新設醫院對於急性心肌梗塞病人之住院醫療品質與治療結果之影響

Impacts of Newly-opened Hospitals on Inpatient Quality of Care and Treatment Outcomes for Patients with Acute Myocardial Infarction

魏璽倫(Shi-Lun Wei)

指導教授 ： 楊銘欽

國立臺灣大學/公共衛生學院/健康政策與管理研究所/博士(2013年)

https://doi.org/10.6342/NTU.2013.10255

摘要

我國自2008年迄今，心臟疾病為十大死因第二名，以2012年統計資料為例，心臟疾病之死亡率為每10萬人中有73.6人，佔所有死因11.13％，對國人的健康與生命威脅可見一斑，其中急性心肌梗塞（Acute Myocardial Infarction, AMI）是最嚴重也最易危及病人的生命，2012年台灣地區急性心肌梗塞之標準化死亡率為每十萬人口22.6人，是心臟疾病的重要殺手。
新設醫院的成立，可能帶來較多的資源以及提高當地民眾之就醫可近性，進而影響治療品質。本研究因此擬探討新設醫院對急性心肌梗塞病人之住院過程面品質與治療結果之影響，及相關影響因素。由於新竹地區於2002年8月與11月新成立兩家醫院，故本研究以在新竹地區住院的急性心肌梗塞病人為研究組，在苗栗地區住院者為對照組，利用2000年至2006年之全民健康保險資料庫，分析新設醫院成立前後急性心肌梗塞住院病人醫療品質與照護結果之變化情形。
本研究目的為（一）探討影響急性心肌梗塞住院病人照護結果之相關因素。（二）探討影響急性心肌梗塞住院病人醫療過程品質之相關因素。（三）探討研究組病人之醫療品質與照護結果於醫療資源投入（醫院設立）前後之變化以及對照組在同一期間之變化。
本研究資料來源為全民健康保險資料庫，以2000年至2002年及2004年至2006年之「全民健保處方及治療明細檔_住院」、「全民健保處方及治療醫令明細檔_住院」、「醫療院所評鑑等級檔」、「專科醫師證書主檔」等，並串聯衛生署之「死因統計檔」進行分析，研究對象為於新竹縣市與苗栗縣住院之急性心肌梗塞病人（ICD-9-CM Code為410.xx），並排除18歲以下及100歲以上及再診療者。自變項包括新設醫院成立前後、醫院特質（權屬別、層級別、教學狀態、服務量）與醫師特質（執業科別、專科執業年資、服務量）；控制變項包括地區別、病人之年齡、性別、共病症等；依變項為住院期間過程面與結果面之品質指標。本研究之醫療品質係以美國老人及貧民保險照護中心(Centers for Medicare & Medicaid Service, CMS)結合美國心臟協會(American Heart Association, AHA)與美國心臟學會(American College of Cardiology, ACC)於2006年所訂定之急性心肌梗塞臨床指引及品質測量指標為評估之依據。其中過程面品質指標包括用藥指標（阿斯匹靈、乙型阻斷劑、血管緊縮素轉化酵素抑制劑、禁用鈣離子阻斷劑、降低膽固醇治療）以及診療指標（低密度脂蛋白測試及血管再通術）。結果面品質指標包括住院期間死亡、住院日數、出院後14天、30天、180天與一年內因急性心肌梗塞及相關疾病再住院情形，以及出院後30天、60天、180天與一年內之死亡情形。研究對象則分別以適用對象(eligible patients)及排除非適應症後之理想對象(ideal patients)進行測量。
本研究統計以羅吉斯迴歸、複迴歸及廣義估計方程式（Generalized Estimating Equation, GEE）探討影響急性心肌梗塞病人之住院醫療品質與照護結果因素，重要研究結果如下：
一、新設醫院成立後急性心肌梗塞病人住院過程品質指標變化與影響因素
新設醫院成立前後的期間，兩組在品質指標表現的變化相近，但是在品質指標遵循情形方面，對照組僅血栓溶解劑之遵循情形退步，其餘品質指標中有六項（阿斯匹靈、血管緊縮素轉化酵素抑制劑、降低膽固醇藥物、針對左心室收縮障礙病人禁用鈣離子阻斷劑、低密度脂蛋白檢測及經皮冠狀動脈擴張術）均呈現統計上的顯著進步；研究組則僅有四項（降低膽固醇藥物、針對左心室收縮障礙病人禁用鈣離子阻斷劑、低密度脂蛋白檢測及經皮冠狀動脈擴張術）呈現統計上的顯著進步。但是，以進步的幅度而言，研究組雖僅有四項品質指標表現進步，但在統計上均呈現顯著提升（p<0.0001），對照組則僅在經皮冠狀動脈擴張術之指標表現有顯著進步（p<0.0001）。影響因素方面，新設醫院成立後的期間，研究組醫院在降膽固醇藥物、低密度脂蛋白檢測、血管再通術以及經皮冠狀動脈擴張術之遵循情形都顯著較新設醫院成立前進步，但血管緊縮素轉化酵素抑制劑之正確使用情形則退步。醫院特質中，教學醫院、區域醫院在阿斯匹靈、降膽固醇藥物、低密度脂蛋白檢測之指標表現較佳，非公立醫院在乙型阻斷劑、血管緊縮素轉化酵素抑制劑或第二型血管轉化酵素接受體抑制劑及降膽固醇藥物之指標表現較佳，服務量高之醫院則在經皮冠狀動脈擴張術之表現較佳。醫師特質部分，心臟內科醫師在阿斯匹靈、降膽固醇藥物及血管再通術之指標表現較佳，專科執業年資較長者在血管緊縮素轉化酵素抑制劑及降膽固醇藥物之指標表現較佳，服務量較高的醫師在乙型阻斷劑之指標表現較佳。
二、新設醫院成立後急性心肌梗塞病人住院治療結果變化與影響因素
在新設醫院成立後，僅研究組的住院天數顯著較成立前長（p=0.0015），且以女性、75歲以上、前壁梗塞、多項合併症，以及公立醫院、區域醫院、血管緊縮素轉化酵素抑制劑遵循情形較差者，其住院天數較長。影響住院期間死亡之因素則以55歲以上、7項合併症以上、非心臟內科、低服務量醫師，以及阿斯匹靈、降膽固醇藥物、低密度脂蛋白檢測之指標遵循情形較差者風險較高。
有關影響出院後因急性心肌梗塞相關疾病短期內再住院（14日內及30日內）之因素，為65歲以上、前壁梗塞、合併症3項以上之病人，以及公立醫院與低服務量醫師；而一年內再住院之病人特質為女性、65歲以上、合併症5項以上，以及公立醫院、醫師執業年資越短者再住院風險較高。在新設醫院成立以後，無論是研究組或對照組，出院後死亡（30日內及60日內）風險均顯著降低，而65歲以上、多項合併症病人及非公立醫院在出院後30日內及60日內死亡風險較高；而一年內死亡，則以女性、65歲以上、合併症3項以上、非心臟內科就醫、低服務量醫師以及血管再通術遵循情形較佳者死亡風險較高。

整體而言，新設醫院成立以後對於住院天數以及出院後30日內及60日內死亡具有顯著影響，對於是否因相關疾病再住院以及住院期間死亡，可能與疾病本身嚴重度具有高度相關，醫療資源變化的影響較不顯著。
依據本研究之結果有以下幾點建議：（一）對衛生主管機關：（1）加強國人預防保健觀念，特別是對於具危險因子之病人，如有共病症之高齡長者，宜加強宣導定期病情追蹤及良好生活習慣之重要性。（2）與心臟專科學會合作共同發展心臟疾病處置相關資料庫，如美國之ACC/AHA與加拿大CCORT，納入重要臨床變項訂定出治療過程品質指標規範據以監測以促進急性心肌梗塞處置品質。（二）對醫療提供者：（1）醫院內可由高服務量醫師對於低服務量醫師定時給予訓練與教學，並加強低手術量醫師之品質監控，以提升醫院整體醫療水準。（2）應安排相關專科醫師也接受急性心肌梗塞之醫學新知，並提供完整教育訓練以降低急性心肌梗塞發生後之死亡風險。（三）對後續研究者：（1）可進行區域變異分析，以探討急性心肌梗塞之住院過程醫療服務之適當性，並結合臨床資料以更精確的方式評估品質指標之遵循狀況。（2）探討急性心肌梗塞病人延遲就醫的原因與疾病表現型態，以降低未到院前死亡之風險。（3）可延長研究期間以提高樣本數量，並降低研究結果偏差，亦可進行不同年度間急性心肌梗塞之醫療品質趨勢變化。

關鍵字

全民健保 ； 新設醫院 ； 急性心肌梗塞 ； 過程品質 ； 治療結果

並列摘要

Since 2008, heart diseases is the second leading cause of death in Taiwan. The death rate of heart disease was 73.6 per 100,000 people, accounting for 11.13% of all causes of death in 2012. Among all the heart diseases, acute myocardial infarction (AMI) posed the highest threat to patients’ lives. In 2012 Taiwan's standardized mortality rate of AMI was 22.6 per 100,000 people, indicated that it was an important killer of heart diseases.
Newly-opened Hospitals may bring more resources and to enhance the accessibility and thus enhance therapeutic qualities. Therefore, this study was to investigate the effects of newly-opened hospitals on the quality of process of care and treatment outcomes for acute myocardial infarction patients during their hospitalization and associated factors. In Hsinchu county, two new hospitals opened in 2002, this study used hospitalized patients with acute myocardial infarction in Hsinchu county as the study group, and inpatients with acute myocardial infarction in in Miaoli county as the control group. The study used the 2000-2006 National Health Insurance Research Database, analyzing the impacts of newly-opened hospitals on inpatient quality of care and treatment outcomes for patients with acute myocardial infarction.
This study aimed to (1) explore the impact of quality of care for acute myocardial infarction patients and the relevant factors. (2) investigate the impacts of treatment outcomes for patients with acute myocardial infarction and the relevant factors. (3) examine the quality of care and treatment outcomes for patients before and after the open of new hospitals and the changes of control group in the same period.
Data source of this study came from the National Health Insurance database, including 2000 to 2006 "H_NHI_IPDTE file", "H_NHI_OPDTE file", "H_NHI_IPDT file", "H_DOH_ACCMF file", "H_DOH_MEDPE file" and "H_OST_DEATH file". The research subjects were inpatients with acute myocardial infarction (ICD -9-CM Code of 410.xx), and excluded those who were less than 18 years old or older than 100 years old and who were re-treated in Hsinchu and Miaoli hospitals. The Independent variables included the time before or after new hospitals opened, hospital characteristics (ownership, accreditation level, teaching status, and service volume) and physician characteristics (specialty, practice seniority, and service volume); control variables included location, patient's age, gender, comorbidities, etc.; dependent variables were inpatient quality of care and treatment outcomes for patients with acute myocardial infarction.
The quality indicators used in this study was based on the recommendation of the Centers for Medicare & Medicaid Services (CMS) combined with the American Heart Association (AHA) and the American College of Cardiology (ACC) in 2006. Process indicators include medication indicators (aspirin, beta-blockers, angiotensin converting enzyme inhibitors, calcium channel blockers inhibited, lower cholesterol treatment) and treatment indicators (LDL test and reperfusion therapy). Outcome quality indicators include hospital mortality, length of stay, whether or not re-hospitalized due to acute myocardial infarction or related diseases within 14 days, 30 days, 180 days and one year after discharge, as well as death within 30 days, 60 days, 180 days and one year after discharge. Study were measured on eligible patients and ideal patients after excluding non-indications.
In this study, logistic regression, multiple regression and generalized estimating equations (GEE) were used to investigate the impact on inpatient quality of care and treatment outcomes for patients with acute myocardial infarction. Important research results are as follows:
A. After the new hospitals opened, the impact of quality of care for acute myocardial infarction patients and the relevant factors
Before and after the new hospitals were established, the changes of the performance of quality indicators were similar in both groups. In the control group, however, only the indicator of thrombolytic agents fall backward, six of the remaining quality indicators (aspirin, angiotensin converting enzyme inhibitors, lower cholesterol drugs, patients with left ventricular systolic dysfunction calcium channel blockers, LDL test and percutaneous transluminal coronary angioplasty, PTCA) showed statistically significant progress. In the study group, only four (lower cholesterol drugs, patients with left ventricular systolic dysfunction calcium channel blockers disabled, LDL test and PTCA) showed statistically significant improvement. However, in terms of the magnitude of the progress in the study group, four quality indicators showed statistically significantly increase (p<0.0001), and only one indicator (PTCA) of the control group showed statistically significantly increase (p<0.0001). Related to influence factors, after the establishment of the new hospitals, the cholesterol-lowering drugs, LDL test, reperfusion, and PTCA in the study group were significantly improved, but the correct use of angiotensin converting enzyme inhibitors fell backwards. In terms of hospital characteristics, being teaching hospitals and regional hospitals performed better in the use of aspirin, cholesterol-lowering drugs, LDL test; being non-public hospitals performed better in the use of beta-blockers, angiotensin converting enzyme inhibitors than public hospitals. Hospitals of high service volume performed better in PTCA. Regarding physician characteristics, cardiologist performed better in use of aspirin, cholesterol-lowering drugs and reperfusion; physicians who has longer years of practice performed better in the use of angiotensin converting enzyme inhibitors and cholesterol-lowering drugs. Physicians of higher service volume performed better in the use of beta-blockers.

B. After the new hospitals opened, the impact of treatment outcomes for acute myocardial infarction patients and the relevant factors
After new hospitals opened, only the length of stay of the study group was significantly longer than before (p =0.0015), and patients who were females, over 75 years old, had anterior infarction, with multiple complications, as well as public hospitals, regional hospitals, and angiotensin converting enzyme inhibitors perform worse, had longer hospital stay.
The factors affecting mortality during hospitalization include over 55 years of age, with seven or more complications, treated by non-cardiologist, physicians of low volume services, as well as the use of aspirin, cholesterol-lowering drugs, LDL test of indicators perform worse had higher mortality.
The factors associated with re-admission due to acute myocardial infarction-related diseases within 14 days and 30 days after discharge include over 65 years of age, anterior infarction, more complications, and low volume of services of public hospitals and physicians. Factors related to re-admission within one year after discharge include being female, over 65 years of age, more than 5 complications, as well as public hospitals, shorter physician practice years had higher risk of re-hospitalization.
After the new hospitals opened, mortality of both the study group and the control group after discharged (30 days and 60 days) were significantly reduced. But those over 65 years, had more complications and treated in non-public hospitals had higher risk of mortality after discharge. Being women, over 65 years of age, had more than 3 comorbidities, treated by non-cardiologist, physicians of lower service volume, better compliance of reperfusion had higher mortality risk after discharge.
Overall, after the new hospitals were opened, it has a significant impact on the length of stay and within 30 days and 60 days mortality after discharge. Whether the re-admission and died in hospital, may be highly associated with the severity of the disease itself, the change of resource is less significant.
The following recommendations were based on the results of this study: (1) For the health authorities: (a) To strengthen and promote the concept of prevention of heart diseases, especially for patients with risk factors, such as the elderly with comorbidities, should emphasize the importance of regularly follow-up and to keep good habits. (b) To cooperate with the society of cardiology and develop the heart disease database, similar to that of the United States of ACC / AHA and Canada CCORT, including important clinical variables and the treatment process to monitor quality indicators to promote standardized data of acute myocardial infarction. (2) For health care providers: (a) Physician with high service volume could regularly provide training and education for low-volume physicians in order to enhance the overall hospital medical standards. (b) To arrange for the relevant specialists to receive related knowledge about acute myocardial infarction, and provide a complete education and training to reduce the occurrence of acute myocardial infarction mortality risk. (3) For future researchers: (a) Regional variation can be analyzed to investigate the appropriateness of care for acute myocardial infarction during hospitalization, and to combine clinical information to assess the quality of indicators more accurately. (b) To explore the reasons of the delay in medical treatment for patients with acute myocardial infarction and disease manifestations patterns, in order to reduce the risk of pre-hospital death. (c) To extend the study period in order to increase the sample size, and reduce research bias as well as to trace the trend of quality changes.

並列關鍵字

national health insurance (NHI) ； newly-open hospital ； acute myocardial infarction (AMI) ； quality of care ； treatment outcomes

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