Edited by: Tanja Mueller, University of Strathclyde, United Kingdom
Reviewed by: Young Shin, University of Cincinnati, United States
Xiaoxi Sun, Medtronic, United States
†These authors have contributed equally to this work
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The Taiwanese government adopted the National Health Insurance (NHI) system in March 1995. This study aimed to understand the difference in medication costs before (year 2019) and during the COVID-19 pandemic (2020–2021) among different hospitals for treating their patients.
The NHI claims database consisting of claims of prescription drugs for inpatients (IPD) and outpatients (OPD) in Taiwan was used to determine drug expenditure in different hospitals, particularly the top 10 prescription Anatomical Therapeutic Chemical (ATC) categories.
In medical centers, L01X (other antineoplastic agents) showed the highest drug expenditure, followed by L04A (immunosuppressants) and J05A (direct-acting antivirals). The drug expenditure pattern in regional hospitals was similar to that in medical centers, with L01X (other antineoplastic agents) showing the highest drug expenditure. L01X (other antineoplastic agents) also showed the highest drug expenditure in district hospitals, followed by N05A (antipsychotics) and A10B (blood glucose-lowering drugs, excluding insulin). In clinics, A10B (blood glucose-lowering drugs, excluding insulin) showed the highest drug expenditure. The total medication costs in 2021 were lower or similar to those in 2019. The use of systemic use anti-infectives decreased over time in OPDs among all hospita1 levels but increased in IPDs in medical centers and district hospitals. Furthermore, our analysis revealed that the trend in drug expenditure closely mirrored the trend in drug prescription volume for the highest annual sum cost item among the top 10 drug subgroups across different hospital levels.
Our analysis found that annual drug expenditures in 2021 were lower or similar to those in 2019, suggesting that the COVID-19 pandemic has contributed to this reduction in drug expenditure.
The National Health Insurance (NHI) system in Taiwan is a comprehensive and government-run healthcare system that provides affordable and accessible medical services to the residents of Taiwan. Established in 1995, the NHI is designed to ensure that all citizens have access to high-quality healthcare without facing financial barriers (
Global health systems were profoundly shaken by the unexpected onset of the COVID-19 pandemic, challenging their resilience and adaptability to sustain essential functions (
Our previous study indicated that annual drug expenditures increased across all hospitals from 2016 to 2018 (
This retrospective cohort study leveraged claims records from 1 million patients from the NHI database from 2019 to 2021. The comprehensive claims database encompasses original data on drug prescriptions for all beneficiaries in Taiwan. Using the ATC classification, we computed specific drug prescription categories (
The main variable under observation was the declared amount (annual sum cost of specific prescription drugs within the Taiwan NHI) of specific prescription drugs across various hospital levels. Hospital levels were categorized into four types: medical centers, regional hospitals, district hospitals, and clinics/others. Fifteen prescription drug types were considered, spanning categories including (A) alimentary tract and metabolism; (B) blood and blood-forming organs; (C) cardiovascular system; (D) dermatologicals; (G) genitourinary system and sex hormones; (H) systemic hormonal preparations excluding sex hormones and insulins; (J) anti-infectives for systemic use; (L) antineoplastic and immunomodulating agents; (M) musculoskeletal system; (N) nervous system; (P) antiparasitic products, insecticides, and repellents; (R) respiratory system; (S) sensory organs; (V) various; and (U) others (with missing ATC coding). The top 10 highest drug annual sum cost ATC categories for different hospital levels were identified based on the annual sum cost of prescription drugs belonging to the same 3rd ATC level (pharmacological subgroup, form A01A to V10X). Furthermore, we divided drug expenditure (annual sum cost of prescription drugs within the Taiwan NHI) into IPD and OPD. The currency exchange rates at the end of the index year were 29.983 in 2019, 28.095 in 2020, and 27.699 in 2021, with the NTD to USD ratio fixed at 1:29 in this study. The unit of cost presented in the
SAS 9.4 (SAS Institute Inc., Cary, NC) was used for data analyses. The selected ATC drug groups or prescription drugs were used to describe their annual sum cost or sum prescription quantity among different hospital levels during 2019–2021.
Among all original claims encompassing drug prescription data for beneficiaries, the annual drug expenditures in medical centers for the 15 specified types rose from $2,511.12 million in 2019 to $2,621.35 million in 2020 (4.38% incremental) and decreased to $2,549.59 million in 2021 (2.74% decremental) (
Drug expenditure among different levels of hospital.
| IPD | OPD | Total | |||||||
|---|---|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2019 | 2020 | 2021 | 2019 | 2020 | 2021 | |
| Medical center | 510.17 | 532.83 (+4.44%) | 522.98 (−1.85%) | 2000.95 | 2088.53 (+4.38%) | 2026.61 (−2.96%) | 2511.12 | 2621.35 (+4.39%) | 2549.59 (−2.74%) |
| Regional hospital | 377.61 | 382.62 (+1.33%) | 371.15 (−3.00%) | 1542.83 | 1537.86 (−0.32%) | 1370.84 (−10.86%) | 1920.44 | 1920.49 (0.00%) | 1741.99 (−9.29%) |
| District hospital | 111.96 | 124.68 (+11.36%) | 137.49 (+10.27%) | 598.56 | 632.61 (+5.69%) | 563.77 (−10.88%) | 710.52 | 757.30 (+6.58%) | 701.26 (−7.40%) |
| Clinics/others | 0.61 | 0.56 (−8.49%) | 0.56 (−0.65%) | 517.45 | 530.94 (+2.61%) | 372.54 (−29.83%) | 518.06 | 531.50 (+2.59%) | 373.10 (−29.8%) |
Hospital levels were categorized into four types: medical centers, regional hospitals, district hospitals, and clinics/others. We divided drug expenditure (annual sum cost of prescription drug within the Taiwan NHI) into in-patient department (IPD) and outpatient department (OPD). The drug expenditure was indicated by million USD and the exchange rate used in this study was 1:29. (+ − percentage) indicated the percent change as compared with the previous year.
Drug expenditure among different level of hospitals based on 15 categories of the first level Anatomical Therapeutic Chemical code.
| Category | IPD | OPD | Total | ||||||
|---|---|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2019 | 2020 | 2021 | 2019 | 2020 | 2021 | |
| (A) Medical center | |||||||||
| A | 42.92 | 42.71 (−0.48%) | 37.44 (−12.36%) | 245.55 | 253.69 (+3.29%) | 262.17 (+3.36%) | 288.47 | 296.35 (+2.73%) | 299.60 (+1.10%) |
| B | 60.90 | 59.59 (−2.16%) | 55.25 (−7.28%) | 193.24 | 202.11 (+4.59%) | 209.35 (+3.58%) | 254.14 | 261.7 (−2.97%) | 264.61 (+1.11%) |
| C | 15.43 | 15.14 (−1.88%) | 14.88 (−1.70%) | 177.44 | 173.54 (−2.20%) | 169.25 (−2.47%) | 192.86 | 188.68 (−2.17%) | 184.13 (−2.41%) |
| D | 1.37 | 1.30 (−5.12%) | 1.23 (−5.13%) | 9.56 | 10.09 (+5.51%) | 12.21 (+21.01%) | 10.93 | 11.39 (+4.18%) | 13.44 (+18.03%) |
| G | 0.98 | 0.96 (−2.34%) | 0.98 (−1.85%) | 32.26 | 30.75 (−4.68%) | 30.92 (+0.55%) | 33.24 | 31.71 (−4.61%) | 31.90 (+0.59%) |
| H | 7.42 | 7.04 (−5.21%) | 7.07 (+0.42%) | 33.07 | 33.21 (+0.42%) | 32.42 (−2.37%) | 40.49 | 40.24 (−0.61%) | 39.49 (−1.88%) |
| J | 194.29 | 196.28 (+1.02%) | 202.76 (+3.30%) | 249.70 | 213.36 (−14.55%) | 190.93 (−10.52%) | 443.99 | 409.64 (−7.74%) | 393.69 (−3.89%) |
| L | 144.96 | 164.93 (+13.78%) | 157.02 (−4.80%) | 755.16 | 862.55 (+14.22%) | 977.52 (13.33%) | 900.12 | 1027.48 (+14.15%) | 1134.54 (+10.42%) |
| M | 4.72 | 11.38 (+141.13%) | 13.59 (+19.35%) | 46.93 | 46.52 (−0.87%) | 48.18 (+3.57%) | 51.65 | 57.9 (+12.11%) | 61.77 (+6.67%) |
| N | 24.14 | 24.68 (+2.26%) | 24.45 (−0.95%) | 145.50 | 147.69 (+1.51%) | 145.92 (−1.20%) | 169.64 | 172.38 (+1.61%) | 170.37 (−1.17%) |
| P | 0.08 | 0.07 (−12.06%) | 0.08 (+15.61%) | 1.34 | 1.33 (−0.73%) | 1.25 (−5.98%) | 1.42 | 1.40 (−1.35%) | 1.33 (−4.93%) |
| R | 5.81 | 4.93 (−15.06%) | 4.84 (−1.98%) | 48.62 | 48.53 (−0.18%) | 49.95 (−2.93%) | 54.43 | 53.47 (−1.77%) | 54.79 (+2.47%) |
| S | 0.47 | 0.46 (−2.73%) | 0.44 (−3.70%) | 42.11 | 42.57 (+1.09%) | 42.85 (+0.66%) | 42.58 | 43.02 (−1.05%) | 43.29 (+0.61%) |
| V | 3.03 | 3.11 (+2.61%) | 2.89 (−7.08%) | 20.19 | 21.78 (+7.86%) | 21.95 (+0.77%) | 23.23 | 24.90 (−7.18%) | 24.84 (−0.21%) |
| U | 3.65 | 0.25 (−93.22%) | 0.07 (−72.46%) | 0.27 | 0.84 (+208.14%) | 0.99 (+17.86%) | 3.92 | 1.09 (−72.29%) | 1.06 (−2.71%) |
| (B) Regional hospital | |||||||||
| A | 19.22 | 19.30 (0.42%) | 18.87 (−2.25%) | 192.03 | 190.25 (−0.93%) | 188.44 (−0.95%) | 211.25 | 209.55 (−0.80%) | 207.30 (−1.07%) |
| B | 41.77 | 41.64 (−0.32%) | 41.75 (+0.27%) | 150.76 | 153.86 (+2.05%) | 150.79 (−2.00%) | 192.54 | 195.5 (−1.54%) | 192.54 (−1.51%) |
| C | 11.57 | 11.33 (−2.07%) | 11.47 (+1.23%) | 194.69 | 187.42 (−3.74%) | 181.37 (−3.23%) | 206.27 | 198.75 (−3.64%) | 192.84 (−2.97%) |
| D | 1.18 | 1.15 (−2.59%) | 1.11 (−3.48%) | 9.27 | 9.39 (+1.28%) | 9.73 (+3.63%) | 10.45 | 10.54 (+0.85%) | 10.84 (+2.86%) |
| G | 1.03 | 1.02 (−0.46%) | 1.01 (−1.35%) | 34.17 | 32.09 (−6.09%) | 32.09 (−0.02%) | 35.2 | 33.11 (−5.93%) | 33.09 (−0.06%) |
| H | 5.87 | 5.37 (−8.59%) | 5.13 (−4.46%) | 19.10 | 18.96 (−0.72%) | 18.25 (−3.72%) | 24.97 | 24.33 (−2.57%) | 23.38 (−3.88%) |
| J | 145.20 | 141.77 (−2.36%) | 139.13 (−1.87%) | 259.26 | 202.19 (−22.01%) | 161.26 (−20.24%) | 404.46 | 343.97 (−14.96%) | 300.39 (−12.67%) |
| L | 108.03 | 119.25 (−10.38%) | 111.48 (−6.51%) | 360.87 | 418.45 (+15.96%) | 485.12 (+15.93%) | 468.9 | 537.70 (+14.67%) | 596.60 (+10.95%) |
| M | 3.83 | 3.49 (−8.93%) | 3.35 (−3.99%) | 54.95 | 53.27 (−3.04%) | 52.71 (−1.06%) | 58.77 | 56.76 (−3.43%) | 56.06 (−1.24%) |
| N | 28.96 | 29.59 (+2.14%) | 29.57 (−0.06%) | 168.53 | 173.91 (+3.19%) | 174.97 (+0.61%) | 197.5 | 203.49 (+3.04%) | 204.53 (+0.51%) |
| P | 0.12 | 0.11 (−3.75%) | 0.11 (−5.93%) | 1.10 | 1.08 (−1.61%) | 0.98 (−9.56%) | 1.22 | 1.19 (−1.82%) | 1.08 (−9.21%) |
| R | 7.46 | 6.076 (−18.52%) | 5.62 (−7.54%) | 58.82 | 56.95 (−3.17%) | 55.57 (−2.43%) | 66.27 | 63.03 (−4.90%) | 61.18 (−2.92%) |
| S | 0.25 | 0.22 (−10.37%) | 0.21 (−5.72%) | 29.29 | 28.95 (−1.16%) | 29.04 (+0.31%) | 29.54 | 29.17 (−1.24%) | 29.25 (+0.27%) |
| V | 2.26 | 2.31 (+2.07%) | 2.34 (+1.37%) | 9.98 | 11.09 (+11.13%) | 11.90 (+7.32%) | 12.24 | 13.39 (−9.45%) | 14.24 (+6.29%) |
| U | 0.86 | 0.00 (−99.82%) | 0.02 (+1080%) | 0.02 | 0.00 (−89.49%) | 0.00 (+35.54%) | 0.88 | 0.00 (−99.60%) | 0.02 (477.38%) |
| (C) District hospital | |||||||||
| A | 6.53 | 7.33 (+12.15%) | 7.47 (+1.89%) | 102.57 | 109.00 (+6.27%) | 113.91 (+4.50%) | 109.1 | 116.33 (+6.62%) | 121.37 (+4.33%) |
| B | 11.99 | 12.01 (+0.19%) | 12.96 (+7.88%) | 57.81 | 56.19 (−2.81%) | 58.77 (+4.59%) | 69.8 | 68.20 (−2.29%) | 71.73 (+5.17%) |
| C | 3.57 | 3.77 (+5.58%) | 4.03 (+6.96%) | 104.13 | 107.56 (+3.30%) | 110.62 (+2.84%) | 107.7 | 111.33 (+3.38%) | 114.65 (+2.98%) |
| D | 0.46 | 0.51 (+9.83%) | 0.54 (+6.26%) | 5.52 | 5.69 (+3.13%) | 6.03 (+6.04%) | 5.98 | 6.20 (+3.64%) | 6.57 (+6.06%) |
| G | 0.53 | 0.54 (+3.15%) | 0.53 (−2.60%) | 19.00 | 19.42 (+2.19%) | 20.87 (+7.50%) | 19.53 | 19.96 (+2.21%) | 21.4 (+7.23%) |
| H | 1.73 | 1.63 (−5.63%) | 1.68 (+2.59%) | 8.74 | 9.50 (+8.69%) | 9.77 (+2.83%) | 10.47 | 11.13 (+6.32%) | 11.44 (+2.80%) |
| J | 53.30 | 56.68 (+6.35%) | 62.90 (+10.96%) | 83.41 | 74.06 (−11.21%) | 55.19 (−25.48%) | 136.71 | 130.74 (−4.37%) | 118.08 (−9.68%) |
| L | 11.09 | 18.78 (+69.39%) | 22.80 (+21.44%) | 60.82 | 86.67 (+42.51%) | 124.96 (+44.18%) | 71.9 | 105.45 (+46.65%) | 147.76 (+40.13%) |
| M | 0.96 | 1.10 (+14.30%) | 1.21 (+10.37%) | 33.34 | 34.05 (+2.14%) | 35.68 (+4.78%) | 34.3 | 35.15 (+2.48%) | 36.89 (+4.95%) |
| N | 17.73 | 18.54 (+4.58%) | 19.52 (+5.27%) | 77.50 | 83.51 (+7.75%) | 89.18 (+6.80%) | 95.23 | 102.05 (+7.16%) | 108.70 (+6.52%) |
| P | 0.08 | 0.08 (+0.16%) | 0.09 (+17.32%) | 0.61 | 0.65 (+5.80%) | 0.65 (+0.20%) | 0.69 | 0.72 (+5.19%) | 0.74 (+1.98%) |
| R | 3.61 | 3.23 (−10.47%) | 3.25 (+0.57%) | 31.97 | 31.85 (−0.36%) | 32.65 (+2.49%) | 35.58 | 35.08 (−1.39%) | 35.89 (+2.31%) |
| S | 0.08 | 0.09 (+13.48%) | 0.08 (−11.44%) | 10.69 | 11.71 (+9.54%) | 12.92 (+10.36%) | 10.77 | 11.80 (+9.57%) | 13.00 (+10.20%) |
| V | 0.32 | 0.40 (+27.88%) | 0.45 (+11.70%) | 2.46 | 2.76 (12.16%) | 3.20 (+15.84%) | 2.78 | 3.16 (+13.95%) | 3.65 (+15.31%) |
| U | 0.00 | 0.00 (−100.00%) | 0.00 (−) | 0.00 | 0.00 (−) | 0.00 (+131.93%) | 0.00 | 0.00 (−97.63%) | 0.00 (+135.13%) |
| (D) Clinics/others | |||||||||
| A | 0.02 | 0.02 (−2.29%) | 0.02 (+9.77%) | 106.05 | 114.55 (+8.01%) | 123.22 (+7.57%) | 106.07 | 114.57 (+8.01%) | 123.24 (+7.57%) |
| B | 0.24 | 0.23 (−4.54%) | 0.22 (−1.66%) | 13.03 | 13.73 (+5.35%) | 15.45 (+12.30%) | 13.27 | 13.95 (+5.17%) | 15.68 (+12.37%) |
| C | 0.01 | 0.01 (−4.46%) | 0.01 (−7.28%) | 152.53 | 162.74 (+6.69%) | 172.85 (+6.21%) | 152.54 | 162.75 (+6.69%) | 172.85 (+6.21%) |
| D | 0.00 | 0.00 (+0.72%) | 0.00 (+22.74%) | 14.38 | 15.05 (+4.66%) | 15.03 (−0.13%) | 14.38 | 15.05 (+4.66%) | 15.03 (−0.13%) |
| G | 0.07 | 0.07 (+4.29%) | 0.08 (+9.59%) | 12.67 | 14.04 (+10.08%) | 15.24 (+8.53%) | 12.74 | 14.11 (+10.77%) | 15.32 (+8.53%) |
| H | 0.05 | 0.05 (−2.58%) | 0.05 (+4.22%) | 2.93 | 3.08 (+5.22%) | 3.17 (+2.93%) | 2.97 | 3.12 (+5.10%) | 3.22 (+2.95%) |
| J | 0.16 | 0.13 (−14.88%) | 0.13 (−0.14%) | 43.85 | 39.92 (−8.96%) | 33.77 (−15.39%) | 44.01 | 40.05 (−8.98%) | 33.91 (−15.34%) |
| L | 0.00 | 0.00 (+196.67%) | 0.00 (−100.00%) | 1.02 | 1.08 (+5.98%) | 1.12 (+4.27%) | 1.02 | 1.08 (+5.98%) | 1.12 (+4.27%) |
| M | 0.03 | 0.03 (−5.30%) | 0.03 (+8.16%) | 23.94 | 22.44 (−6.28%) | 21.81 (−2.80%) | 23.97 | 22.47 (−6.28%) | 21.84 (−2.79%) |
| N | 0.03 | 0.02 (−42.29%) | 0.01 (−66.45%) | 70.79 | 75.49 (+6.64%) | 80.09 (+6.09%) | 70.82 | 75.51 (+6.62%) | 80.09 (+6.07%) |
| P | 0.00 | 0.00 (−14.85%) | 0.00 (+35.04%) | 0.47 | 0.47 (+0.21%) | 0.46 (−3.53%) | 0.47 | 0.47 (+0.20%) | 0.46 (−3.52%) |
| R | 0.01 | 0.00 (−58.93%) | 0.00 (−45.60%) | 53.27 | 45.16 (−15.23%) | 39.73 (−12.02%) | 53.28 | 45.16 (−15.24%) | 39.73 (−12.02%) |
| S | 0.00 | 0.00 (−59.62%) | 0.00 (+142.86%) | 21.39 | 22.25 (+4.03%) | 22.56 (+1.39%) | 21.39 | 22.25 (+4.03%) | 22.56 (+1.39%) |
| V | 0.00 | 0.00 (−15.16%) | 0.00 (−10.26%) | 1.13 | 0.95 (−16.17%) | 0.88 (−7.44%) | 1.13 | 0.95 (−16.17%) | 0.88 (−7.44%) |
| U | 0.00 | 0.00 (−) | 0.00 (−) | 0.00 | 0.00 +(1299.10%) | 0.01 (+427.56%) | 0.00 | 0.00 (+1299.10%) | 0.01 (+427.56%) |
Hospital levels were categorized into four types: medical centers, regional hospitals, district hospitals, and clinics/others. We divided drug expenditure (annual sum cost of prescription drug within the Taiwan NHI) into in-patient department (IPD) and outpatient department (OPD). Fifteen prescription drug types were considered, spanning categories including (A) alimentary tract and metabolism; (B) blood and blood-forming organs; (C) cardiovascular system; (D) dermatologicals; (G) genitourinary system and sex hormones; (H) systemic hormonal preparations excluding sex hormones and insulins; (J) anti-infectives for systemic use; (L) antineoplastic and immunomodulating agents; (M) musculoskeletal system; (N) nervous system; (P) antiparasitic products, insecticides, and repellents; (R) respiratory system; (S) sensory organs; (V) various; and (U) others (with missing ATC coding). The drug expenditure was indicated by million USD and the exchange rate used in this study was 1:29. (+ − percentage) indicated the percent change as compared with the previous year.
To elucidate the nuanced patterns of drug prescription across various categories, we further subdivided the drug groups into pharmacological subgroups (3rd level) based on the ATC code.
Drug expenditure among different level of hospitals based on the top 10 highest three digital Anatomical Therapeutic Chemical code.
| IPD | OPD | |||||
|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2019 | 2020 | 2021 | |
| (A) Medical center | ||||||
| L01X: other antineoplastic agents | 82.93 | 101.25 (+22.10%) | 98.18 (−3.14%) | 355.64 | 440.92 (+23.98%) | 535.44 (+21.44%) |
| L04A: Immunosuppressants | 7.50 | 8.32 (+10.94%) | 8.40 (+0.98%) | 242.95 | 262.41 (+8.01%) | 270.29 (+3.00%) |
| J05A: Direct Acting Antivirals | 5.99 | 6.37 (+6.30%) | 7.34 (+15.20%) | 208.85 | 174.61 (−16.39%) | 152.69 (−12.56%) |
| A16A: other alimentary tract and metabolism products | 24.52 | 23.35 (−4.78%) | 18.50 (−20.78%) | 113.58 | 125.54 (+10.53%) | 135.76 (+8.14%) |
| B02B: Vitamin k and other hemostatics | 12.59 | 10.72 (−14.87%) | 6.14 (−42.74%) | 69.64 | 78.07 (+12.10%) | 85.80 (+9.91%) |
| L01B: antimetabolites | 20.07 | 20.04 (−0.15%) | 18.28 (−8.80%) | 59.43 | 58.23 (−2.02%) | 57.47 (−1.30%) |
| J01D: Other beta-lactam antibacterials | 63.57 | 66.75 (+5.00%) | 69.31 (+3.83%) | 5.52 | 4.44 (−19.46%) | 4.37 (−1.75%) |
| B01A: Antithrombotic agents | 6.24 | 6.22 (−0.41%) | 6.30 (+1.30%) | 64.85 | 66.29 (+2.21%) | 66.92 (+0.95%) |
| A10B: Blood glucose lowering drugs, excl. Insulins | 0.84 | 0.90 (+6.68%) | 0.99 (+9.74%) | 64.89 | 63.06 (−2.83%) | 62.97 (−0.14%) |
| C10A: lipid modifying agents, plain | 0.74 | 0.75 (+2.52%) | 0.75 (−0.98%) | 52.77 | 51.17 (−3.03%) | 49.53 (−3.19%) |
| (B) Regional hospital | ||||||
| L01X: other antineoplastic agents | 68.7 | 80.03 (+16.48%) | 74.68 (−6.68%) | 166.88 | 212.38 (+27.27%) | 260.35 (+22.58%) |
| J05A: Direct Acting Antivirals | 2.74 | 2.88 (+5.14%) | 2.87 (−0.14%) | 237.48 | 181.95 (−23.38%) | 142.17 (−21.86%) |
| L04A: Immunosuppressants | 1.09 | 1.32 (+20.80%) | 1.86 (+40.46%) | 101.26 | 110.78 (+9.40%) | 117.95 (+6.48%) |
| A10B: Blood glucose lowering drugs, excl. Insulins | 1.19 | 1.21 (+1.80%) | 1.25 (+2.87%) | 90.68 | 89.81 (−0.97%) | 89.10 (−0.79%) |
| N05A: Antipsychotics | 12.01 | 11.97 (−0.32%) | 12.08 (+0.85%) | 59.59 | 62.23 (+4.42%) | 63.86 (+2.63%) |
| B01A: Antithrombotic agents | 5.73 | 5.79 (+1.03%) | 5.99 (+3.39%) | 64.59 | 65.30 (+1.10%) | 65.88 (+0.89%) |
| J01D: Other beta-lactam antibacterials | 58.95 | 60.25 (+2.21%) | 60.19 (−0.11%) | 4.24 | 3.77 (−11.01%) | 3.65 (−3.24%) |
| C10A: lipid modifying agents, plain | 0.82 | 0.84 (+2.53%) | 0.82 (−2.88%) | 62.94 | 61.82 (−1.77%) | 60.14 (−2.72%) |
| L01B: antimetabolites | 15.33 | 14.34 (−6.48%) | 13.47 (−6.04%) | 30.80 | 30.68 (−0.39%) | 32.01 (+4.35%) |
| B02B: Vitamin k and other hemostatics | 2.11 | 2.02 (−4.03%) | 2.18 (+7.71%) | 39.08 | 41.39 (+5.90%) | 38.67 (−6.56%) |
| (C) District hospital | ||||||
| L01X: other antineoplastic agents | 6.80 | 11.18 (+64.32%) | 13.92 (+24.54%) | 21.50 | 36.91 (+71.68%) | 62.25 (+68.64%) |
| A10B: Blood glucose lowering drugs, excl. Insulins | 0.64 | 0.70 (+10.48%) | 0.77 (+9.05%) | 53.64 | 57.28 (+6.78%) | 60.56 (+5.73%) |
| J05A: Direct Acting Antivirals | 0.44 | 0.78 (+77.88%) | 1.34 (+73.39%) | 74.32 | 64.88 (−12.70%) | 45.63 (−29.67%) |
| N05A: Antipsychotics | 11.31 | 11.59 (+2.45%) | 11.83 (+2.13%) | 25.15 | 27.00 (+7.39%) | 28.79 (+6.62%) |
| C10A: lipid modifying agents, plain | 0.31 | 0.34 (+9.71%) | 0.38 (+10.44%) | 33.12 | 35.05 (+5.83%) | 36.66 (+4.58%) |
| L04A: Immunosuppressants | 0.04 | 0.38 (+861.05%) | 0.71 (+85.49%) | 25.63 | 30.43 (+18.70%) | 35.05 (+15.17%) |
| J01D: Other beta-lactam antibacterials | 25.92 | 27.55 (+6.29%) | 30.28 (+9.91) | 2.02 | 1.94 (−3.95%) | 2.02 (+4.15%) |
| B01A: Antithrombotic agents | 1.18 | 1.38 (+16.66%) | 1.5 (+9.27%) | 24.43 | 27.27 (+11.66%) | 29.73 (+9.00%) |
| C09D: Angiotensin II antagonists, combinations | 0.34 | 0.36 (+6.10%) | 0.40 (+10.88%) | 24.59 | 25.93 (+5.44%) | 26.83 (+3.47%) |
| A10A: Insulins and analogs | 0.93 | 0.97 (+5.18%) | 0.99 (+1.32%) | 17.13 | 17.72 (+3.42%) | 18.09 (+2.11%) |
| (D) Clinics/others | ||||||
| A10B: Blood glucose lowering drugs, excl. Insulins | 0.00 | 0.00 (−64.39%) | 0.00 (−1.090%) | 63.07 | 70.49 (+11.76%) | 77.54 (+10.00%) |
| C10A: lipid modifying agents, plain | 0.00 | 0.00 (−100.00%) | 0.00 (−) | 51.05 | 55.93 (+9.57%) | 61.03 (+9.11%) |
| C09D: Angiotensin II antagonists, combinations | 0.00 | 0.00 (−) | 0.00 (−) | 33.37 | 37.43 (+12.17%) | 42.47 (+13.48%) |
| N06A: Psychoanaleptics | 0.00 | 0.00 (+0.00%) | 0.00 (+275.00%) | 22.72 | 25.80 (+13.53%) | 27.57 (+6.87%) |
| C09C: Angiotensin II receptor blockers (ARBs), plain | 0.00 | 0.00 (+32.05%) | 0.00 (−100.00%) | 23.96 | 25.31 (+5.63%) | 25.70 (+1.52%) |
| J05A: Direct Acting Antivirals | 0.00 | 0.00 (+515.38%) | 0.00 (−85.68%) | 28.14 | 26.64 (−5.32%) | 21.79 (−18.22%) |
| C08C: Selective calcium channel blockers with mainly vascular effects | 0.00 | 0.00 (+22.50%) | 0.00 (31.42%) | 20.11 | 18.96 (−5.75%) | 17.63 (−6.97%) |
| A10A: Insulins and analogs | 0.00 | 0.00 (−69.64%) | 0.00 (−100.00%) | 12.42 | 13.93 (−12.12%) | 14.92 (+7.11%) |
| N05A: Antipsychotics | 0.00 | 0.00 (+13.70%) | 0.00 (+32.16%) | 11.16 | 12.76 (+14.36%) | 13.90 (+8.92%) |
| N05B: Anxiolytics | 0.00 | 0.00 (−32.26%) | 0.00 (−38.09%) | 10.23 | 11.16 (+9.07%) | 11.87 (−6.30%) |
Hospital levels were categorized into four types: medical centers, regional hospitals, district hospitals, and clinics/others. The top 10 prescription ATC categories for different hospital levels were identified based on the annual sum cost of prescription drugs belonging to the same 3rd ATC level (pharmacological subgroup, form A01A to V10X), and the drug expenditure was indicated by million USD and the exchange rate used in this study was 1:29. (+ − percentage) indicated the percent change as compared with the previous year.
Furthermore, we examined OPD drug prescriptions for the highest drug expenditure item within the top 10 drug subgroups. In medical centers, osimertinib (L01XE35) recorded the highest drug expenditure at $44.20 million/year (median) with 92.75% incremental in 2021, followed by coagulation factor VIII (B02BD02) at $49.22 million/year (median), agalsidase alfa (A16AB03) at $31.55 million/year (median), and emtricitabine/tenofovir alafenamide/bictegravir (J05AR20) at $24.55 million/year (median). Regional hospitals showed the highest drug expenditure on antivirals for the treatment of Hepatitis C virus (HCV) infections (J05AP) at $87.85 million/year (median) with 37.25% decrease in 2020 and 42.85% decrease in 2021, followed by osimertinib (L01XE35) at $16.88 million/year (median), coagulation factor VIII (B02BD02) at $29.13 million/year (median), and clopidogrel (B01AC04) at $26.30 million/year (median). District hospitals exhibited the highest drug expenditure on antivirals for the treatment of HCV infections (J05AP) at $50.21 million/year (median) with an 18.12% decrease in 2020 and a 43.25% decrease in 2021, followed by valsartan and amlodipine (C09DB01) at $12.41 million/year (median), atorvastatin (C10AA05) at $10.68 million/year (median), and clopidogrel (B01AC04) at $9.90 million/year (median). Clinics saw the highest drug expenditure on valsartan and amlodipine (C09DB01) at $22.92 million/year (median) with 2.00% incremental in 2020 and 15.67% incremental in 2021, followed by atorvastatin (C10AA05) at $24.62 million/year (median), amlodipine (C08CA01) at $15.27 million/year (median), and antivirals for the treatment of HCV infections (J05AP) at $18.48 million/year (median). Because drug expenditure may be influenced by changes in prescription volume or other factors, we also analyzed the prescription volume for these highest drug expenditure OPD drugs. In general, the drug expenditure trend was aligned with the drug prescription volume trend (
Drug expenditure among different levels of hospitals based on the top 10 drugs.
| Drug expenditure | Drug prescription volume | |||||
|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2019 | 2020 | 2021 | |
| (A) Medical center | ||||||
| L01XE35 Osimertinib | 0.00 | 44.2 (−) | 92.75 (+109.83%) | 0.00 | 331,689 (−) | 732,934 (+120.97%) |
| J05AR20 emtricitabine, tenofovir alafenamide, and bictegravir | 1.66 | 24.55 (+1381.18%) | 33.77 (+37.56%) | 109,227 | 1,618,064 (+1381.38%) | 2,225,940 (+37.57%) |
| A16AB04 agalsidase beta | 25.40 | 31.55 (+24.20%) | 36.68 (+16.28%) | 4,180 | 5,220 (+24.87%) | 6,072 (+16.33%) |
| B02BD02 coagulation factor VIII* | 45.98 | 49.22 (+7.03%) | 52.18 (+6.01%) | 56,707,348 | 64,633,208 (+13.98%) | 69,327,984 (+7.26%) |
| L01BA04 pemetrexed | 32.96 | 31.96 (−3.02%) | 30.23 (−5.42%) | 67,516 | 66,067 (−2.15%) | 64,935 (−1.71%) |
| B01AC04 clopidogrel | 23.25 | 22.23 (−4.40%) | 21.31 (−4.13%) | 18,388,580 | 18,090,532 (−1.62%) | 18,007,160 (−0.46%) |
| J01DH02 meropenem | 20.84 | 21.48 (+3.06%) | 22.01 (+2.49%) | 1,860,415 | 1,952,166 (+4.93%) | 2,048,519 (+4.94%) |
| A10BH05 linagliptin | 7.33 | 7.21 (−1.63%) | 6.90 (−4.39%) | 11,595,084 | 11,625,201 (+0.26%) | 11,409,022 (−1.86%) |
| C10AA05 atorvastatin | 20.57 | 20.78 (+1.02%) | 20.38 (−1.89%) | 30,027,076 | 31,371,008 (+4.48%) | 32,286,872 (+2.92%) |
| N05AX13 paliperidone | 11.99 | 12.83 (+7.00%) | 13.47 (+5.02%) | 890,496 | 862,341 (−3.16%) |
823,276 (−4.53%) |
| (B) Regional hospital | ||||||
| J05AP Antivirals for treatment of HCV infections | 140.00 | 87.85 (−37.25%) | 50.20 (−42.85%) | 2,004,142 | 1,425,644 (−28.87%) | 851,980 (−40.24%) |
| L01XE35 Osimertinib | 0.00 | 16.88 (−) | 37.58 (+122.59%) | 0.00 | 91,052 (−) | 203,669 (+123.68%) |
| L04AB04 adalimumab | 16.82 | 18.38 (+9.28%) | 18.48 (+0.50%) | 35,461 | 39,261 (+10.72%) | 40,072 (+2.07%) |
| A10BH05 linagliptin | 10.55 | 10.69 (+1.41%) | 10.43 (−2.46%) | 16,741,889 | 17,294,452 (+3.30%) | 17,339,176 (+0.26%) |
| N05AX13 paliperidone | 14.63 | 16.13 (+10.27%) | 17.81 (+10.39%) | 1,430,455 | 1,478,434 (+3.35%) | 1,559,162 (+5.46%) |
| B01AC04 clopidogrel | 26.30 | 26.33 (+0.10%) | 26.12 (−0.80%) | 20,949,466 | 21,563,652 (+2.93%) | 22,200,594 (+2.95%) |
| C10AA05 atorvastatin | 20.67 | 21.04 (+1.82%) | 20.42 (−2.98%) | 32,810,202 | 34,583,672 (+5.41%) | 35,024,112 (+1.27%) |
| J01DH02 meropenem | 11.43 | 12.47 (+9.07%) | 11.99 (−3.83%) | 991,389 | 1,092,883 (+10.24%) | 1,079,449 (−1.23%) |
| L01BA04 pemetrexed | 17.76 | 15.89 (−10.53%) | 15.74 (−0.94%) | 38,506 | 35,571 (−7.62%) | 36,493 (+2.59%) |
| B02BD02 coagulation factor VIII* | 29.13 | 30.86 (+5.95%) | 26.66 (−13.59%) | 37,170,968 | 40,640,860 (+9.33%) | 35,691,760 (−12.18%) |
| (C) District hospital | ||||||
| J05AP Antivirals for treatment of HCV infections | 61.33 | 50.21 (−18.12%) | 28.50 (−43.25%) | 68,867 | 14,736 (−78.60%) | 1,001 (−93.21%) |
| A10BD08 metformin and vildagliptin | 6.13 | 6.21 (+1.38%) | 6.22 (+0.10%) | 13,647,774 | 15,723,724 (+15.21%) | 16,282,984 (+3.56%) |
| N05AH04 quetiapine | 8.30 | 8.66 (+4.40%) | 8.92 (+2.95%) | 15,264,334 | 16,776,926 (+9.91%) | 18,258,974 (+8.83%) |
| C10AA05 atorvastatin | 9.89 | 10.68 (+7.98%) | 11.37 (+6.52%) | 16,389,333 | 18,177,116 (+10.91%) | 20,245,444 (+11.38%) |
| L01XE35 Osimertinib | 0.00 | 2.63 (−) | 10.34 (+293.61%) | 0 | 13,752 (−) | 53,156 (+286.53%) |
| J01DH02 meropenem | 5.77 | 6.74 (+16.83%) | 7.35 (+8.97%) | 486,777 | 562,524 (+15.56%) | 623,444 (+10.83%) |
| L04AB06 golimumab | 4.71 | 5.93 (+25.78%) | 6.84 (+15.40%) | 4,410 | 5,568 (+26.26%) | 6,447 (+15.79%) |
| B01AC04 clopidogrel | 9.05 | 9.90 (+9.43%) | 10.70 (+8.08%) | 7,203,215 | 8,104,149 (+12.51%) | 9,082,635 (+12.07%) |
| C09DB01 valsartan and amlodipine | 12.07 | 12.41 (+2.80%) | 12.72 (+2.53%) | 24,877,696 | 26,184,508 (+5.25%) | 27,730,066 (+5.90%) |
| B02BD02 coagulation factor VIII* | 12.56 | 9.49 (−24.41%) | 8.35 (−12.06%) | 15,739,778 | 12,233,016 (−22.28%) | 10,726,518 (−12.32%) |
| (D) Clinics/others | ||||||
| A10BA02 metformin | 9.17 | 9.36 (+2.01%) | 9.56 (+2.18%) | 164,774,672 | 169,135,232 (+2.65%) | 174,504,752 (+3.17%) |
| C10AA05 atorvastatin | 23.00 | 24.62 (+7.06%) | 25.92 (+5.25%) | 54,256,536 | 60,777,800 (+12.02%) | 68,141,536 (+12.12%) |
| C09DB01 valsartan and amlodipine | 22.47 | 22.92 (+2.00%) | 26.51 (+15.67%) | 60,095,632 | 63,557,436 (+5.76%) | 74,617,856 (+17.40%) |
| J05AP Antivirals for treatment of HCV infections | 20.22 | 18.48 (−8.62%) | 13.52 (−26.84%) | 328,573 | 332,103 (+1.07%) | 253,191 (−23.76%) |
| C09CA08 Olmesartan | 4.55 | 7.79 (+71.14%) | 8.35 (+7.14%) | 9,072,812 | 14,877,530 (+63.98%) | 23,757,904 (+59.68%) |
| N06AB10 escitalopram | 7.24 | 7.86 (+8.54%) | 8.12 (+3.35%) | 22,069,612 | 25,790,508 (+16.86%) | 29,574,170 (+14.67%) |
| C08CA01 amlodipine | 16.21 | 15.27 (−5.76%) | 14.18 (−7.16%) | 120,464,400 | 118,787,056 (−1.36%) | 116,470,672 (−1.95%) |
| M01AB05 diclofenac | 3.92 | 3.28 (−16.16%) | 2.92 (−11.12%) | 158,280,864 | 129,689,904 (−18.06%) | 112,476,392 (−13.27%) |
| A10AE04 insulin glargine | 7.62 | 8.22 (+7.78%) | 8.49 (+3.35%) | 524,694 | 557,997 (+6.35%) | 582,344 (+4.36%) |
| R06AE09 levocetirizine | 2.65 | 2.65 (+0.26%) | 2.55 (−3.88%) | 43,684,112 | 44,361,760 (+1.55%) | 43,808,084 (−1.25%) |
Hospital levels were categorized into four types: medical centers, regional hospitals, district hospitals, and clinics/others. *The drug prescription volume unit used in this drug is I.U. The top 10 prescription ATC categories for different hospital levels were identified based on the annual sum cost of prescription drugs belonging to the same 5th ATC level (chemical substance, form A01AA01 to V10XX05), and the drug expenditure was indicated by million USD and the exchange rate used in this study was 1:29. (+ − percentage) indicated the percent change as compared with the previous year. The drug prescription volume trend for these highest drug expenditure items among the top 10 drug subgroups across different hospital levels was measured using the sum prescription quantity.
This study explored variations in drug expenditure across different hospital types and drug categories in Taiwan. We observed a consistent increase in drug expenditure across all hospital types in Taiwan in 2020, similar to the patterns observed in 2018 or 2019, based on a comprehensive analysis of a nationwide health insurance database (
Taiwan implemented various measures to prevent COVID-19 outbreaks (
In the context of COVID-19 treatment, healthcare providers have been prescribing antiviral medications and other experimental drugs under emergency use authorization or clinical trials (
Although analysis of NHIRD data has yielded various advantages, inherent limitations persist because of the NHIRD design, which lacks blind randomization. First, data gaps exist concerning self-payment-funded medications due to the NHIRD’s specific objectives. Disease severity remains challenging to quantify. Second, our study relies solely on the claim system, which introduces potential inaccuracies from coding errors and misclassifications. Third, the generalizability of our results may be limited by differences in healthcare systems, demographics, and lifestyle factors across regions or countries. Finally, the extensive time required by the NHI to compile and release annual data precluded the inclusion of the most recent patients in our study, emphasizing the need for additional data for long-term observations.
Our findings revealed a consistent rise in annual drug expenditures across all hospitals from 2019 to 2020 but a decrease from 2020 to 2021. This effect may be caused by the number of locally acquired confirmed cases of COVID-19 in 2020 (only 56), and an outbreak of approximately 15,000 cases occurred in 2021. Notably, antitumor and immunological agents had the highest drug expenditures at medical centers, regional hospitals, and district hospitals. In contrast, cardiac and hypertension drugs were the highest expenditure categories in clinics. While drug expenditure for anti-infectives for systemic use decreased in 2020 (−15.9%) but slightly increased in 2021 (0.6%) in the United States (
The data analyzed in this study is subject to the following licenses/restrictions: Taiwan national claim data sets are available through formal application to Applied Health Research Data Integration Service provided by the BNHI of Taiwan by provide detail research proposal. Restrictions applied to these data, which were used under license for our study, and so are not publicly available for duplication. Further data analysis may be requested after discussion with authors. Requests to access these datasets should be directed to
The studies involving humans were approved by MacKay Memorial Hospital Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements.
S-IW: Conceptualization, Investigation, Methodology, Writing – review & editing. A-SL: Data curation, Investigation, Project administration, Writing – review & editing. C-HC: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by grant from MacKay Memorial Hospital (MMH-11103 to S-IW). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
This study is based on data from the Applied Health Research Data Integration Service provided by the BNHI and the Center for Health and Welfare Data Science Center at the Ministry of Health and Welfare (H111077). The interpretation and conclusions contained herein do not represent those of the BNHI or Ministry of Health and Welfare.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.
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