Thanassoulis George, Karp Igor, Humphries Karin, Tu Jack V, Eisenberg Mark J, Pilote Louise
Divisions of Clinical Epidemiology, Cardiology, and Internal Medicine, McGill University Health Center, Montreal, Quebec, Canada.
Circ Cardiovasc Qual Outcomes. 2009 Sep;2(5):484-90. doi: 10.1161/CIRCOUTCOMES.108.804351. Epub 2009 Sep 1.
Prescription plans frequently use restrictive strategies to control drug expenditures. Increased restrictions may reduce access to evidence-based therapy among patients with chronic disease. We sought to evaluate the impact of increased restrictions on medication use among heart failure (HF) patients.
We conducted a population-based cohort study of administrative data from 3 Canadian provinces. During 1998 to 2001, Quebec (QC) had a minimally restrictive plan, whereas Ontario (ON) and British Columbia (BC) had more restrictive prescription plans. We evaluated drug use at 30 days of discharge stratified by prescription plan. Provincial rates of filled prescriptions for HF drugs in QC, ON, and BC were 62%, 58%, and 47% for angiotensin-converting enzyme inhibitors; 34%, 22%, and 16% for beta-blockers; 9%, 5%, and 3% for angiotensin receptor blockers; and 79%, 76%, and 62% for loop diuretics, respectively. In multivariate analyses, patients residing in provinces with restrictive plans were less likely to be prescribed drugs that were restricted, such as beta-blockers (odds ratio, 0.53; 95% CI, 0.46 to 0.60; 0.36, 0.29 to 0.44, for ON and BC, respectively) and angiotensin receptor blockers (0.50, 0.45 to 0.56; 0.38, 0.32 to 0.46, for ON and BC, respectively), than drugs with no restrictions, such as loop diuretics (0.81, 0.74 to 0.88; 0.40, 0.36 to 0.45, for ON and BC, respectively) and angiotensin-converting enzyme inhibitors (0.80, 0.75 to 0.86; 0.47, 0.43 to 0.52, for ON and BC, respectively).
Among HF patients, residing in a province with a more restrictive prescription plan may be associated with lower use of restricted HF medications over and above the expected regional differences in HF drug use across provinces.
处方计划经常采用限制性策略来控制药物支出。限制增多可能会减少慢性病患者获得循证治疗的机会。我们试图评估限制增多对心力衰竭（HF）患者用药的影响。
我们对来自加拿大3个省份的行政数据进行了一项基于人群的队列研究。在1998年至2001年期间，魁北克省（QC）的处方计划限制最少，而安大略省（ON）和不列颠哥伦比亚省（BC）的处方计划限制更多。我们根据处方计划对出院30天时的用药情况进行了评估。QC、ON和BC三省心力衰竭药物的处方配药率分别为：血管紧张素转换酶抑制剂62%、58%和47%；β受体阻滞剂34%、22%和16%；血管紧张素受体阻滞剂9%、5%和3%；襻利尿剂79%、76%和62%。在多变量分析中，居住在处方计划限制较多省份的患者，与使用无限制药物（如襻利尿剂，ON和BC分别为0.81, 0.74至0.88；0.40, 0.36至0.45；血管紧张素转换酶抑制剂，ON和BC分别为0.80, 0.75至0.86；0.47, 0.43至0.52）相比，使用受限制药物（如β受体阻滞剂，ON和BC分别为比值比0.53；95%置信区间0.46至0.60；0.36, 0.29至0.44；血管紧张素受体阻滞剂，ON和BC分别为0.50, 0.45至0.56；0.38, 0.32至0.46）的可能性较小。
在心力衰竭患者中，居住在处方计划限制较多的省份，除了各省心力衰竭药物使用的预期区域差异外，可能还与受限制心力衰竭药物的使用减少有关。
