- 學位論文
醫院經營社區到點乳房超音波與子宮頸抹片篩檢服務之成效探討
The Analysis of Community Health Screening by Breast Ultrasound and Pap Smear—A Hospital Perspective
摘要
研究目的：醫院在執行社區婦女健康篩檢時常包括子宮頸抹片及乳房觸摸檢查或乳房超音波檢查。前者有健保制度的預防保健費用支付，但乳房篩檢則無。本研究探討醫院經營婦女乳房超音波篩檢活動之策略，採用免費且每月常態深入社區舉行時，所投入之成本是否可藉異常篩檢結果的個案返院門診診療及追踪所產生的申報費用收入來分擔以自給自足。 研究方法：本研究設計採回溯性之縱貫性研究(Retrospective longitudinal study design)，蒐集高雄市市立民生醫院所屬「社區健康服務中心」，自民國90年8月至民國91年7月至高雄市各個社區鄰里機構等場所實施婦女乳房超音波及子宮頸抹片等健康檢查服務之資料，並且針對結果異常經轉介返回該醫院就醫者自民國90年11月至92年12月進行門住診追踪，分析此兩項篩檢之篩檢場所類別、執行醫師行為及受檢婦女年齡對於篩檢結果與返回醫院醫療資源利用之影響，並進一步探討投入成本及後續產出之收益。 研究結果：子宮頸抹片檢查共施行15021人次，平均年齡50.3歲。 乳房超音波檢查在同場次共施行11871人次，受檢年齡平均48.4歲；比較兩項檢查的受檢平均年齡則有統計上顯著的差異。將篩檢場所分類為社區組與機構組兩類，社區組174場，共6941人次且異常者349人，平均每場約40受檢人次，平均年齡47.9歲。機構組有86場次，篩檢共4930人次且異常者334人，平均每場次約57人受檢，平均年齡42.2歲；兩組類別之異常率及平均年齡皆有統計上顯著的差異。乳篩異常回診之醫療資源耗用在醫師之間所申報總費用並無差異；本研究中乳房篩檢異常個案以細針抽吸細胞學檢查診斷共施行244例(74.4%),總費用平均為4071元，可降低費用但與未進行細針抽吸細胞學檢查者間並無統計顯著差異。本研究共施行粗針穿刺切片檢查46例(14.0%)，總計費用平均為13310元，醫療總費用會明顯增加且有統計上顯著差異。 子抹篩檢活動在社區到點為醫院產生的效益成本比(Revenue/cost)為7,292,319元/2,065,977元(比值3.82)；乳超檢查為醫院所產生效益成本比為2,063,029元/1,401,677元(比值1.47)；若比較子抹及乳篩兩項服務之邊際效益成本比結果為2.60(3.82/1.47)。因此以本研究實証資料推估，若以此模式繼續執行乳癌之社區到點篩檢，則每年醫院需在社區辦理123個場次(5610人次)以上才符合經營效益。 結論：醫院舉辦之社區到點婦癌兩項篩檢服務，以醫院經營之角度，子宮頸抹片檢查可因健保申報給付獲較大效益；而婦女乳房超音波檢查以免費且每月常態舉行性質，所投入之成本(cost)可藉異常篩檢結果的個案返院門診以疾病診療及追踪一年所產生的申報費用收入(revenue)歸屬來分攤。若以病人服務之觀點來看，使用細針抽吸之微侵入性檢查不但提高了乳房診斷之準確性及病患就醫品質(medical care quality)且不增加醫療費用；而社區到點婦癌兩項篩檢服務也促使醫院形象(hospital image)獲得公眾認同提昇之邊際效益。
並列摘要
Background and purposes: Cancer of uterine cervix and breast has been the two leading causes of women cancer in Taiwan. Therefore, both were always included in women health screen activities in hospitals. The latter was done popularly by breast ultrasound exam but in freely insurance payment; the former performed well by pap smear in NIH insurance covered since 1995. This study aims to building up the strategy of breast screening freely in community, that the revenues of the cases with abnormal screening results back to hospital for management and follow-up could break-evened the previous costs input; and to further analyzing the screening results and behaviors of both of screening and outpatient management in hospital. Methods: The data of this study were collected retrospectively from the health screening activities in community, since Aug., 2001 to Jul., 2002, by the municipal Min-Sheng hospital of Kaohsiung, that women been attended to screening of breast ultrasound and pap smear. Associated follow up recorded in hospital were also traced since Oct., 2001 to Dec., 2003. About women cancer screening, to calculating all costs input and benefit from insurance revenues in community and hospital, to exploring the population of high risk women and to analyzing the factors influenced the behavior of examined women and served surgeon in breast exam were well performed. Results: The hospital provided 260 courses of women screen activities in community totally within one year. Pap smear and breast ultrasound exams were performed in 15021 and 11871 women. The average examined age of both was 50.3 and 48.4(p<0.0001). The screening rate and average age of both abnormality was 10.3% vs. 5.75% (p≦0.0005) and 46.5 vs. 45.1 year-old (p<0.005). The community women of breast ultrasound exam were divided into society group and institute group. The latter was younger than the former (42.2±9.4 vs. 47.9±9.3, p<0.001); and abnormality rate was higher in institute group (6.77% vs. 5.03%, p<0.0001). The abnormality rate of pap smear was higher within four to six decades. There were no statistically significant, in interval of back to hospital from screen date, medical consumption for diagnosis at out-patient, and follow up after initial visit, between served surgeons. About diagnosis procedures of breast abnormalities, the financial consumption of micro-invasive procedures (fine needle aspiration cytology) was lower but not significant statistically. However, core needle biopsy procedure used more medical resources (p<0.05). Financially, The revenue/cost of pap smear was 7,292,319/ 2,065,977 NTD (rate: 3.82) and of breast ultrasound 2,063,029/ 1,401,677 NTD (rate: 1.47). The final marginal ratio of both was 2.60. Furthermore, the breakeven point of free-charge breast ultrasound service was 5610 women in 123 courses by hospital annually. Conclusion: The pap smear service under NIH insurance provided got more benefit than the free charge breast ultrasound in community by hospital. Besides, more than the breakeven point service volume of women in community by the hospital, the overall cost could be fit by the revenues from medical consumption of abnormal screened cases back to hospital for further management.