台灣剖腹產率的區域性差異、醫師剖腹產率的影響因素及剖腹產率與嬰兒初次周產期住院率的相關性

Area Variations of Cesarean Section Rates, Factors Influencing Physician’s Cesarean Section Rates and Association between Cesarean Section Rates and Perinatal Morbidity

陳進典(Gin-Den Chen)

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.2015.02643

摘要

過去20 年裡，大部分學者對於台灣剖腹產率的研究都使用個人層級的資料，探討非臨床相關因素與總體剖腹產率的關係。本研究以健保分局轄區、院所和醫師為分析單位，探討下列三個研究主題：一、探討不同分局轄區的剖腹產率差異和剖腹產適應症的變化趨勢，二、評估醫師和醫院層級的因素對醫師剖腹產率的影響，三、找出院所剖腹產率與院所內新生兒周產期住院率是否相關。
先以1998 到2010 年的全國住院資料檔案的住院費用清單明細檔 (in-patientexpenditures by admissions, DD)，進行先驅型的分析之後，三個主題都使用1998、2002、2006 和2010 年等四個年度的年度生產資料特殊需求檔進行分析。此特殊需求檔包括醫事機構基本資料檔(HOSB)、醫事人員基本資料檔PER)、住院費用清單明細檔(DD)、住院醫療費用醫令清單明細檔(DO)、門診處方及治療明細檔(CD)和門診處方醫令明細檔(OO)等，由資料庫裡的處置代碼整理出不同的生產方式。剖腹產率的計算方式是以年度剖腹產數除以全年度的活產數(申報資料裡的剖腹產加陰道產)，計算出台灣總體、分局轄區、院所和醫師的年度剖腹產率。第三個主題裡加入2002、2006 和2010 年由全國住院資料檔案的住院費用清單明
細檔計算出的院所內新生兒周產期住院數資料，將此資料串回前述的2002、2006和2010 年特殊需求檔之後，算出院所的新生兒周產期住院率，進行分析。主題一的結果顯示，不同分局轄區的最高與最低的剖腹產率差距：1998 年是9.53%、2002 年是12.5%、2006 年是8.44%和2010 年是10.84%。此結果代表以最低剖腹產率的分局轄區為基準時，最高分局轄區年度剖腹產率是最低分局轄區年度剖腹產率的1.29 至1.46 倍。而剖腹產適應症在各分局的分布情形也有顯著的差異，這四個年度裡主觀性剖腹產適應症無顯著的變化，再次剖腹產率逐漸的下降；但是胎位不正呈異常且顯著的升高趨勢，2006 和2010 年高危險妊娠適應症在分局轄區和院所層級也顯著且無法解釋的升高。 主題二的結果發現，控制了醫師和院所層級的因素之後，較低年服務量的醫師剖腹產率顯著的比高年服II務量的醫師高( 年接生數少於104 者的迴歸係數是0.0224, 95% CI:0.0051~0.0434, p =0.0363; 年接生數介於105 至363 者的迴歸係數是0.0234, 95%CI: 0.0051~0.04175, p=0.0122)；院所的特約別和院所對剖腹產的偏好扮演著影響該院所醫師剖腹產率的角色，相對於低剖腹產變異程度的院所的醫師，在中度和高度變異程度院所的醫師剖腹產率迴歸係數各為：0.026 和 0.0332 (95% C.I.：0.0068~0.0452, p=0.00781; 95% C.I.：0.0069~0.0595, p=0.0135)。 主題三的結果指出，在控制院所內的剖腹產適應症和高齡產婦的比例之後，院所的剖腹產率愈高者，該院所內出生嬰兒的初次周產期住院率也愈高(β= 0.21797, p=0.0221)。
本研究得到三個主要結論：台灣各健保分局轄區的剖腹產率有極大的差異，但只要能監控剖腹產適應症的不實申報(up-coding or code creep)，即可將台灣的剖腹產率降低至32%以下；醫師的剖腹產率主要是受到醫師產科的服務量、院所的特約別和院所對剖腹產的偏好所影響；高的院所剖腹產率與高的院所內新生兒初次周產期住院率有關，高剖腹產率確實會造成較高新生兒周產期的負外部效應。

關鍵字

剖腹產率 ； 區域性差異 ； 醫師剖腹產率 ； 周產期住院率

並列摘要

In the past two decades, most investigators have focused on overall CSRs and have used individual level data to demonstrate non-clinical associated factors of the CSR. The units of analysis in this study focused on branches of the National Health Insurance, institutions and physicians. Aims of this study were: 1. Evaluate variations in CSRs at different NHI branches and changes of indications for cesarean section; 2. Investigate factors influencing physicians’ CSRs from the physician and institutional levels; and 3. Investigate relationships between CSRs and perinatal morbidity in the, institutions.
The in-patient expenditures by admissions (DD) for other research usage were employed to confirm the trend of CSRs from 1998 to 2010 in a pilot study. The specific subject datasets for annual childbirth in Taiwan were used throughout these three areas of research. This dataset includes registry for contracted medical facilities (HOSB), registry for medical personnel (PER), inpatient expenditures by admissions (DD), details of inpatient orders (DO), ambulatory care expenditures by visits (CD) and details of ambulatory care orders (OO). The order codes in the NHI claim data were used to determine modes of delivery. The operational definition of CSR was annual cesarean delivery divided by all annual live births (claims of live births by cesarean delivery and vaginal delivery) in Taiwan, for each branch, institution and physician. In the third subject area, the in-patient expenditures by admissions (DD) in 2002, 2006 and 2010 were joined with the specific subject datasets for annual childbirth and were used to determine the perinatal admission rate in each institution.
In the first subject area, the differences in CSRs between the highest and lowest branch were 9.53% in 1998, 12.5% in 2002, 8.44% in 2006 and 10.84% in 2010.
These findings revealed that the CSR in the highest branch was ranging from 129.16% to 146.52% of the CSR in the lowest branch. Distributions of indications for cesarean section in different branches were divergent. Subjective indications such as failure to progress in labor and fetal distress fluctuated only slightly in these four years. Previous cesarean sections gradually decreased. However, malpresentation and malposition increased significantly. High risk indications increased in 2006 at the NHI branch and institutional levels as well as in 2010. In the second subject area, physicians with lower volume of services performed significantly more cesarean sections than their counterparts with high volume of services when controlling institutional factors (0.0237, 95% CI: 0.0041~0.0434, p =0.018 for less than 104 per year; 0.0252, 95% CI: 0.0075~0.0429, p=0.0053 for ≧104-<364 per year). Institutional factors such as policy or preference in institutions (0.026, 95% C.I.：0.0068~0.0452, p=0.00781 for the institutions with medium variation in cesarean section ratios; 0.0332, 95% C.I.: 0.0069~0.0595, p=0.0135 for the institutions with high variation in cesarean section ratios) and accreditation level, not ownerships, played an important role in influencing the physician’s choice of mode of delivery. In the third subject area, higher institutional CSRs correlated to higher institutional perinatal admission rates for respiratory distress syndrome or other respiratory conditions, such as intrauterine hypoxia and birth asphyxia or infections of the fetus and newborn after controlling indications for cesarean section and proportion of older women(≧35 years old) in institutions (β= 0.21797, p=0.0221).
This study showed that variations of CSRs in the NHI branches did exist and the CSRs in Taiwan would be less than 32% if the NHI bureau could control up-coding or code creep by institutions or physicians. Physicians’ CSRs were influenced by institutional policy or preference for modes of delivery and accreditation level as well as service volume of physicians. Higher CSRs could result in a negative externality in prenatal newborns.

並列關鍵字

cesarean section rates ； area variations ； perinatal morbidity ； physician's cesarean section rates

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