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題名：高血壓藥物對台灣高血壓年長婦女尿失禁及其醫療費用之影響
作者：張耿銘
作者(外文)：CHANG,KENG-MING
校院名稱：輔仁大學
系所名稱：商學研究所博士班
指導教授：江漢聲
李天行
學位類別：博士
出版日期：2016
主題關鍵詞：高血壓；高血壓藥物；尿失禁；尿失禁手術；醫療利用；醫療費用；資料探勘；決策樹；關聯法則；hypertension；hypertensive drugs；urinary incontinence；urinary incontinence surgery；medical cost；medical utility；data mining；decision tree；association rule
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台灣地區60歲以上婦女之高血壓與尿失禁盛行率皆高達30%以上，且高血壓為尿失禁的共病症之一，故高血壓婦女尿失禁成因，可提供臨床醫師治療高血壓與尿失禁時，臨床診斷與醫療服務提供的建議與參考。
本研究資料來源分別為透過問卷調查取得的初級資料(1999年臺灣地區中老年身心社會生活狀況長期追蹤調查結果)，分析60歲以上高血壓婦女的尿失禁危險因子，並以次級資料，台灣1997年至2011年全民健康保險申報資料檔，2005年版百萬歸人檔資料(NHRID)，分析高血壓藥物與尿失禁之關係，及後續醫療利用情形。本研究利用多變項羅吉斯迴歸、條件式羅吉斯迴歸及線性迴歸，分別探討高血壓婦女尿失禁危險因子、高血壓藥物與尿失禁的關係，並以多變項線性迴歸分析影響醫療利用及尿失禁手術費用的相關因子。本研究並利用資料採礦分析中決策樹(Decision tree ,CART)與關連法則(Association Rules )探索高血壓藥物與醫療利用間的規則。
研究結果發現，60歲以上高血壓婦女罹患尿失禁的危險因子為年齡、糖尿病、BMI及先前有泌尿道疾病。我們也發現規則治療高血壓的婦女有較低的尿失禁盛行率。本研究進一步透過健保資料庫百萬歸人檔，追蹤1997年至2011年間具高血壓且罹患尿失禁的60歲以上婦女。本研究發現，利尿劑、乙型阻斷劑、鈣離子阻斷劑、ARB、ACEI等高血壓藥物，若持續使用，可避免尿失禁的發生。若同時考量藥物持續性及順從性，則發現利尿劑、乙型阻斷劑、鈣離子阻斷劑、ARB、ACEI持續性及順從性高的情況下，藥物對於尿失禁具有保護作用，而甲型阻斷劑、ACEI則有危險性。此外，鈣離子阻斷劑及其他類藥物，部分使用狀況會有得尿失禁的危險。
在尿失禁醫療利用方面，研究發現部分藥物，如利尿劑、鈣離子阻斷劑的使用狀況會影響醫療利用，即順從性高或最近使用，則醫療利用較多。而尿失禁手術方面，使用鈣離子阻斷劑有保護效果，而於醫學中心及婦產科就診，有較高的危險性。我們也透過決策樹及關聯規則發現找出高血壓藥物間與尿失禁醫療利用的規則，可了解不同條件下，高血壓藥物、醫療利用、個人醫療特質間的關係模式。
最後也透過健保資料庫發現1997年至2011年間尿失禁手術發生率及年度費用、住院總費用與手術費用逐年增加，但住院天數卻逐年下降。而尿失禁手術的發生率、費用，在年齡、醫院評鑑等級及科別間存在著差異。本研究觀察到2010年起各項發生率、件數、費用都有下降趨勢，這樣的趨勢是否與全民健康保險實施TwDRG有關，應持續觀察。
研究探討60歲以上高血壓婦女與尿失禁間的關係，更進一步了解高血壓藥物治療對尿失禁及後續醫療利用的影響，希望本研究的結果能供衛生主管機關推動高血壓、尿失禁防治政策制定時參考，亦建議臨床醫師於治療高血壓及尿失禁時得多加考量，並規劃最好的婦女尿失禁醫療服務。最後，建議在社會高齡化趨勢下，能將尿失禁服務導入長期照護系統中，有效的改善老年人尿失禁的症狀，重拾自信心，並擁有高品質的生活。
In Taiwan, the prevalence of hypertension and urinary incontinence affects 30% of women above 60 years of age. In fact, high blood pressure is one of the comorbidities of urinary incontinence. Thus, hypertension causes women urinary incontinence and which may provide reference and recommendation to clinicians who treat hypertension and urinary incontinence during clinical diagnosis and health care services.
In this study, the primary source of information was obtained through questionnaires of the 1999 “Survey of Health and Living Status of the Middle Age and Elderly in Taiwan”, which provides the analysis of risk factors for urinary incontinence for women over age 60 with hypertension. And, the secondary source was from the 2005 edition of one million people, sampled from Taiwan National health Insurance claims data file from 1997 to 2011, which provides the analysis of the relationship between anti-hypertensive medications and urinary incontinence, and the status of the subsequent medical utilization. In this study, multivariate logistic regression, conditional logistic regression were used respectively to investigate hypertensive women urinary incontinence risk factors, and the relationship between hypertension drugs and urinary incontinence. Multivariate linear regression analysis was also implemented to assess the impact of medical utilization and related factors for incontinence surgery costs. This study also used Decision Tree Analysis “CART” and Association Rules in data mining to explore the correlation rules between hypertensive drugs and medical utilization.
Study found that women aged over 60 with hypertension suffering from urinary incontinence have risk factors as age, diabetes, BMI and previous urinary tract disease. We also found that women under regular treatment of hypertension have a lower prevalence of urinary incontinence. This study went further through the database owned by NHI of one million people file, to track data, between 1997-2011, on hypertension and urinary incontinence for women over 60 years old. The study found that diuretics, beta blockers, calcium channel blockers, ARB, ACEI and other anti-hypertensive drugs, if continually used, may help patients to avoid the occurrence of urinary incontinence. If also considering the persistent and adherence, diuretics, beta blockers, calcium channel blockers, ARB, and ACEI under continually used and highly compliant situation, medication has a protective effect on urinary incontinence, while alpha blockers and ACEI have a high risk effect. In addition, calcium channel blockers and other drugs, under some usage conditions, will cause urinary incontinence.
In urinary incontinence medical utilization, study found that usage of some drugs, such as diuretics and calcium channel blockers, will affect medical utilization. Namely, for high adherence or recently used, medical utilization is more than usual. As in urinary incontinence surgery, the use of calcium channel blockers have a protective effect, and, in obstetrics and gynecology and medical center, it has a higher risk effect. We also use decision trees and association rules to find the correlation rules among hypertensive drugs and medical utilization of incontinence. By which, we can learn, under different conditions, the relationship among hypertension medicines, medical utilization, and personal medical traits.
Finally, through the National Health Insurance database, we also found that, from 1997 to 2011, the incidence of urinary incontinence surgery and annual costs, the total cost of inpatient and surgical fee had increased year by year, but the length of hospital stay had decreased. However, the incidence and cost of urinary incontinence surgery varies among age, hospital accreditation level, and specialties divisions. This study observed that the incidences, numbers, costs had decreased since 2010. If this trend is affected by NHI's implementation of TwDRG, we should continue to observe.
We hope the result of this study could become a reference for the health authorities on making the policies that promote the prevention of hypertension and urinary incontinence, as well as be a consideration basis for clinicians to treat hypertension and urinary incontinence, and to cautiously plan such medical services for women. At last, we suggest, under the trend of aging society, to include the services for urinary incontinence into the long-term care system, to effectively improve the symptoms of urinary incontinence in the elderly, letting them regain confidence and have high-quality living.
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