探討急性心肌梗塞病人心臟復健介入成效及成本效用分析

The Effectiveness and Cost-Utility of Cardiac Rehabilitation in Acute Myocardial Infarction Patients - A Propensity Score Matched Comparison Study

李彥蓉(Yen-Jung Lee)

指導教授 ： 許弘毅

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2019年)

摘要

研究目的
心血管疾病是造成全球人口死亡及失能的主要疾病之一，個案也存在相對較高風險續發性重大心血管復發事件或是死亡，因此次級預防極為重要，當病況穩定後心臟復健的介入即為首要目標。而台灣目前在心臟復健花費與成本效益上的研究相對稀少，因此本研究探討急性心肌梗塞患者介入心臟復健的臨床療效與花費成本之成本效用分析，期待帶給臨床醫療人員更明確的決策選擇。

研究方法
本研究採取回溯性次級資料分析設計，蒐集台灣南部某醫學中心於101-105年確診為急性心肌梗塞(AMI)患者為研究對象，接受心導管後轉介心臟復健者為實驗組，同時以年齡、性別及過去病史進行1:1傾向分數配對，未接受心臟復健者為控制組，各分別納入33位個案(平均年齡61.7歲)，並彙整相關研究報告文獻數據、臨床效果指標及追蹤一年的醫療費用進行成本效用分析。

研究結果
心臟復健組病患其總醫療花費為新台幣253,491元，未接受心臟復健組病患其總醫療花費為新台幣182,829元; 臨床療效部分，實驗組的品質調整存活年(Quality-Adjusted Life Year, QALYs)為0.88，控制組的QALYs為0.70，實驗組相對於控制組的遞增成本效果比(Incremental Cost-Effectiveness Ratio, ICER)為新台幣392,567元/QALY，在願付價格(Willingness to Pay, WTP)設定為755,561元的條件下(一倍國內生產總值Gross Domestic Product, GDP)，心臟復健是非常具成本效用優勢的決策選擇。

結論與建議
急性心肌梗塞患接受心導管後轉介心臟復健介入是具成本效用優勢的，台灣的統計數據顯示病患出院後轉介參與門診心臟復健比率低，期待能提升後續心臟復健的參與率以符合成本考量與經濟效益，使醫療資源能夠更合理有效地運用。

關鍵字

急性心肌梗塞 ； 心臟復健 ； 臨床療效 ； 成本效用分析

並列摘要

Objective
Cardiovascular disease is one of the major diseases that cause death and disability in the general population. With relatively high risk of the following cardiovascular recurrence and death, secondary prevention is the key factor. Cardiac rehabilitation is considered to be the gold standard of post acute myocardial infarction (AMI) intervention. However, few studies focused on the cost and cost-effectiveness of cardiac rehabilitation in Taiwan. Therefore, this study purposed to explore the effectiveness and cost-utility of cardiac rehabilitation in acute myocardial infarction patients.

Methods
This study retrospectively compared cardiac rehabilitation with no cardiac rehabilitation for acute myocardial infarction patients from Jan 2012 to Dec 2016 in a southern medical center in Taiwan. The caliper matching method (“greedy algorithm”) was used for 1:1 Propensity Score Matching (PSM) between these two groups (mean age 61.7 years old). The generalized estimation equation (GEE) model also was used to analyze the change trends of maximum oxygen consumption (VO2max) and a one-year cost-utility analysis of cardiac rehabilitation was performed by using TreeAge decision tree model.

Results
The result showed that peak VO2 had a significant improvement from baseline to the 6th month and the 1st year (p < .001). The cost –utility analysis revealed the total medical cost of cardiac rehabilitation group was higher than non-cardiac rehabilitation group. The incremental cost-effectiveness ratio for cardiac rehabilitation group against non-cardiac rehabilitation was NT＄392,567 for per quality-adjusted life year (QALY) gained.

Conclusions and Suggestions
Cardiac rehabilitation can not only enhance maximum oxygen consumption for acute myocardial infarction patients but also is a highly cost effective program. The findings of this study provide insight into important implications for patient referral rate. Therefore, we hope to optimize cardiac rehabilitation participation rate to grasp the balance of economic consideration. The government could distribute the medical resources more appropriately in the future.

並列關鍵字

Acute Myocardial Infarction (AMI) ； Cardiac Rehabilitation ； Clinical Effectiveness ； Cost-Utility Analysis

參考文獻

中文文獻

王瑋德. (2015). 心臟復健-心血管疾病復健. 血管醫學防治季刊, 21-23.

朱素貞. (2017). 成本效用分析中的效用測量. 當代醫療法規月刊, 75, 11-16.

林郁珊, 蔡美文, 殷偉賢, 黃心怡, 許青翎, 魏崢, & 莊義成. (2012). 急性心肌梗塞後之運動訓練. [Exercise-Based Cardiac Rehabilitation in Patients after Acute Myocardial Infarction]. 重症醫學雜誌, 13(3), 138-147. doi:10.30035/tccm.201209.0002

洪素鶯, 周正亮, 曹昭懿, 楊銘欽, 王水深, & 吳英黛. (2005). 冠狀動脈繞道手術病患接受門診運動訓練之成本效用分析. [Cost-Utility Analysis of Outpatient Exercise Training after Coronary Artery Bypass Grafting]. 物理治療, 30(1), 12-20.