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  • 學位論文

多條冠狀動脈阻塞之病患使用不同療法的治療成效與醫療資源耗用暨相關因素探討

The Therapeutic Effectiveness of Different Treatments and The Related Factor of Medical Resources Utilization in Patients with Multiple Vessel Coronary Artery Disease

指導教授 : 李易蓁

摘要


研究背景 冠狀動脈阻塞性心臟病簡稱為冠心症。台灣由於經濟的發展及公共衛生的進步,使得國人平均餘命延長。近幾年來國人生活型態的改變以及飲食習慣逐漸西化,加上缺乏適當運動的習慣,以致罹患冠狀動脈阻塞心臟病的人數與日俱增。由本土流行病學資料顯示,國人冠狀動脈心臟病流行比率約4∼8%。換言之,每10到25人極有可能1人罹患冠心症。根據2013年行政院衛生福利部統計資料,心血管疾病位居的國人十大死因的第二位,每十萬人口約有76位死於心臟疾病。心血管疾病中又以冠狀動脈心臟病占最大多數(Nicholas,2013)。冠狀動脈阻塞心臟病好發於壯年及老年人口(M.G. Marmot,2005)。治療不僅耗費國家的醫療資源,對於社會或家庭的經濟損失更是無法估計(J LY,Liu.,2002)。 冠狀動脈疾病的治療,一直不斷地在發展。從藥物治療、冠狀動脈氣球擴張整型術到血管支架的置放和冠狀動脈繞道手術都有相當的成效。傳統支架很容易產生再狹窄的現象,導致半年內病患血管再度狹窄機率高達20%至25%。國外的研究顯示對於多條冠狀動脈阻塞的病患,冠狀動脈繞道手術比傳統支架有較好的結果跟效益。然而塗藥支架的發展,可降低傳統支架引起的病灶再狹窄比率。因此,本研究的目的為比較多條冠狀動脈阻塞病患的治療方法、治療成效與醫療資源耗用的相關影響因素。 研究方法: 研究樣本是擷取南部某一區域教學醫院2009年至2013年間,經診斷為多條冠狀動脈阻塞心臟病之病人,且接受單一種治療。治療方法係為接受冠狀動脈氣球擴張整型術並裸支架163位、塗藥型支架89位、冠狀動脈繞道手術134位。以SPSS軟體進行分析病歷檢視收集到的樣本資料,追蹤一年內的醫療資源耗用、治療成效。醫療資源耗用包含住院總天數、加護病房住院天數、治療手術費用、治療耗材費用、健保申報總金額、一年內再次入院次數及費用、一年內門診次數及費用;治療成效包含併發症、14日內再入院率、30日內及一年內死亡率。整合的資料以敘述性統計、卡方檢定、迴歸分析等,探討病患個人屬性、疾病特性、治療方式、影響存活因子與醫療資源耗用的差異。 研究結果: 當次治療平均住院日:塗藥型支架(6.85日)較冠狀動脈氣球擴張整型術和裸支架(10.98日)和冠狀動脈繞道手術(23.75日)住院天數少(p<0.05)。加護病房平均住院日:塗藥型支架(3.54日)較冠狀動脈氣球擴張整型術和裸支架(5.28日)和冠狀動脈繞道手術(10.08日)住院天數少(p<0.05)。首次治療總醫療費用上相比較,冠狀動脈繞道手術組(477137.78元)比裸支架組(249716.71元)和塗藥型支架組(28644.81元)高(p<0.001)。經多變量複迴歸分析之統計結果,高血脂、冠狀動脈阻塞位置、左心室功能和多條冠狀動脈阻塞心臟病首次醫療總費用有相關性且達顯著意義(p<0.05)。 當次治療後發生心臟血管不良併發症經邏輯斯迴歸分析,冠狀動脈繞道手術及塗藥支架組均比裸支架組有較少的心臟血管不良併發症;30日及一年死亡率,與治療方式無顯著相關。一年內再入院健保費用,經多變量複迴歸分析顯示冠狀動脈繞道手術組及塗藥型支架組較裸支架組少且有顯著相關(p<0.05);且與冠狀動脈阻塞數目、高血脂、婚姻及教育程度國小以下有相關性。 結論: 對於多條冠狀動脈阻塞心臟病之病人,高血脂、冠狀動脈阻塞位置、左心室功能和首次治療醫療總費用有相關性。冠狀動脈繞道手術與塗藥支架治療後發生心臟血管不良併發症較其裸支架組少。選擇冠狀動脈繞道手術當次的整體醫療資源利用較裸支架及塗藥支架多,但後續一年再入院健保費用比裸支架少(P<0.05)。塗藥支架當次治療醫療耗用資源少,但病患當次負擔費用較其他二組高(P<0.05),後續一年內再入院健保費用比裸支架少,與冠狀動脈繞道手術無顯著差異。多條冠狀動脈阻塞心臟病,冠狀動脈繞道手術或塗藥支架置放皆有不錯的成效。應積極接受治療,避免心臟功能惡化及合併症的衍生,減少增加的死亡風險及當次醫療資源耗用。

並列摘要


Background: Obstructive coronary heart disease referred to as coronary artery disease. In Taiwan, due to the development of economy and progress in public health, so that the average life expectancy of people lengthened. In recent years, people's lifestyle and eating habits change gradually westernized, adding on the lack of proper exercise habits, so that the number of people suffering from coronary artery disease increased. The local epidemiological data show that the prevalence rate of coronary artery disease is about 4-8%. In other words, every 10-25 people most likely to suffer from coronary artery disease. According to the the Ministry of Health and Welfare statistics in 2013, Cardiovascular disease was the 2nd in the top of ten death causes of people, approximately 76 per 100,000 population died of heart disease. Coronary artery disease accounts for the overwhelming majority of cardiovascular disease (Nicholas,2013). Coronary artery disease predisposed to occur in middle-aged and elderly population(M.G. Marmot,2005). Medical treatment is not only the waste of national resources,but the economic loss of society or family is unable to estimate. Treatment of coronary artery disease, has been constantly in development, from drug treatment, percutaneous transluminal coronary angioplasty with stents and coronary artery bypass surgery have a considerable effect. Traditional bare metal stents are prone to restenosis, leading to the probability of re-stenosis up to 20-25% within six months. Research abroad showed that coronary artery bypass surgery have better results with efficiency than conventional stents. However, the development of drug-eluting stents can reduce the restenosis rate of the conventional stent. Therefore, the purpose of this study is to compare the treatments in patients with multiple veseel coronary artery disaese, and elucidate realted factors of therapeutic effectiveness and medical resource utilization. Method : The study sample is collected the patients diagnosed with multiple vessel coroanry artery disease between 2009 to 2013, which accepted one type of treatment. There are 163 patients in BMS group, 89 patients in DES group and 134 patients in CABG group. We use the SPSS software to analyze the colleted medical records, tracking within a year of medical resource utilization, therapeutic effectiveness. The medical resource utilization included the days of hospitalization, ICU length of stay, treatment cost of surgery, therapy supplies costs, the total cost of health care, number and cost of re-admission and outpatient within a year. The therapeutic effectiveness included complications, readmission rates within 14 days, 30 days and one year mortality. We use integration of information in descriptive statistics, chi-square test, regression analysis to explore personal property, disease characteristics, treatments, survival factors and differences in consumption of medical resources. Result : The average length of hospital stay was 6.85 days in DES group,10.98 days in BMS group and 23.75 days in CABG group (p<0.05). The average length of the intensive care unit was 3.54 days in DES group, 5.28 days in BMS group and 10.08 days in CABG group (p<0.05). Total medical costs of the first treatment in CABG group (477137.78 NTD)was higher than BMS group (249716.71 NTD)and DES group (28644.81 NTD) (p<0.001). After multiple regression analysis of the statistical results, high cholesterol, coronary artery occlusion position, left ventricular function have relevance and meaning of significant in total medical costs of the first treatment (p<0.05). After logistic regression analysis of the cardiovascular adverse complications after treatment, CABG and DES group had fewer cardiovascular adverse complications than BMS group; three treatments had no significant relevant with 30 days and one year mortality. After multiple linear regression analysis, health care costs of readmission within one year in CABG and DES group were less than BMS group, and there is significant relevance (p<0.05); It was correlated with the number of ostructive coronary artery, high cholesterol, marriage and education below the elementary school. Conclusion : For patients with multiple vessel coronary artery disease, high cholesterol, coronary artery occlusion position, left ventricular function are relevant with total medical costs of the first treatment. CABG and DES group had fewer cardiovascular adverse complications than BMS group. The overall medical resource utilization of CABG was higher than BMS and DES, but the number and health care costs of readmissions in follow-up one year were less than BMS (P<0.05). DES had less treating medical resource utilization, but expense for patients was higher than other two groups(P<0.05); Health care costs of subsequent readmission within one year cost less than BMS stents, but had no significant differences compared to CABG. Coronary artery bypass surgery or drug-eluting stent have well results in treating multiple veseel coronary artery disease. It should be actively treated to avoid deterioration of cardiac function and complications of derivatives, reducing the increased risk of death and medical resources utilization of treatment.

參考文獻


英文文獻
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