壞死性筋膜炎病人發生率、醫療資源耗用及死亡率之探討

研究目的壞死性筋膜炎(Necrotizing fasciitis)於103年7月正式導入第二階段DRGs(共254項)。雖然健保署已將部分特殊疾病排除於Tw-DRGs適用範圍，但壞死性筋膜炎屬於重症疾病，由於治療項目多且耗費大量醫療資源，醫療機構在健保支付制度規定下，面臨醫療費用虧損的困境，本研究係藉由統計資料整合分析發生率、醫療費用、住院天數、死亡率及此疾病介入的相關影響因素，期許醫療資源得以合理分配與資源的有效利用係為本研究之最主要目的。研究方法本研究針對壞死性筋膜炎病人為研究對象，採用回溯式縱貫性研究方法，以全民健康保險資料庫的次級資料進行研究，研究期程為2004年1月1日起至2012年12月31日止，共計9年。運用卡方檢定、單因子變異數分析(ANOVA)、複迴歸分析及Cox存活分析等方法探討壞死性筋膜炎病人發生率、醫療資源耗用、死亡率及其相關影響因素。研究結果研究樣本為排除異常值後的主要分析樣本為16,331人。壞死性筋膜炎疾病發生率從2004年的4.8/每十萬人口到2012年的9.5/每十萬人口，結果顯示有逐年升高的趨勢(P<0.001)，好發月份則發生在每年7、8、9月最高，男性約為65.3%、而女性為34.7%；術後截肢共141人(約佔0.9%)，且有逐年下降的趨勢。整體而言，合併症嚴重度(CCI指數)對住院天數及醫療費用影響最大(P＜0.001)，社經地位及機構特性、醫院及醫師服務量都會影響出院後三十天再入院(P＜0.001)。住院天數越短，截肢的機會就會越低(P＜0.001)。年齡及機構特性為壞死性筋膜炎病人三十天死亡及出院後三十天再入院的風險因子(P<0.001)。結論與建議研究結果顯示壞死性筋膜炎病人發生率有顯著升高的趨勢，此現象與國外主要國家研究相似；合併症嚴重度對於該疾病醫療資源耗用影響很大，因此有效控制合併症將可降低醫療花費及住院天數；整體醫療照護中，減少醫院及醫師的服務量可降低出院後三十天再入院與三十天死亡的風險。依據研究的結果建議主管機關未來資源分配宜考量疾病別的特性，做為資源公平分配重新規劃之依據，並提供醫療機構於未來疾病管控及工作量調整政策推動之參考。

關鍵字

壞死性筋膜炎；截肢；合併症嚴重度指數(CCI指數) ；診斷關聯群

並列摘要

Specific Aim Necrotizing fasciitis was formally led into the second stage of DRGs, which include totally 254 records, in July 2014. National Health Insurance Administration has excluded some specific disease from the applicable scope of Tw-DRGs. However, necrotizing fasciitis is a critical disease, which costs numerous medical resources due to many kinds of therapy. It makes medical institutions mired in difficulties of deficit under the budget system of health insurance. Incidence rates, medical cost, length of hospitalization, mortality and relative factors of this disease are analyzed by integrated statistical data. The specific aim is to make a reasonable distribution and efficient utilization of medical resources. Methods The object of this research is aimed at patients of necrotizing fasciitis. Secondary data from 1st Jan 2004 to 31st Dec 2012 in the database of National Health Insurance is analyzed by backtracking longitudinal approach. Chi-square test, analysis of variance (ANOVA), multiple regression analysis and Cox proportional hazard model are used to discuss the incidence rates, consumption of medical resources, mortality and relative factors of necrotizing fasciitis. Result There are 16,331 people being sample after excluding abnormal data. The prevalence rate tends to increase year after year from 4.8 per hundred thousand populations in 2004 to 9.5 per hundred thousand populations (P<0.001). The highest rate occurs in July, August and September, among which 65.3% for male and 34.7% for female. About 141 people (0.9%) undergo an operation of amputation with a decreased tendency year after year. Generally, the seriousness of complication, which is indicated by Charlson Comorbidity Index, influences the length of hospitalization and the medical cost the most (P<0.001). Social-economic status, characteristic of medical institution, service of doctors and hospitals would affect rehospitalization within 30 days (P<0.001). The shorter length of hospitalization causes the lower opportunity of amputation (P<0.001). Patients’ age and characteristic of medical institution are the risk factors of expiration or rehospitalization within 30 days. Conclusion and Advise The result shows that the prevalence rate of necrotizing fasciitis increases year after year, which is similar to the result of researches in main countries. The seriousness of disease influences the consumption of medical resources very much. Therefore, efficiently controlling complications would decrease the length of hospitalization and medical cost. In general medical care, decreasing the quantity of hospitals and doctors’ service makes the risk of rehospitalization or expiration within 30 days decline. It advises the authorities that not only the distribution of medical resources but also the disease control and the adjustment of doctors’ workload in the future should base on the characteristic of disease.