髖部骨折病人術後療效和醫療資源使用

The Effectiveness and Resource Utilization in Surgical Hip Fracture Patients

林文莉(Wen-Li Lin)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士班/碩士(2015年)

摘要

目的：
　　髖部骨折雖在現今社會是不容忽視之議題，但目前較少有研究提及髖部骨折合併失智症以及帕金森氏症族群療效以及資源使用之差異。先前有研究提高服務量醫師患者術後療效較好醫療資源使用也較低。因此本研究探討髖部骨折合併失智症、帕金森氏症患者之術後短中期療效以及醫療資源使用，也針對不同服務量醫師術後療效以及醫療資源使用做進一步了解。
方法：
　　本研究為回溯性研究。資料來源為國家衛生研究院所提供之全國健保資料庫，資料年度為1996年至2009年，選取患者主診斷碼為髖部骨折(ICD-9-CM code 820.0~820.19、820.2~820.32、820.8與820.9)且接受手術治療(處置碼 79.15、79.35、81.52)之住院患者。本研究失智症定義為ICD-9-CM診斷碼290.0-290.9、292.82、294.1-294.2、331.82、780.93，帕金森氏症定義為332.0、332.1。經過研究篩選後，研究樣本共183,059人。本研究將各年度醫師服務量選取每年度第33、67百分位將醫師服務量分為低、中、高三組。研究工具為SPSS20.0，以描述性統計以及推論性統計進行統計分析。
研究結果：
　　髖部骨折患者合併失智症有更高的風險發生併發症 OR=1.35，95%CI：1.25~1.46以及Prolong stay OR=1.19，95%CI：1.10~1.36。此外，髖部骨折合併帕金森氏症患者傾向於更高的併發症風險OR=1.28，95%CI：1.18~1.38以及Prolong stay風險OR=1.15，95%CI：1.07~1.25。患者合併失智症出院後一年骨科再入院風險較低(OR=0.88，95%CI：0.79~0.98)，合併帕金森氏症患者風險較高(OR=1.22，95%CI：1.11~1.35)。出院後一年死亡風險合併失智症患者(OR=1.41，95%CI：1.32~1.51)以及帕金森氏症患者(OR=1.11，95%CI：1.02~1.21)顯著較高。此外，醫師服務量越高患者發生併發症風險、Prolong stay風險以及手術當次死亡風險越低。
髖部骨折患者當次住院天數平均為10.7±6.44天，平均醫療費用為80,074 ±50,165元。研究發現患者合併失智症當次手術住院天數則會增加0.47天(P<0.001)，患者合併帕金森氏症則會增加0.49天(P<0.001)，但此兩疾病對於當次醫療費用則沒有顯著差異。此外，針對醫師服務量而言，醫師服務量越高患者手術當次住院天數、醫療費用則越低。
結論與建議：研究結果顯示髖部骨折合併失智症、帕金森氏症患者療效相對較差，也有更長的住院天數，此外，醫師服務量也是影響術後療效以及醫療資源使用的影響因子。希望透過本研究能讓醫療院所對於已知高風險族群有更完善的照護，以期降低患者的併發症、Prolong stay以及死亡風險。

關鍵字

髖部骨折 ； 失智症 ； 帕金森氏症 ； 醫療效果 ； 醫療資源使用 ； 醫師服務量

並列摘要

Purpose:
Although hip fracture is an important topic in today’s society, very few empirical studies on the effectiveness and resource utilization in hip fracture patients comorbid with dementia or Parkinson’s disease. Previous researches indicated that high volume physician tend better outcomes and lower resource utilization. Therefore, the thesis investigated the short-term and midterm medical outcomes and resource utilization in surgical hip fracture patients and explored the relationship between physician volume and outcomes.
Methods:
This study adopted retrospective study design. The data source was derived from Taiwan National Health Insurance Research Database. The study sample was patents diagnosed with hip fracture (ICD-9-CM code 820.0~820.19, 820.2~820.32, 820.8 and 820.9) and received operation (ICD-9-CM code 79.15, 79.35 and 81.52) between 1996 and 2009. The dementia was patients with ICD-9-CM code 820.0~820.19, 820.2~820.32, 820.8 and 820.9. Whereas, Parkinson’s disease was patients with code ICD-9-CM code 332.0 and 332.1. After exclusion, totally 183,059 hip fracture patients were included at the study. Physician volume was divided into three groups by the 33 and 67 percentile every year: classified as low, middle and high volume. The computer software 20.0 was used to conduct descriptive and theoretical comparison and analysis.
Results:
Hip fracture patients with dementia had greater likelihood to have complications OR=1.35, 95%CI: 1.25~1.46 and prolong length of stay OR=1.19, 95%CI: 1.10~1.36. Hip fracture patients with Parkinson’s disease also tended to have higher probability of having complications (OR=1.28, 95%CI: 1.18~1.38) and prolong stay (OR=1.15, 95%CI: 1.07~1.25). Patients with dementia had lower risk of orthopedics readmission (OR=1.88, 95%CI: 0.79~0.99) 1 year after discharged, on the other hand, compared to with patients without PD, patients with PD had higher risk of orthopedics-related readmission 1 year (OR=1.11, 95%CI: 1.02~1.21) after discharges. Compared with low volume physician, high volume physician had lower risk of complication, prolong stay and index-hospital death.
Hip fracture patients had average length of hospital stay 10.7 (±6.44) days; the average hospitalization cost was 80,074 (±50,165) NTD. Hip fracture patients with dementia increased 0.47 days of hospital stay (P<0.001), and patient with PD stayed extra 0.49 days (P<0.001). No statistically significant was found in index hospital cost for patients comorbid with PD or dementia.. High volume physician compare to low volume physician, to have shorter hospital stay and lower hospitalization cost.
Conclusions:
Hip fracture patients with dementia and PD had poorer clinical outcome but had longer hospital stay. Physician experience also affect the outcome and efficient care .The study suggested that clinical team need to pay extra attention for patients with different comorbidities to improve quality of care and enhance service efficiency.

並列關鍵字

Hip fracture ； dementia ； Parkinson’s disease ； effectiveness ； resource utilization ； physician volume

參考文獻

英文參考文獻

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