過程和過程品質對髖部骨折手術病人療效和資源使用之影響

Impact of Process and Process Quality on Outcome and Resources Utilization in Surgical Hip Fracture Patients

蘇庭裕(Ting-Yu Su)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士班/碩士(2016年)

摘要

研究目的
台灣髖部骨折發生率持續上升，高齡者持續增加。目前國內外較少研究住院輸血及物理治療對髖部骨折之療效、資源使用及存活之影響，本研究目的主要探討醫療過程對髖部骨折手術病人醫療品質和醫療資源使用之影響。
研究方法
本研究為縱貫性之回溯性研究，以百萬抽樣歸人檔資料庫分析2000和2005世代，研究對象為髖部骨折接受手術病人，在2000世代研究期間1997至2010年追蹤至2010年或死亡，而2005世代研究期間1997至2012年追蹤至2012年或死亡2000和2005世代分析樣本共7,906人及8,091人。探討依變項輸血、物理治療、併發症、再入院、死亡率、住院天數及醫療費用。
研究結果
2000與2005世代病人輸血之30天再入院風險高(OR=1.45及OR=1.7)；住院天數較多1.23天及1.22天，醫療費用較多8,239元及9,596元，入院30天內死亡風險高(OR=2.76及OR=2.61)。2000世代物理治療之30天再入院風險低(OR=0.83)；入院30天內死亡風險低(OR=0.65)。一般併發症之30天再入院風險高(OR=1.31及OR=1.32)，住院天數多4.24天及3.72天，醫療費用多15,872元及16,008元，入院30天內死亡風險高(OR=3.67及OR=4.11)。超長住院之30天再入院風險高(OR=1.64及OR=1.35)，醫療費用多42,086元及38,894元。
結論
醫療過程及過程品質皆對輸血、物理治療、再入院、死亡率、住院天數及醫療費用有影響。建議醫師制定治療指標增加護理過程及手術品質，而減少DRG支付制度的住院天數和費用，建議衛生保險機關定期審查過程品質指標。

關鍵字

髖部骨折 ； 輸血 ； 復健 ； 併發症 ； 療效 ； 醫療資源使用

並列摘要

Background
Incidence rates in hip fractures population have been increasing with the growth of elderly population in Taiwan. Process indicators, blood transfusion and physical therapy during hospitalization have impact on the outcomes, resources utilization and mortality for surgical hip fracture patient. However, few studies on this important elderly health care issue at Taiwan. The objectives of this study are examining how process and process quality on the medical quality and resources utilization for surgical hip fracture patients.
Method
This study used longitudinal retrospective study. Data sources were derived from The Longitudinal Health Insurance Database (LHID). The study analysed 2000 and 2005 LHID cohorts. The subjects were hip fracture patients with surgery during these the study period. In 2000 dataset, patients were identified had surgery between 1997-2010 and followed up to death or 2010, whereas, 2005 dataset were those patients had surgery between 1997-2012 and followed up to 2012 or death. The 2000 cohort and 2005 cohort had total sample of 7,960 and 8,091 respectively. The interested variables were complication, 30-day readmission, mortality, hospital days and healthcare expenditure.
Results
Patients had blood transfusion in 2000 and 2005 cohorts, had greater risk in 30-day readmissions (OR=1.45 and OR=1.75 ), longer stay in hospital (1.23 days and 1.22 days), have more medical costs ($NTD 8,239 and $NTD 9,596), death within 30 days of admission (OR=2.76 and OR=2.61). Patients in both cohorts with physical therapy in 2000 cohort had less risk readmitted to hospital 30-day after admissions (OR=0.83), death within 30 days of admission (OR=0.65). Patients had general complications had higher risk in 30-day readmissions (OR=1.31 and OR=1.32), more length of stays (4.24 days and 3.72 days), have more medical costs ($NTD 15,872 and $NTD 16,008), death within 30 days of admission (OR=3.67 and OR=4.11). Patients had surgical complications had higher risk in 30-day readmissions (OR=1.60 and OR=1.63 ), more longer stay in hospital (8.40 days and 8.87 days), have more medical costs ($NTD 45,059 and $NTD 57,665), death within 30 days of admission (OR=2.25 and OR=2.08). Patients had prolonged stay had higher risk in 30-day readmissions (OR=1.64 and OR=1.35), have more medical costs ($NTD 42,086 and $NTD 38,894).
Conclusions
The study confirmed that medical process and process quality had greater impact on blood transfusion, physical therapy, readmission, mortality, hospital length of stay and cost. Hospital clinicians is suggested to establish guidelines to have a better care in process, to improve quality of surgical patients, and consequently, decrease the hospital stay and cost under DRG payment system. For health Insurance administration, the study is suggested to have periodically review on process quality indicators.

並列關鍵字

Hip fracture ； Transfusions ； Rehabilitation ； Complications ； Outcome ； Resources Utilization

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