.54 ± 1.75 vs. 4.31 2.01 筆）， 平均處方金額也較少（ 1425.46 ± 903.20 vs.1640.47 1498.87 元）。

高血壓合併痛風使用禁忌藥物 thiazide 類利尿劑之禁忌處方佔率為 10.6% ，高血壓合併慢性阻塞性肺病，使用禁忌藥物乙型阻斷劑之禁忌處方佔率為 16.1% ，高血壓合併缺血性心臟病伴隨穩定性心絞痛（ 80.1% ）、心臟衰竭（ 75.0% ）與糖尿病（ 96.4% ）案例之用藥情形與診療指引用藥建議符合度較高。高血壓合併中風病人，接受診療指引建議之 thiazide 類利尿劑與血管張力素轉換 ? 抑制劑（ ACEI ）患者比率只有 15.4% （ thiazide diuretics 9.4%, ACEIs 7.7% ）。

研究結論 結果顯示，大部分高血壓慢連箋病人接受兩種或兩種以上降血壓劑治療，和臨床指引用藥原則相符。高血壓慢連箋在平均用藥項數及藥費

上均明顯低於非慢性病處方箋患者，因此為節省健保資源，慢性病連續處方箋是值得鼓勵的。內分泌科與心臟內科病人，降血壓用藥品項、總用藥項數與費用均比其他科高，加強對此科病人的預防保健，應可收最大的經濟效益。經本研究初步調查個案醫院的臨床指引建議用藥符合率，在使用 thiazide 類或 ACEIs防止再次中風，仍有待改善。透過此研究方式，將可應用於其他慢性病的照護監測，以執行品質增進方案並定期評估。

Aims. Current study is a pilot study to investigate the patterns of antihypertensive medications by their pharmacological classifications, to measure the degree of adherence to JNC 7 hypertension treatment guideline recommendations, and to provide a reference for quality improvement.

Methods. A restrospective and cross-sectional analysis was performed. The data was collected from the outpatient services of a medical center in 2005 March. Patients with primary ICD-9-CM diagnosis code 401-405 and had chronic refilled prescription were included. Claim data to The Bureau of National Health Insurance （ BNHI ） for each prescription were exported to Microsoft Excel. Statistical analysis was performed using the Statistical Package for Social Science （ SPSS version 11.5 ） . T-test and Oneway ANOVA were used to determine differences.

Results and Discussion. A total of 5,753 patients were collected during the one month period. The average number of drugs per prescription was 3.54 ± 1.75. Expenditure analysis showed that antihypertensive agents accounted for 66.5% of the total prescription fee. Comparision to non-refill prescriptions, total medication cost was less in refill prescriptions （ 1425.46 ± 903.20 vs.1640.47 1498.87 ） . Thirty-one percentage patients received monotherapy, 43.63% received two antihypertensive combination therapy, and 20.58% for three antihypertensive combination therapy. The most popular combination therapy was a calcium channel blocker （ CCB ） plus a -blocker （ 30.40% ） , and then a calcium channel blocker （ CCB ） plus angiotensin receptor blocker （ ARB, 22.91% ） . CCB （ 68.23% ） were most often prescribed, both as monothapy and overall, in despite of Taiwan hypertension guidelines suggesting compelling indication for long-acting CCB only in patients with stable angina pectoris and diabetes mellitus. Prescribing patterns were relatively consistent with guidelines for congestive heart failure patients withstable angina （ 80.1% ） , congestive heart failure （ 75.0% ） and diabetes mellitus （ 96.4% ） , but low adherence in stroke prevention （ 15.4% ） . There was 10.6% patients with gout has received compelling contraindicated drugs, thiazide diuretics, and 16.1% patients with chronic obstructive pulmonary diseases （ COPD ） received compelling contraindicated drugs, -blocker.

Conclusion. Most of the patients who received refill prescriptions in the hospital needed combination therapy for blood pressure control. Comparision to non-refill prescriptions, total medication cost and the average number of drugs per prescription was less in refill prescriptions. For cost-saving ， refill prescriptions will be encouraged. Strategy for elevation prescription adherence in stroke prevention should be scheduled, regularly. The methods used in this study can be easily implemented in other chronic disease care as part of ongoing medical quality improvement efforts.

Study of Refill Prescriptions for Hypertensive Patients in a Medical Center