臺灣住院診斷關聯群(Tw-DRGs)對多重慢性病患資源耗用及照護結果的影響

The Impact of Tw-DRGs Payments on Resource Use and Care Outcomes for Patients with Multiple Chronic Conditions

汪辰陽(Chen-Yang Wang)

指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2016年)

https://doi.org/10.6342/NTU201610395

摘要

背景：自1995 年我國健保開辦以來，實行過多次支付制度的改革，其中包含2010 年臺灣住院診斷關聯群（Tw-DRGs）的實施。由於此項制度為一種前瞻性支付制度，預先訂定支付標準，因此醫療院所有傾向減少處置亦或選擇病人。而多重慢性病經常使用較多醫療資源，目前尚未有研究探討DRG制度實施對於有無多重慢性病的病患是否有不同影響。
目的：本研究旨在探討臺灣住院診斷關聯群實施後，對於多重慢性病患之醫療利用與照護結果的影響。
方法：本研究以冠狀動脈繞道手術及經皮內冠狀動脈形成術的病人為介入組，尚未納入DRG之同大類MDC5項目手術的病人為對照組，資料來源為2008 年至2011 年全民健康保險資料庫。研究中利用傾向分數配對法（PSM）增加DRG實施前後個案的可比較性，並利用廣義估計方程式（GEE）與差異中的差異法（DID）進行分析。
結果：DRG實施後，相較於對照組，介入組在住院天數、用藥醫令數、總醫療費用皆顯著下降，照護結果則無差異；然而，介入組中有無多重慢性病相比，醫療利用與照護結果皆無統計上顯著差異。
結論：本研究的心臟病手術病人，在Tw-DRGs實施後並不會因為多重慢性病狀態的不同在醫療資源耗用與照護結果上有所差異。建議未來應針對其他疾病類別進行分析，以做為未來健保署繼續推行DRG制度之參考。

關鍵字

診斷關聯群 ； 多重慢性病 ； 冠狀動脈繞道手術 ； 經皮內冠狀動脈形成術 ； 醫療資源利用 ； 照護結果

並列摘要

Background: The National Health Insurance has been introduced since 1995, and several payment reforms have been implemented, including Taiwan diagnosis related group (Tw-DRGs). Under the prospective payment system with a pre-determined payment standard, hospitals tend to reduce medical service or select patients. Patients with multiple chronic conditions (MCCs) usually consume more medical resource than others. However, the impact of DRG payment on patients with multiple chronic conditions has not been examined.
Object: This study was to examine the impacts of implementing Tw-DRGs systems on medical resource usage and health care outcomes for patients with MCCs.
Methods: Patients who underwent coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty were included as the intervention group, and the comparison group consisted of patients who underwent the MDC5 surgeries which were not yet included in the Tw-DRGs. The data used was from
National Health Insurance Research Database, from 2008 to 2010. Propensity score matching was used to enhance the comparability between subjects before and after the implementation of DRG, and the generalized estimating equations model and difference-in-difference analysis was also used in this study.
Result: The introduction of DRG payment resulted in decrease in patient’s length of stay, the number of medication orders, and total inpatient expenses in the intervention group in relation to the comparison group, yet no significant changes were found concerning health care outcomes. However, in the intervention group, we found no significant difference between MCC patients and non-MCC patients in medical resource use and health care outcomes.
Conclusion: For the patients underwent cardiac surgery, the implementation of Tw-DRGs did not result in the differences in medical resources consumption or health care outcome between MCC patients and non-MCC patients. We suggest that more analysis on various kinds of diagnosis groups should be conducted and the findings may be useful for the National Health Insurance Administration DRG payment system.

並列關鍵字

diagnosis related groups ； multiple chronic conditions ； coronary artery bypass graft surgery ； percutaneous transluminal coronary angioplasty ； meducal resource use ； health care outcome

參考文獻

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