以心肌梗塞與頭部外傷探討經急診轉住院病患醫療利用與預後

研究目的：本研究探討 2004 至 2008 年高屏地區經急診住院之頭部外傷，急性心肌梗塞之病患與就醫醫院特質，及其住院之治療預後與醫療資源利用分佈趨勢。研究方法：以中央健康保險局高屏分局特約申報急診126家地區級以上醫院 ( 3家醫學中心、10家區域醫院及113家地區醫院) 急診就醫後住院之頭部外傷，急性心肌梗塞個案和其申報費用◦ 研究資料為2004至2008年急診個案，以每一年度為一期，研究期間符合｢經急診就醫後住院病人｣納入分析，分析方法為:類別變項以卡方檢定，連續變項以變異數分析，另以對數迴歸分析與複迴歸分析探討個別因子之影響 ◦ 研究結果：這五年間共有急性心肌梗塞15,035人次、頭部外傷70,300人次◦ 2004年為2,648與15,284人次、2005年為2,834與15,574人次、2006年為2,985與14,327人次、2007年為3,175與13,162人次、2008年為3,393與11,953人次，經由急診辦理住院。病患人口學特質: 在性別方面，男性百分比為急性心肌梗塞佔67.9%、頭部外傷佔62.8%，年齡層：急性心肌梗塞以70-79歲為最多(30.9%)、其次為60-69歲(22.3%)，頭部外傷以20-20歲最多(17.7%)、其次是40-49歲(14.9%)◦急診檢傷分類級數項目:急性心肌梗塞以檢傷一級最多(64.3%)、頭部外傷以檢傷三級最多佔(64.1%)◦ 合併症以Charlson index計分，心肌梗塞以1分最多佔53.3%，頭部外傷以0分最多佔86.5% ◦ 病患就醫醫院層級:急性心肌梗塞以醫學中心為最多佔50.5%、頭部外傷以地區醫院最多佔50.9% ◦ 待床機會：心肌梗塞以醫學中心之9.1%最高，頭部外傷以區域醫院之2.9%較高，但均呈現逐年快速惡化現象。急性心肌梗塞平均總住院天數為10.86 天，平均總醫療費用154,283元◦ 頭部外傷則為7.2天與47,519元◦ 醫學中心之治療預後三項數據較其他層級醫院均有顯著差異◦ 可喜的是整體急性心肌梗塞病患死亡率逐年顯著減少(10.6%降至3.9%)，頭部外傷死亡率也呈現下降(3.6%至2.4%)，證明經急診住院之兩種傷病有逐年改善現象 ◦ 結論：急診醫療供給情形：在本研究中之兩種傷病，地區醫院所佔之比率逐年降低，醫學中心所佔比率持平或略微下降，而區域醫院對於此兩種急診重症之服務量卻逐年上升 ◦ 醫學中心與檢傷一級病患所使用之總醫療費用與總住院天數及急診待床天數均較多◦ 急診醫療服務情形：轄區內之醫院在整體收治急性心肌梗塞人次有明顯增加，然而頭部外傷病患人次卻相對明顯減少◦ 在急診整體照護品質：住院後死亡率，兩種傷病均有明顯且逐年降低情形，且在各層級醫院間無明顯差異存在，顯見整體急診醫療有明顯改善。建議：由研究結果得知，提供急診轉住院治療之醫院層級，區域醫院佔率有提升現象◦ 可能與其總體醫療能力提升有關◦ 因此於醫學中心因待床而無法收治之病患，可改由此層級醫院收治◦ 心肌梗塞之病患數增加幅度較快且頭部外傷之患者數卻相對減少，心肌梗塞病患於急診待床之比率高於頭部外傷者，各醫院應調整所需病床配置，以利整體醫療之合理使用◦ 對後續研究者: 1.本研究僅就2004-2008年期間之地區性資料進行分析，建議未來可以全國性資料，利用時間序列進行長期性的分析評估◦ 2.未來亦可針對供給面深入探討醫院行為之影響◦ 3.是否進行個別醫院之探討，待主管機關決定，如此可做為健保給付之參考。

關鍵字

急診醫療利用；急性心肌梗塞；頭部外傷；住院

並列摘要

Objective: This study aimed to explore the characteristics of hospitals and admitted patients via emergency services with head injury or acute myocardial infarction (AMI) and to examine the trends of their medical utilization and prognostic outcomes. Methods: Included for analysis were medical claims of admitted patients with head injury or acute myocardial infarction via emergency services to the 126 hospitals (three medical centers, 10 district hospitals and 113 regional hospitals) contracting with the bureau of National Health Insurance, Kaohsiung branch. Patients’ demographics and claims data from 2004 through 2008 were collected and analyzed. The Chi-square test (for categorical variables), ANOVA (for continuous variables), logistic regression modeling, and multiple regression techniques were conducted for statistical analyses. Results: During the study period (2004~2008), in total there were 15,035 cases with AMI and 70,300 cases with head injury; specifically, 2,648 and 15,284 cases, respectively, for the year 2004, 2,834 and 15,574 cases for the year 2005, 2,985 and 14,327 cases for the year 2006, 3,175 and 13,162 cases for the year 2007, and 3,393 and 11,953 cases for the year 2008. In terms of patients’ demographics, 67.9% of patients with AMI and 62.8% with head injury were male. Most AMI patients were 70-79 of age (30.9%), followed by the age of 60-69 (22.3%); nevertheless, most head injury patients were 20-29 of age (17.7%), followed by the age of 40-49 (17.7%). Regarding the ER triage categories, the majority of AMI patients (64.3%) were of Level I while the majority of head injury were of Level III (64.1%). Charlson index 1 accounted for the majority of AMI patients (53.3%), and 0 for the majority of head trauma patients (86.5%). More than half of the patients were sent to medical centers for emergency services (50.5% for AMI patients and 50.9% for head injury patients). For the AMI patients, the medical centers had the highest probability of waiting for admission (9.1%); for the head injury patients, the district hospitals had the highest (2.9%), which even became worse year after year. On average, the ALOS was 10.86 for the AMI patients and 7.2 for the head injury patients; the health expenditures were 154,283 and 47,519 for the AMI and head injury patients, respectively. As for the three prognostic outcome indicators, the medical centers were significantly different from other levels of hospitals. Overall, both the AMI and head injury mortality rates decreased annually (10.6% to 3.9% vs. 3.6% to 2.4%). Conclusions: The percentages of AMI and head injury patients admitted to regional hospitals decreased annually; to the contrary, patients admitted to district hospitals increased. The ALOS, total health expenditures, and length of waiting for admission were higher for the medical centers and patients with ER triage Level I as opposed their counterparts. Overall, the number of AMI patients jumped but the number of head injury patients dropped significantly. In addition, both the AMI and head injury mortality rates decreased and no significant difference was found across different levels of hospitals, indicating significant improvement in emergency medical services. Suggestions: The results showed that the regional hospitals accounted for more and more admitted patients via emergency services, which might be attributed to the improvement of medical services over the regional hospitals. It is expected that the concern over waiting for admission among medical centers could be alleviated if more patients could be treated by regional hospitals. The number of AMI patients increased and the number of head injury patients decreased. Consequently, the probability of waiting for admission is higher for the AMI patients as opposed to the head injury patients. It is suggested that hospitals should consider re-allocating their bed resources. Further researchers might consider using national database to conduct time-series analyses for a longer period of time. A study on hospitals’ behavior from the supply perspective is also suggested. The decision of whether to scrutinize each individual hospital’s operations remains with the authority.