台灣地區1999~2003年經皮冠狀動脈擴張術之醫師服務量與醫療利用及品質之相關性分析

The Association of Physician Volume of Percutaneous Transluminal Coronary Angioplasty with Medical Utilization and Quality in Taiwan from 1999 to 2003

曾鴻如

《科技教育課程改革與發展學術研討會論文集》 2008期 (2009/09) Pp. 67-73

https://doi.org/10.29495/CITE.200909.0067

摘要

Objectives本研究目的欲運用全國性樣本探討經皮冠狀動脈擴張術(Percutanueous Transluminal Coronary Angioplasty; PTCA)醫師服務量多寡對醫療利用及品質之影響。Background PTCA醫療服務量與醫療療效關係(volume-outcome)之研究發現高服務量醫師相較於低服務量醫師，其病人有較少的住院死亡率與同次住院併行CABG率。
Methods本研究設計是採用橫斷性研究法(Cross-sectional study)，資料收集時間上則採回溯研究法(Retrospective study)，利用1999~2003年國家衛生研究院「全民健康保險學術研究資料庫」之「特定主題檔之住院醫療費用清單明細檔」，其中主手術（處置）碼為36.01、36.02、36.05之PTCA手術患者，共78,961位，控制病患特質（年齡、性別、合併症嚴重度、置放支架）、醫師特質（執業年數）、醫院特質（權屬別、層級別、地區別）後，以Multiple linear regression與Multivarible logistic regression分析手術量多寡對住院中與手術後醫療利用（住院天數、醫療費用）、品質（住院中死亡、當次住院併行冠狀動脈繞道手術、14天內因缺血性心臟病再住院）之影響。
Results控制病患特質、醫院特質與醫師特質後，在醫療利用方面，低服務量醫師之住院天數(p=0.00)與醫療費用(p=0.00)高於高服務量醫師。在醫療品質方面，低服務量醫師與高服務量醫師相比，高出1.96倍的住院中死亡(95% CI=1.58-2.42)，高出86倍的當次住院併行CABG(OR=85.97; 95% CI=61.00-121.16)，而14天內因缺血性心臟病再住院率於低服務量醫師方面則較不顯著(OR=1.17; 95% CI=0.88-1.55)。
Conclusions依據本研究結果得知，在台灣，施行PTCA手術量愈高的醫師的確能減少醫療耗用與改善住院中死亡及再住院之發生風險。

關鍵字

經皮冠狀動脈擴張術 ； 醫師服務量 ； 醫療利用 ； 醫療品質

並列摘要

Objectives The purpose of this study was to examine the relationship between physician volume and medical utilization and quality of Percutaneous Transluminal Coronary Angioplasty (PTCA) by analyzing nationwide inpatient database in Taiwan from 1999 to 2003. Background
A majority of pervious studies evaluated volume-outcome relationship of PTCA using quality as outcome estimators, but rarely considering both utilization and quality. Besides, prior studies of PTCA dwelled on quality evaluation of in-hospital rather than post-surgery. This study investigated the relationship between physician volume of PTCA and medical utilization, inhospital and post-surgery quality.
Methods A retrospective study was conducted by using the National Health Insurance Research Database (NHIRD) since the years from 1999 to 2003. Clinical modification procedures with ICD-9-CM code 36.01, 36.02, 36.05 were selected from each year and total 78,961 PTCA cases were identified. Physicians were divided into low-volume (＜40 procedures), medium-volume (41 to 149 procedures), and high-volume (＞=150 procedures) institutions as a function to assess the effect of volume on outcome. Multiple logistic and linear egression models were used to analyze the association of physician volume with utilization (length of stay and medical expenditure), inhospital quality ratio (in-hospital mortality and same-day coronary artery bypass grafting [CABG] after PTCA) and post-surgery quality evaluation (14-day readmission rate caused by Ischemic Heart Disease [IHD]) while adjusting patient and hospital characteristic factors.
Results After adjustment for patient and hospital characteristics, we observed significant differences in the medical utilization and quality across physicians with low to high PTCA volume. Length of stay (p=0.00) and expenditure (p=0.00) of low-volume physicians were higher than high-volume physicians. In-hospital mortality rate of low-volume physicians was 1.96 times that of highvolume physicians (OR=1.96, 95% CI= 1.58-2.42). Further, 14-day readmission rate of medium-volume physicians was 1.29 times more than high-volume physicians (OR=1.29, 95% CI=1.12-1.50). Moreover, compared with same-day CABG at high-volume physicians, low-volume physicians had adverse outcomes less than high-volume physicians (OR=85.97; 95% CI=61.00-121.16)..
Conclusions Our study confirmed that volume-outcome relationship for medical utilization and quality improvement. These results suggested that high-volume physicians could improve better than low-volume physicians in medical utilization, in-hospital and post-surgery quality.

並列關鍵字

Percutanueous Transluminal Coronary Angioplasty ； physician volume ； medical utilization ； medical quality