全民健保論質計酬制度及都治計畫對結核病防治之成效評估

Performance Evaluation of the Pay-for-Performance Program and Directly Observerd Treatment, Short-course for Tuberculosis Control

李政益(Cheng-Yi Lee)

指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/健康政策與管理研究所/博士(2015年)

https://doi.org/10.6342/NTU.2015.01012

摘要

背景：為解決結核病防治的困境，提供完整個案照護、提升醫療品質，衛生福利部疾病管制署與健保署於2001年試辦執行「論質計酬」（Pay for Performance, P4P），2004年擴大執行；之後疾病管制署亦於2006年全面推動「都治計畫」（Directly Observed Treatment, Short-course, DOTS）。

目的：一、評估我國執行結核病論質計酬方案成效，分析加入方案與否其治療結果與醫療利用的差異。二、進行結核病論質計酬方案以及結核病都治計畫成本效果評估。

方法：一、研究採2004年結核病通報確診之法定個案（N=15,557），並串連健保資料庫以瞭解其醫療利用情形。針對加入與未加入P4P之個案，採傾向分數配對法（Propensity Score Matching）以提高兩組間可比較性，並利用多變項迴歸模型以瞭解P4P方案之效果。二、採2006-2007年結核病通報確診之法定個案，並符合第一階段都治執行之痰抹片陽性個案（N=10,766），串連健保資料庫，以分析其醫療利用（直接成本）；搭配行政院主計總處人力資源調查資料庫，依該年度結核病個案特質，分別計算社會生產力以及陪病家屬生產力損失（間接成本），並以社會觀點呈現總成本支出。

結果：一、加入P4P方案與否兩組病人特性無統計顯著差異。P4P個案門診利用頻次較未加入者高14%（P<0.001），但住院、急診頻率則無統計上之差異。P4P總醫療成本比未加入者少4.6%（新台幣6,450元）；治療成功勝算比，為未加入者之1.56（OR:1.38-1.76, P<0.001），死亡率亦低3.9%。二、同時加入P4P與DOTS者，比起僅加入P4P、DOTS、皆未加入組，同時加入組病況較嚴重，但治療成功比例最高（83.1%），皆未加入方案者最低（24.2%）。以直接成本（含醫療利用與都治計畫）而言，皆未加入組平均成本新台幣66,707元最低；同時加入P4P與DOTS者平均成本新台幣93331最高。以社會觀點成本（加計社會生產力損失與陪病成本等）而言，皆未加入組平均成本新台幣83,767元最低；同時加入P4P與DOTS者平均成本新台幣109,266最高。如以平均成本效果比（Average Cost-Effectiveness Ratio , ACER）而言，P4P（121,335元）、DOTS（171,226元）、P4P+DOTS（131,530元）以及常規治療方案（346,187元）；加入P4P平均每名治療成功個案所需耗費的成本最低。多元方案比較，利用增量成本效果比（Incremental Cost-Effectiveness Ratio, ICER）進行分析，加入P4P為最具成本效果比之方案。若以世界衛生組織評估衛生政策介入是否具成本效果之基準（WHO-CHOICE, CHOosing Interventions that are Cost-Effective），利用ACER進行方案評估後，各方案皆小於1 GDP per capita，皆為高度成本效果比（Highly cost-effective）之介入方案。

結論：一、P4P方案可提高照護結果，並節省整體醫療費用。二、同時加入P4P與DOTS者，其治療結果最佳，以社會層面觀點（societal perspective）考量直接成本以及間接成本而言，加入P4P方案平均耗費成本最低。利用世界衛生組織評估標準，P4P、DOTS皆為高度成本效果之介入措施。

關鍵字

結核病 ； 論質計酬 ； 都治計畫 ； 成本效果分析 ； 醫療利用

並列摘要

Background: Taiwan Centers for Disease Control (CDC) and Bureau of National Health Insurance (BNHI) implemented the tuberculosis (TB) pay-for-performance (P4P) program in 2001 to improve health care qualities and case management, and which program was broadly adopted in 2004. A nationwide campaign “Directly Observed Treatment, Short-course” (DOTS) was then introduced in 2006.
Objectives: The objective of the study was to evaluate the efficacy of TB P4P program, and to explore treatment outcomes and health care utilizations. The other purpose was cost-effectiveness analysis of P4P and DOTS programs.
Methods: This study recruited 15,557 TB cases who were reported to the Taiwan CDC in 2004, and then linked with health care utilization claimed data from BNHI. To improve the comparability of the two groups, we used Propensity Score Matching to compare the performance between cases with and without P4P program, and also used multinomial logistic regression model to investigate the efficacy of P4P. In the other part of the study, the study recruited 10,766 cases diagnosed in 2006-2007 and eligible for DOTS stage I (sputum smear positive cases). Data linking to BNHI was to analyze the medical utilization (direct costs). To explore social productivity loss of patients and family members, we used data from Directorate-General of Budget, Accounting and Statistics survey of human resources database to explore the indirect costs, and the study represented societal perspective costs.
Results: The results showed that no significant difference in case characteristics between two groups with and without P4P program. The study revealed that P4P group had a higher Outpatient Department (OPD) utilization rate of 14% (P<0.001), but no significance in hospital admission or emergency utilization. Total medical costs in P4P group were 4.6% lower (NTD. 6,450; USD. $215) than non-P4P group. Odds Ratio of treatment success was 1.56 times higher than non-P4P group. (OR: 1.38-1.76, P<0.001). Death rate in the P4P group was 3.9% lower than non-P4P group. Comparing group with P4P and DOTS, group with P4P only, group with DOTS only, and group without P4P or DOTS, P4P and DOTS group had inferior medical conditions, but had the highest treatment success rate (83.1%), group without P4P or DOTS had the lowest treatment success rates of 24.2%. Regarding to the direct costs, average cost of group without P4P or DOTS were the lowest (NTD. 66,707; USD. $2223.6), while of P4P and DOTS group were the highest (NTD. 93,331; USD. $3111.0). As for societal perspective costs, including loss of social productivity of patients and family member companions, group without P4P or DOTS had the lowest average costs of NTD. 83,767 (USD. $2,792.3), whereas P4P and DOTS group had the highest of NTD. 109,266 (USD. $3,642.2). As for Average Cost-effectiveness Ratio (ACER), P4P group was NT121,335 (USD. $4,044.5), DOTS group as NT171,226 (USD. $5,707.5), P4P and DOTS group as NT131,530 (USD. $4,384.3), and conventional TB treatment was NT346,187 (USD. $11,539.6) . Overall, P4P group had the lowest expenditures of per treatment success case. Comparing with multiple programs, we adopted Incremental Cost-Effectiveness Ratio (ICER), the P4P was the most cost-effective program. According to WHO-CHOICE (CHOosing Interventions that are Cost-Effective), adopting ACER to evaluate programs, P4P and DOTS programs were all highly cost-effective interventions.
Conclusion: The TB P4P program can improve health care outcomes, and save the health care expenditure. Secondly, patients enrolled both in P4P and DOTS programs, had the best treatment outcomes. Considering direct and indirect costs in societal perspective, P4P program costs the lowest with average. P4P and DOTS programs are both highly cost-effective intervention programs according to the World Health Organization standard (WHO-CHOICE, CHOosing Interventions that are Cost-Effective).

並列關鍵字

Tuberculosis ； Pay for Performance (P4P) ； Directly Observed Treatment ； Short-course (DOTS) ； Cost-Effectiveness Analysis ； Health Care Utilization

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