類風濕性關節炎病患中西醫之就醫選擇與醫療利用

Choice and Utilization of Chinese Medicine and Western Medicine Services among Patients with Rheumatoid Arthritis

陳美玲(Mei-Ling Chen)

指導教授 ： 許玫玲

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2010年)

https://doi.org/10.6831/TMU.2010.00069

摘要

研究背景與目的：
類風濕性關節炎為全身的慢性自體免疫系統疾病，病程長需終身治療且會反覆發作逐漸惡化，其醫療需求高。而現今醫療體系多樣性，除主流西醫外，病患尚可選擇中醫或中西醫併用等治療模式， 本研究主要探討病患中西醫就醫型態之選擇與醫療利用情形。
研究方法：
本研究資料來源為1999~2008年全民健康保險資料庫，研究樣本之條件為年齡大於(含)18歲、於2000年之後才首次出現類風濕性關節炎(國際疾病主次診斷為714.0)診斷，且觀察期間至少有三次就診記錄或者總醫療點數大於3,000點之病患，總共76,211人。分析單位是每人每季資料，總樣本數為558,718人季。統計方法採Multinomial Logistic Regression模型以及廣義估計方程式(Generalised Estimating Equations, GEE)模型進行分析。
研究結果：
一、研究對象76,211人中，男性有22,021人、女性有54,190人，男女比例約為1：2.5。
二、本研究樣本顯示病患之主要就醫型態以西醫為主，占94.07％，其次為中醫，占3.11％，而中西醫併用之患者占率為2.82％。
三、類風濕性關節炎病患女性較會以中西醫複向治療，70歲以上老人其醫療支出較19歲以下高出1.3倍，觀察期間累計罹病季數1~4季其平均每季每人之總醫療花費、住院費用、門診就診次數、住院次數均高於其他季別。原住民比漢人較不會選擇中醫或中西醫並用，醫療費用也較低。
四、本季之就醫型態、醫療利用均受前季影響，當前季以中醫為治療主要方式，本季亦會循中醫求診，而前季若為中醫、中西醫併用者，本季同時看中醫之機會大增，而前季為中西醫併用者，本季之醫療費用及門診就診次數也會較高。凡前季僅看中醫或西醫者，其本季門診就醫次數、住院次數及醫療費用均會低於前季無看診者；前季中西醫併用者，本季之就診次數較高，醫療費用則較前季無看診者低。
五、領有類風濕性關節炎重大傷病卡之患者會尋找西醫或中西醫合併看診比率較高，選擇中西醫達無類風濕性關節炎重大傷病卡3.31倍，有冠狀動脈心臟病使用西醫或中西醫併用機率高於無冠動脈心臟病者。有使用生物製劑者、有骨質疏鬆症者、有骨折病患均以西醫為主要治療型態。有類風濕性關節炎重大傷病卡、有其他疾病重大傷病卡、有身心障礙、有冠狀動脈心臟病、有骨質疏鬆症或有骨折者，門診就醫次數、醫療費用亦高。有使用生物製劑之患者，門診就醫次數增加、醫療費用更高於未使用生物製劑者5倍以上。
結論：
本研究顯示西醫是類風濕性關節炎治療的主流，有一些疾病嚴重度較高者會同時尋求中、西醫治療，只利用中醫治療者，其疾病嚴重度較輕。個人的特質如性別、年齡與種族也會影響醫療利用。尋求中西醫治療者其醫療費用較高，其治療結果是否較佳，有待後續研究分析。生物製劑成本非常高，其成本效益如何，值得未來深入研究。

關鍵字

類風濕性關節炎 ； 醫療利用 ； 中醫 ； 病人就醫選擇

並列摘要

Background and Objective
Rheumatoid Arthritis (RA) is a chronic autoimmune disease. The demand for medical care of RA is high, because the health of the patients will fluctuate and deteriorate over time and they need lifelong treatments. There are various medical services available nowadays. In addition to mainstream Western medicine services, patients can also choose Chinese medicine service or Chinese and Western medicine service simultaneously. This study aimed to examine the associations between the characteristics of the RA patients, and their choice and utilization of these available health care services.
Method
The data came from the National Health Insurance claim database from 1999 to 2008. Patients with RA (ICD-9-CM code 714.0) first diagnosed in or after 2000, age over 18 years old, and with health care visits more than 3 times or health expenditures more than 3,000 points were selected for the study. The final sample included 76,211 individuals. The unit of observation is quarterly data for each individual. The total observations were 558,718 person-quarters. The statistical and analysis methods were Multinomial Logistic Regression Model and Generalized Estimating Equations (GEE) Model.
Result:
1. Among the total 76,211 subjects, 22,021 were men and 54,190 were women. The proportion of male and female patients with RA was about 1 to 2.5.
2. Most RA patients chose Western medicine, around 94.07% of the sample. Those chose Chinese medicine only or used both Chinese and Western medicine accounted for 3.11% and 2.82%, respectively.
3. Female patients were more likely to use both Chinese and Western medicine simultaneously than male. The medical expenses of those over the age of 70 were 1.3 times higher than those under 19. The average total health expenditures, inpatient expenditures, number of outpatient visits and inpatient admissions per person per quarter were highest among those with the cumulative number of observed quarters from 1 to 4. Aboriginals were less likely to choose Chinese medicine and their health expenditures were lower.
4. RA patients’ choices of medical services and the health care utilization of the current quarter were highly correlated with their health care seeking behavior in the previous quarter. Those who chose Chinese medicine or Chinese-and-Western medicine in the previous quarter would prefer Chinese medicine or Chinese-and-Western medicine to Western medicine in the current quarter than those who did not seek any type of medical care previously. But for those who only used Western medicine previously, they were less likely to use Chinese medicine in the current quarter than those who did not seek any type of medical care in the previous quarter. Health care utilization in the current quarter was lower for those only seek Chinese or Western medicine in the previous quarter than those who did not had any health services previously. However, those who used both Chinese and Western medicine in the previous quarter had more outpatient visits and health care expenditures than those who did not had any health services in the previous quarter.
5. Patients with the RA Catastrophic Illness Card or those with coronary heart diseases were more likely to choose Western medicine or both Chinese and Western medicine. Patients receiving biological agent treatments, and with Osteoporosis or fracture tended to chooe Western medicine than the comparison groups. Outpatient visits and expenditures were higher among those who had Catastrophic Illness Card, Physically and Mentally Disabled card, Coronary Heart Diseases, or Osteoporosis or fracture. Patients receiving biological agent treatments not only had more outpatient visits but also had health expenditures more than 5 times higher than those who did not receive the treatments.
Conclusion:
This study confirmed that Western medicine is the main stream for RA treatments. More severe patients might also use Chinese medicine, whereas those who only chose Chinese medicine were less severe. Individual characteristics such as gender, age and race were also associated with patients’ health care utilization. Since patients who seek both Chinese and Western medicine had higher health expenditure, whether or not they have better outcomes needs further study. The costs for biological agent treatments are very high. How cost-effective they are also requires solid research.

並列關鍵字

Rheumatoid Arthritis ； health care utilization ； Chinese Medicine ； patient choice

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