血管支架治療對醫療資源耗用與術後結果分析－以某醫學中心為例

A Study of Stenting on Resources Utilization and Clinical Outcome of a Medical Center

沈文節(Wen-Jay Sum) ； 劉建志(Jen-Che Liu) ； 錢慶文(Ching-Wen Chien)

《醫務管理期刊》 5卷4期 (2004/12) Pp. 529-542

https://doi.org/10.6174/JHM2004.5(4).529

摘要

心臟病一向是先進國家死亡的主要原因。台灣地區近年來十大死亡原因中，心臟疾病也一直高居前三名。此外我國國民1998年醫療保健支出中在循環系統疾病上就花了403億元，佔健保門診支出的10.13%。由於冠狀動脈硬化所導致的缺血性心臟病是心臟科疾病中較常見的疾病，研究發展治療這種疾病的技術就引起許多心臟科專家、醫療保險管理當局和醫院管理者上的興趣。有鑑於此，本研究即以治療缺血性心臟病裝置血管支架為例，比較有無裝置血管支架（僅作PTCA）的醫療資源耗用與術後結果，研究結果將可以做為臨床處置、醫院管理及醫療保險政策制定之參考。
本研究以北部某醫學中心民國89年1月至90年12月接受冠狀動脈介入性療法（門診及住院ICD-9-CM編碼為410-414之缺血性心臟病且主手術碼為36.01及36.05）的病忠為研究對象，擷取其PTCA治療出院後一整年（12個月）之醫療費用和病歷等相關資料，共計283人。其中只接受PTCA治療者計179人，接受PTCA且加裝stent治療者有104人（健保36人，自費68人）。在分析病忠的性別、年齡、疾病嚴重度和醫療費用等資料後發現：
1．本研究的結果大致和目前國外的研究發現相類似，即裝stent的病人（不管是健保還是自費）在當次住院時的醫療資源耗用和在其術後一年內門診醫療資源耗用和門診次數都呈現出較只做PTCA的病人要多。
2．本研究的結果並無法支持裝置stent對於病人術後一年內的效果有明顯的比只做PTCA要好的假設。
由本研究的結果可以建議健保當局應該採用類似「統包」或「保國款」的方式來給付stent，以減少醫師在臨床上對於裝置stent的經濟壓力。此外由於本研究的樣本數可能不足，因此建議未來類似的研究應該增加研究機構和樣本數，並延長研究期間以增加研究結果的效度。

關鍵字

缺血性心臟病 ； 血管支架 ； 冠狀動脈介入性療法

並列摘要

Heart diseases have been major causes of death for many developed countries for many years. In recent years, heart diseases have become leading causes of death in Taiwan, too. According to the Department of Health, more than 40.3 billion of New Taiwan Dollars (NTD, or 10.13% of outpatient expenditure, was spent on treating heart diseases. Since Ischemic Heart Disease (IHD) is the most common heart disease, inventing new techniques, medicine and procedure to cure IHD have receive much attention of cardiovascular specialists, health insurance administration and hospital managers. Therefore, this study aims at comparing clinical outcome and resource-consumption by inserting stent (or stenting) for treating IHD patients. Results of this study can be used to assist clinicians, hospital managers and health policy maker in making decisions.
Data used in this study were collected by a medical center locating in northern Taiwan for the year of 2000 and 2001. Financial data and clinical abstracts were analyzed for IHD patients who discharged from the medical center for one year. 283 patients were included in this study; 179 of them received PTCA and 104 received PTCA and stenting (36 NHI patients and 68 self-paid patients). After analyzing patients' demographic, severity-of-illiness and resource-consumption data, two important conclusions were made:
1. Stenting patients consumed more resource than PTCA patients while receiving PTCA. In addition, they also consumed more resource for 12 consecutive months after they discharged from the center. 2. Results of this study do not provide any evidence which asserts better clinical outcome of stenting than PTCA alone.
Therefore, the Bureau of National Health Insurance should adopt a ”packaged-payment” or ”warranty” paying stenting so that physicians do not receive economical pressure while they are making clinical decisions. Besides, future similar studies should include more hospitals, subjects and length of time in order to increase external validity of the studies.

並列關鍵字

IHD ； Stent ； PTCA

參考文獻

全民健康保險醫療費用統計

江儀輝(1997)。冠狀動脈氣球擴張術及血管支架拭之介紹與探討。中華放射線技術學雜誌。21(1)，45-49。

統計資料

邱俊仁(2000)。急性心肌梗塞後直接經皮導管冠狀動脈氣球擴張術及血管內支架放置之單一醫院臨床經驗。中華民國心臟學會雜誌。16，15-24。

周友三、吳再成(1983)。經皮導管冠狀動脈管內整形術。代醫學。10(1)，62-64。