台灣心臟移植手術患者住院醫療資源利用
—以1996-2003年全民健保資料庫為例

中文摘要研究背景及動機：心臟移植是心臟衰竭的治療方式之一，接受心臟移植讓病人脫離長期需要依賴強心劑的生活。早期照護的重點在於延長病人壽命，現今乃在於提升病人醫療品質。健保局為改善民眾之醫療品質並延長生命，自民國八十四年即給付腎臟及心臟移植手術費用，目前國內醫學中心多已成立器官移植中心，提供病患移植前評估及資源協調、移植後排斥反應之治療及生活調適。所提供之心臟移植手術服務，已屬先進國家水準。然而綜觀國內對於心臟移植手術後，影響醫療品質及醫療服務利用的研究甚為缺乏，因此本研究主要在探討影響心臟移植病人醫療服務利用的各項相關因素，以期作為提升移植病人醫療品質之重點。環顧國內尚未有人針對心臟移植的醫療服務利用做探討的文獻，故激起研究者探討之動機。研究方法：本研究採用次級資料的回溯性分析，以民國八十五年至九十二年間所有在台灣進行過心臟移植手術之病人為基礎，探討心臟衰竭病人接受心臟移植手術後當次的住院醫療服務利用情形，並長期追蹤病人術後的醫療品質結果。分析內容為探討不同病人特質、機構特質對於當次移植手術後醫療服務資源利用以及醫療品質的影響。病人特質分為年齡、性別、合併症個數、合併症疾病別、死亡等。機構特質則分為醫院權屬別、醫院層級別、醫院服務量、醫師服務量和醫院所屬健保分局別等。醫療品質為當次手術死亡率。當次手術醫療服務利用包括移植當次手術住院醫療費用以及當次手術住院天數。長期醫療品質則為手術後第一年內死亡和手術後第三年內死亡。研究結果：本研究顯示當次手術醫療服務利用方面，每人平均當次手術住院天數為41.59天，平均當次手術住院醫療費用為870,620元。有腎臟疾病者為增加住院天數之預測因子，而有週邊血管疾病者為增加住院醫療費用之預測因子。當次手術醫療品質方面，當次手術院內死亡率17.81%，第一年死亡率25.67%，第三年死亡率36.06%。週邊血管疾病、腎臟疾病、法人醫院，中、低服務量醫院皆為當次手術院內死亡之預測因子。長期醫療品質方面則與人口學、疾病特質或機構特質均無相關。討論與建議：當次手術住院天數就人口學特質而言，年齡、性別均非影響當次手術住院天數的顯著因子。合併症方面則發現有腎臟疾病病患為增加當次手術住院天數的顯著因子，此點為本研究之特別發現。而在機構特質方面，無論是醫院權屬別、醫院層級別、醫院服務量、醫師服務量或是醫院所屬健保分局都不是增加住院天數的顯著因子。當次手術住院醫療費用就人口學特質而言，年齡、性別均非影響當次手術住院醫療費用顯著因子。合併症方面，則發現有週邊血管疾病者為增加當次手術住院醫療費用的顯著因子。此點為本研究之特別發現。有腎臟疾病及週邊血管疾病、中低服務量醫院有顯著影響到當次手術醫療品質；而醫院層級別則沒有影響。本研究發現，心臟移植病患長期醫療品質與原本疾病特質並無關係，後來研究者當可從後續門診追蹤資料中探究疾病特質變化，尋找真正影響長期醫療品質的原因。從研究中發現有腎臟疾病與週邊血管疾病者，有較高的醫療服務利用與較負面的醫療品質。在國人整體健康狀況日益提升之際，加強這兩類疾病患者的健康照護，避免長期慢性疾病的發生，也是本研究的貢獻。本研究發現高服務量的醫院，有較佳的術後醫療品質。然而施術的醫院，多侷限在北部，對於南部心臟衰竭病患就醫的可近性，有明顯不足。因此建議南部醫療機構，為了提升台灣南部病患的就醫品質，應該重點發展心臟移植手術。關鍵字：心臟移植、醫療服務利用、醫療品質

關鍵字

心臟移植；醫療服務利用；醫療品質

並列摘要

英文摘要 Background and Objective: Cardiac transplantation has been chosen as one of the feasible methods to treat terminally ill patients suffering from severe cardiac illness. It aims to help patients get away from hospitalization as well as dependence on inotropic agent injection. The health service at early stage was proposed to extend patient’s life, nowadays, it emphasizes on the improvement of health care quality and utilization of health service. Starting from the year 1995, National Health Insurance covers the expenditure of kidney and cardiac transplantation in order to upgrade the quality of health care and to prolong patients’ lives. Today, most domestic medical centers have established organ transplantation centers so as to provide the pre-transplant evaluation, resources coordination, treatment of rejection post operation as well as life accommodation. The cardiac transplantation services being offered have met the standards of developed countries. There is hardly any research paper on the utilization of health services post cardiac transplantation, this research is therefore aimed to study various factors affecting the utilization of health services with an expectation to enhance the health services. The writer is inspired to investigate into the utilization of cardiac transplantation services since there has never been any documentation on this aspect. Methods: For the research, retrospective analysis on secondary data is adopted. It is based on the data of heart failure patients underwent cardiac transplantation from 1996 to 2003 in Taiwan to study the utilization of health service during hospitalization and subsequently a long-term follow-up on the quality of health care. The focal points are to analyze how the patient characteristics and hospital characteristics have affected the utilization of health services and quality of health care post transplantation surgery. The patient characteristics include age, gender, comorbidity, death, etc. The hospital characteristics involve hospital ownership, hospital level, hospital cardiac transplantation volume, physician cardiac transplantation volume and hospital area. The quality of health service relates to in-hospital mortality. The surgery utilization of health service includes the surgery hospital expenditure and length of stay. The quality of long-term health service refers to 1-year mortality and 3-year mortality. Results: In terms of surgery utilization of health service, the research reveals that the average length of stay for surgery hospitalization is 41.59 days, and the average cardiac transplantation hospital expenditure is NT$870,600. Post operation, the significant factor extending the length of stay is renal disease, while the significant factor increasing the hospital expenditure is peripheral vascular disease. As regard to surgery utilization of health service, the in-hospital mortality takes 17.81%, 9.89% for 1-year mortality and 23.53% for 3-year mortality. Peripheral vascular disease, renal disease, legal hospital as well as low volume hospital are all significant factors for in-hospital mortality. However, as regard to long-term health service quality, it has no correlation with patient characteristics, disease characteristics or hospital characteristics. Discussion and Suggestion: As for surgery hospitalization, neither age nor gender is the significant factor affecting the length of stay. In terms of cormobidity, it is found that renal disease is a significant factor to extend the length of stay for patients having surgery. In terms of hospital characteristics, none can be regarded as the significant factor to extend the length of stay, no matter hospital ownership, hospital level, hospital cardiac transplantation volume, physician cardiac transplantation volume, or hospital area. As regard to cardiac transplantation hospital expenditure, a special finding in this research is that neither age nor gender of the patients has anything to do with it. The research shows that peripheral vascular disease is a significant factor to increase the hospital expenditure for patients having transplantation. Generally speaking, renal disease, peripheral vascular disease as well as low volume hospital are all significant factors affecting the quality of surgery health service, while the hospital level has no connection with it. It is found that long-term health service quality has no connection with the disease characteristics for patients receiving cardiac transplantation. It is expected that the successor may study the changes of disease characteristics through the long-term follow-up clinic research to discover the real causes affecting the long-term health service quality. This research reveals that patients with renal disease or peripheral vascular disease have more utilization of health service, whereas, with lesser service quality. It reminds us to enhance the health care of patients suffering from these two diseases so as to reduce the risk of chronic disease. According to this research, high volume hospitals tend to offer better postoperative health service quality. However, most hospitals performing operation are located at northern part of Taiwan, for patients residing at southern part of Taiwan and suffering from heart failure, they are not equally accessible to considerate health services. It is therefore recommended that a systematic development of cardiac transplantation should be proposed as a priority in southern medical organizations in order to upgaade the health service quality for patients in southern Taiwan. Keyword: cardiac transplantation, quality of heath care, utilization of health service