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

The impact of expansion of dyslipidemia drug coverage on cardiovascular disease incidence and costs under the National Health Insurance scheme

10.6288/TJPH.202006_39(3).108132

郭蓓蓓(PEI-PEI KUO)；鄭守夏(Shou-Hsia Cheng)

降血脂藥物 ； 心血管疾病 ； 高血脂 ； 醫療費用 ； 健保給付 ； hypolipidemic drugs ； cardiovascular diseases ； hyperlipidemia ； health expenses ； National Health Insurance benefit package

台灣公共衛生雜誌

39卷3期（2020 / 06 / 15）

269 - 277

繁體中文

目標：全民健保於2013年8月1日放寬高危險族群使用降血脂藥物的給付規定，本研究旨探討該政策對於心血管疾病發生率與醫療費用之影響。方法：使用全民健康保險全人口資料庫進行分析，針對用藥給付放寬的範圍去界定研究與對照組，選取無心血管疾病史的糖尿病患者118,912人為研究組；無心血管疾病史且無糖尿病史的高血壓患者150,930人為對照組。追蹤觀察期為2013年8月1日前後各3年。統計分析採用差異中的差異法，檢視政策實施前後，兩組病人在降血脂藥物開立、心血管疾病（急性心肌梗塞與缺血性腦中風）發生、及醫療花費的差異。結果：研究發現在政策實施後，研究組的病人比對照組較容易獲得降血脂藥物的開立（OR=1.095, p＜0.0001），其心血管疾病的發生機率也較低（OR=0.914, p=0.0046），且降血脂藥物費用較低（β=-0.016, p=0.0019），而心血管疾病的花費雖然有比較低，但未達統計上的顯著差異（β=-0.087, p=0.1504）。結論：2013年的放寬降血脂給付政策讓高風險族群的糖尿病患者的用藥人數上升、心血管疾病發生趨緩，但尚未見可以節省健保花費，建議未來可以做更長期的觀察評估。

Objectives: Aiming to reduce the occurrence of cardiovascular disease (CVD), Taiwan's National Health Insurance (NHI) Administration expanded coverage for hypolipidemic drugs for high-risk patients, including patients with a history of CVD or diabetes in 2013. This study intended to evaluate the impact of this policy. Methods: Patients with diabetes but without a history of CVD (118,912 subjects) were selected as the study group, and patients with hypertension but without a history of CVD or diabetes (150,930 subjects) were the comparison group. Using August 1, 2013, as the cut-off point we defined 3 years each in the pre- and post-policy periods. Generalized estimation equation (GEE) models with a difference-in-differences analysis were used to estimate the effects of the new policy in 2010 and 2016. Outcome variables included the likelihood of receiving hypolipidemic drugs, occurrence of CVD (acute myocardial infarction and ischemic stroke), and expenses for drugs and CVD. Results: After introduction of the policy, subjects in the study group were more likely to receive hypolipidemic drugs (OR=1.095, p＜0.001), and less likely to have CVD (OR=0.914, p=0.0046) than subjects in the comparison group. The subjects in the study group also had lower expenses for hypolipidemic drugs (β=-0.016, p=0.0019), but the lower expenses for CVD did not reach the significance level (β=-0.087, p=0.1504). Conclusions: The expanded coverage for hypolipidemic drugs significantly increased the use of medications for high-risk patients, and reduced the occurrence of CVD in Taiwan. Long-tern evaluation of this medication policy is recommended.

1. Baigent, C,Keech, A,Kearney, PM(2005).Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins.Lancet,366,1267-1278.
2. Barker-Collo, S,Bennett, DA,Krishnamurthi, RV(2015).Sex differences in stroke incidence, prevalence, mortality and disability-adjusted life years: results from the global burden of disease study 2013.Neuroepidemiology,45,203-214.
3. Cholesterol Treatment Trialists’ (CTT) Collaborators(2008).Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis.Lancet,371,117-125.
4. Cui, Y,Hao, K,Takahashi, J(2017).Age-specific trends in the incidence and in-hospital mortality of acute myocardial infarction over 30 years in Japan -- report from the Miyagi AMI Registry Study.Circ J,81,520-528.
5. Degano, IR,Salomaa, V,Veronesi, G(2015).Twenty-five-year trends in myocardial infarction attack and mortality rates, and case-fatality, in six European populations.Heart,101,1413-1421.
6. Hennessy, DA,Tanuseputro, P,Tuna, M(2016).Population health impact of statin treatment in Canada.Health Rep,27,20-28.
7. Lee, M,Wu, YL,Ovbiagele, B(2016).Trends in incident and recurrent rates of first-ever ischemic stroke in Taiwan between 2000 and 2011.J Stroke,18,60-65.
8. National Cholesterol Education Program Expert Panel on Detection E, Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)(2002).Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report.Circulation,106,3143-3421.
9. Pencina, MJ,Navar-Boggan, AM,D’Agostino, RB(2014).Application of new cholesterol guidelines to a population-based sample.N Engl J Med,370,1422-1431.
10. Rosamond, WD,Chambless, LE,Heiss, G(2012).Twenty-two-year trends in incidence of myocardial infarction, coronary heart disease mortality, and case fatality in 4 US communities, 1987-2008.Circulation,125,1848-1857.
11. Stone, NJ,Robinson, JG,Lichtenstein, AH(2014).ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation,129,S1-S45.
12. Thai, LP,Moss, JR,Godman, B,Vitry, AI(2016).Cost driver analysis of statin expenditure on Australia’s Pharmaceutical Benefits Scheme.Expert Rev Pharmacoecon Outcomes Res,16,419-433.
13. Wang, W,Zhang, B(2014).Statins for the prevention of stroke: a meta-analysis of randomized controlled trials.PLoS One,9,e92388.
14. WHO. Cardiovascular disease. Available at: http://www.who.int/cardiovascular_diseases/en/. Accessed December 6, 2019.
15. 中華民國血脂及動脈硬化學會=Taiwan Society of Lipids & Atherosclerosis(2008)。2008台灣地區血脂治療共識摘要。中華民國心臟學會會訊，11月
16. 衛生福利部：106年國人死因統計結果。https://www.mohw.gov.tw/cp-16-41794-1.html。引用2019/12/06。Ministry of Health and Welfare, R.O.C. (Taiwan). 2017 cause of death statistics in Taiwan. Available at: https://www.mohw.gov.tw/cp-16-41794-1.html. Accessed December 6, 2019. [In Chinese]
17. 衛生福利部中央健康保險署：全民健康保險藥物給付項目及支付標準－第六編第八十三條。http://www.nhi.gov.tw/resource/bulletin/4616_%E4%BF%AE%E6%AD%A3%E8%A6%8F%E5%AE%9A.pdf。引用2019/12/06。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). National Health Insurance Drug Payment Program and Payment Standards: Part VI Article 83. Available at: http://www.nhi.gov.tw/resource/bulletin/4616_%E4%BF%AE%E6%AD%A3%E8%A6%8F%E5%AE%9A.pdf. Accessed December 6, 2019. [In Chinese]
18. 衛生福利部中央健康保險署：藥品給付規定修訂對照表，2019。http://www.nhi.gov.tw/BBS_Detail.aspx?n=73CEDFC921268679&sms=D6D5367550F18590&s=8ABC95630C477EF6。引用2019/12/06。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). Amendment comparison table for drug payment regulations, 2019. Available at: http://www.nhi.gov.tw/BBS_Detail.aspx?n=73CEDFC921268679&sms=D6D5367550F18590&s=8ABC95630C477EF6. Accessed December 6, 2019. [In Chinese]
19. 衛生福利部中央健康保險署：全民健康保險降血脂藥物給付規定表。http://tsoc.org.tw/upload/2014/03/20140308160954.pdf。引用2019/12/06。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). Reimbursement scheme of hypolipidemic agents covered by the National Health Insurance. Available at: http://tsoc.org.tw/upload/2014/03/20140308160954.pdf. Accessed December 6, 2019. [In Chinese]
20. 衛生福利部中央健康保險署：全民健康保險藥物給付項目及支付標準共同擬訂會議藥品部分第3次（102年6月）會議紀錄：降血脂藥物財務推估。https://bit.ly/3fyhEGl。引用2019/12/06。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). Meeting minutes of National Health Insurance payment items and criteria for medical services: the third time in medicinal portion (June 2013): financial estimation of hypolipidemic drugs. Available at: https://bit.ly/3fyhEGl. Accessed December 6, 2019. [In Chinese]
21. 衛生福利部國民健康署：2007年台灣地區高血壓、高血糖、高血脂之追蹤調查研究。https://www.hpa.gov.tw/Pages/ashx/File.ashx?FilePath=~/File/Attach/1243/File_1005.pdf。引用2019/12/06。Health Promotion Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). A follow-up survey of high blood pressure, hyperglycemia and high blood lipid profile in Taiwan in 2007. Available at: https://www.hpa.gov.tw/Pages/ashx/File.ashx?FilePath=~/File/Attach/1243/File_1005.pdf. Accessed December 6, 2019. [In Chinese: English abstract]
22. 衛生福利部國民健康署：2009-2013年急性心肌梗塞標準化發生率。http://www.tsim.org.tw/board/276.files/103 09 26%E6%96%B0%E8%81%9E%E7%A8%BF%E9%99%84%E4%BB%B6_%E4%B8%89.pdf。引用2019/10/05。Health Promotion Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). Standardized incidence rate of acute myocardial infarction in 2009-2013. Available at: http://www.tsim.org.tw/board/276.files/1030926%E6%96%B0%E8%81%9E%E7%A8%BF%E9%99%84%E4%BB%B6_%E4%B8%89.pdf. Accessed October 5, 2019. [In Chinese]
23. 衛生福利部統計處：歷年死亡原因。https://www.mohw.gov.tw/dl-18472-6bf0ba7a-a435-47ff-ae4c-03b73ca1ae76.html。引用2019/12/06。Department of Statistics, Ministry of Health and Welfare, R.O.C. (Taiwan). Causes of death over the years. Available at: https://www.mohw.gov.tw/dl-18472-6bf0ba7a-a435-47ff-ae4c-03b73ca1ae76.html. Accessed December 6, 2019. [In Chinese]