探討原發退化性關節炎、類風濕性關節炎、股骨頭缺血性壞死對於全人工髖關節置換術的醫療資源利用與療效之影響

研究目的全人工髖關節置換術對於末期關節疾病是一個有效的治療方式，在台灣接受全人工髖關節置換術的患者，主要以退化性關節炎(OA)、類風濕性關節炎(RA)、股骨頭缺血性壞死(AVN)的比例最多，尤其以AVN的比率更高於其他國家。因此本研究的目的，主要在比較OA、RA、AVN患者施行初次全人工髖關節置換術的趨勢分析、醫療資源利用及療效影響比較。研究方法本研究利用全民健康保險研究資料庫，進行回溯性的次級資料分析，為縱貫型的研究。針對全國接受初次全人工髖置換術 (ICD-9-CM code =8151)且主診斷為OA、RA、AVN患者病人為研究對象，並排除其他非原發性病因。研究期間為1996年1月1日至2012年12月31日總共十七年，比較OA、RA、AVN間的盛行率、住院天數、住院相關費用的趨勢，以複迴歸分析比較OA、RA、AVN間對住院總費用和住院天數的影響；以對數迴歸分析比較OA、RA、AVN間對30日及90日再入院的影響因子；以存活分析Kaplan-Meier法和Cox迴歸分析，探討OA、RA、AVN間對人工關節感染、人工關節脫臼、人工關節旁骨折及關節再置換危險因子分析。研究結果本研究結果顯示，在盛行率方面，OA、AVN呈現上升趨勢。在住院天數、住院總費用、手術費用、麻醉費用及特殊材料費用方面，OA、RA、AVN皆呈現下降趨勢。在30日、90日再入院率方面，RA(6.3%、22.5%)與AVN(6.6%、22.7%)皆高於OA(3.9%、12.8%)。在對住院總費用及住院天數影響方面，RA、AVN較OA有較高的住院總費用與較長的住院天數，皆呈現顯著差異(p<0.001)。在30日再入院方面，AVN顯著高於OA(OR=1.44，p<0.001)，RA與OA則無顯著差異(OR=1.13，p=0.397)；在90日再入院方面，AVN與RA皆顯著高於OA(OR=1.57、1.44，p<0.001)。在人工關節感染、人工關節脫臼、人工關節旁骨折及關節再置換方面，除人工關節旁骨折外，其餘在Kaplan-Meier存活分析模式下，OA、RA、AVN的整體比較皆達顯著差異。在Cox迴歸分析模式下，人工關節感染方面，OA、RA、AVN的整體無顯著差異；人工關節脫臼方面，AVN顯著高於OA(HR=1.11，p=0.024)，RA與OA則無顯著差異(HR=0.67，p=0.085)；在人工關節旁骨折方面，OA、RA、AVN的整體無顯著差異；在人工關節再置換方面，RA顯著低於OA(HR=0.59，p=0.003)，AVN與OA則無顯著差異(HR=1.00，p=0.881)。結論與建議隨著時間增加，OA與AVN患者接受全髖人工關節置換術的盛行率隨之上升，但在住院天數及住院總費用方面，卻呈現下降的趨勢，顯示在現行健保制度規劃下，即使利用全髖人工關節置換術治療的病人增加，在醫療資源利用上仍可以維持有效率的控制與利用。而在RA的患者，可能因為治療藥物的進步，減緩RA病程進展，需要接受置換術治療呈現減緩現象，因此將來可以考慮將相關新藥給付，列為優先評估項目。在再入院方面，RA與AVN患者的比例及風險皆高於OA，且AVN患者佔所有全髖人工關節置換術半數以上，建議相關單位可就AVN患者再入院原因進行分析，以降低再入院率並節省額外的醫療資源利用。

關鍵字

退化性關節炎；類風濕性關節炎；股骨頭缺血性壞死；全人工髖關節置換術；醫療資源利用

並列摘要

Purpose Total hip replacement (THR) is a useful treatment for end-stage hip joint disease. In Taiwan, osteoarthritis (OA), rheumatoid arthrirtis (RA), and avascular necrosis of femoral head (AVN) are three main causes for THR, especially the prevalence of AVN is higher than other country. The pourse of this study is to compare the trends, medical resourse utilization, and outcomes of THR among these three main diseases. Methods This is a retrospective longitudinal study. We used the National Health Insurance Research Database and collected the sample from 1996 to 2012 with the main diagnosis of OA, RA or AVN, and the revision cases were excluded. We compared the trends of prevalence, length of stay, and first operational hospitalized fees among OA, RA and AVN. Multiple linear regression was used to analyse the factors that affected the length of stay and hospitalized fees. We conducted a logistic regression method to analyse the factors of re-admission among these three diseases and the Cox survival analysis to analyse the risk factors of prosthetic infection, joint dislocation, peri-prosthetic fracture, or revision of THR among OA, RA and AVN. Results The prevalence of OA and AVN rise year by year gradually. The trends of length of stay, hospital fees, operation fees, anesthesia fees and special material fees are trending down in OA, RA and AVN. In rates of 30 days and 90 days re-admission, RA(6.3%、22.5%) and AVN(6.6%、22.7%) are higher the OA(3.9%、12.8%). In total hospital fees and length of stay, RA and AVN reveal significant higher fees and longer stay than OA(p<.001). In 30 days re-admission rate, AVN is higher than OA(OR=1.44，p<.001). In 90 days re-admission rate, ANV and RA are higher than OA (OR=1.57、1.44，p<.001). By Cox regression method, there is no significant difference in prosthetic infection amoung OA, RA, and ANV. In joint dislocation rate, ANV is higher than OA (HR=1.11，p=.024). In peri-prosthetic fractures, there is no significant difference. But in prosthesis revision, RA is significant lower than OA (HR=0.59，p=.003). Suggestions As THR is getting popular, and the prevalence of OA and AVN has risen gradually. The length of stay and total medial costs trends downward. This indicates even the numbers of THR increase, but the medical resource utilization maintains stable effectively by health insurance policy and regulation. In RA patients, the decreasing trend of receiving THR may be due to control of disease progress by improvement of medicine. The effects of RA disease control should be considered in the future. In re-admission, the risks of RA and AVN are higher than OA. Further evaluation of factors of AVN is necessary for reducing re-admission and saving the extra medical resource utilization.