梗塞性腦中風復健與復健合併針灸治療之成本效果分析

The cost effectiveness analysis of rehabilitation treatment and combination of rehabilitation with acupuncture treatment among patients with cerebral infarction

許家蓁(Chia-Chen Hsu)

指導教授 ： 張永源

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(2013年)

摘要

研究目的
梗塞性腦中風為台灣及全國十大死因前三位(行政院衛生署，2010)。現代醫學強調中西醫結合治療，世界衛生組織（WHO）於1980年起公佈了43種針灸有效的病症，認定針灸是一種有效而安全的治療方法，其中就包括腦中風。
本研究針對全民健保資料庫百萬歸人檔梗塞性腦中風住院個案，比較復健有無針灸治療進行成本效果分析，本研究目的如下:
一、探討梗塞性腦中風病人接受針灸治療有無與人口學特性、臨床
特性上的差異。
二、比較梗塞性腦中風病人接受針灸治療有無之成本差異。
三、比較梗塞性腦中風病人接受針灸治療有無之效果差異。
四、比較梗塞性腦中風病人接受針灸治療有無之成本效果分析。
研究方法
本研究以國家衛生研究院之全民健康保險研究資料庫2000年承保抽樣歸人檔，分析自2006-2010年梗塞性腦中風病人為研究對象(ICD9-CM:433-435)，排除年齡小於18歲、併發出血性腦中風、住院有開刀、無復健及針灸者後共計3,176人，有復健治療為3,003人，復健合併針灸為173人。治療方式在復健組的復健訓練：住院期間及出院後針對肢體障礙接受物理與職能治療，若有語言障礙或吞嚥困難時，加入語言治療；每週治療二次以上；復健合併針灸治療組除復健訓練外，在住院期間或出院3個月內有接受針灸治療，每週三次為收案條件。為降低選樣偏差對研究結果解釋的干擾，因此採用Rosenbaum與Rubin(1983)所提出的傾向分數(Propensity Score; PS)分析方法，而經傾向分數1:1配對後，兩組各取173人為醫療資源使用成本效果分析之研究樣本。
研究結果
　　復健組與復健合併針灸組之人口學特質與臨床特徵之比較，復健組年齡為69.9±12.5歲，復健合併針灸組年齡為 67.7±13.1歲，有顯著性差異(P=.024)，性別兩組皆為男生多於女生，統計結果無差異(P=.496);危險因子：高血壓、糖尿病、高血脂、心臟病無顯著性差異; 復健組在合併症嚴重指數(CCI)為1.17±1.26分，住院天數16.2±
16.5天，復健合併針灸組在合併症嚴重指數(CCI)為1.38±1.24分，住院天數28.6±20.5有顯著差異(P＜.05)，加護病房天數及呼吸器使用天數無統計上的差異。
經傾向分數配對後成本之比較，住院總費用、醫療總費用檢定成本有顯著差(P＜.05)，門診總費用無顯著差異;復健合併針灸總醫療費用501,879±421,349元多於復健組427,752±394,942元。而在效果檢定再次中風次數無顯著差異，總住院天數、再入院次數、二年存活時間(月) 皆達顯著性差異(P＜.05)。
增量成本效果分析(ICER)以總住院天數、再次中風次數、再入院次數、二年存活時間(月)分析，結果發現復健合併針灸組醫療總費用比復健組高，但效果優於復健組，且ICER值小於三倍GDP。
結論與建議
由本研究結果發現，復健與復健合併針灸治療，在成本效果評估指標(成本效果比、增量成本效果比)之檢定下，均為值得推行之方案，因受限健保資料庫資料取的，無法獲得間接和間接成本，再做評估健康風險及生活品質調整人年 (QALY)成本效果評估，應同時考慮存活時的生活品質。
建議醫療機構腦中風發生早期針灸治療，可增加腦灌注，建議將針灸治療列入標準治療。成立腦中風中心，整合跨團隊共同照護，降低生理殘障，提高治療後生活品質。

關鍵字

梗塞性腦中風 ； 復健合併針灸治療 ； 成本效果分析

並列摘要

Research purposes
Ischemic stroke as the top three leading causes of death in Taiwan and the country (Department of Health, 2010). Modern medicine emphasizes Integrative Medicine, the World Health Organization (WHO) in 1980 published the 43 kinds of acupuncture effective disease, finds that acupuncture is an effective and safe method of treatment, including stroke.
In this study, the National Health Insurance database normalization million people hospitalized cases of ischemic stroke file compare whether acupuncture treatment for rehabilitation cost-
effectiveness analysis, the purpose of this study are as follows:
Ⅰ.explore ischemic stroke patients receiving acupuncture treatment
without and demographic characteristics, clinical Characteristic differences.
Ⅱ.comparing ischemic stroke patients receiving acupuncture treatment
without the cost difference.
Ⅲ.the comparison ischemic stroke patients receiving acupuncture
treatment without the effect of differences.
Ⅳ.the relatively ischemic stroke patients receiving acupuncture
treatment without the cost-effectiveness analysis.
Research Methods
In this study, the National Institutes of Health National Health Insurance Research Database 2000 Insurance Beneficiaries file analysis from 2006-2010 ischemic stroke patients for the study (ICD9-CM :
433-435), excluding younger than 18 years, and issued bloody stroke, hospitalization have surgery, no after rehabilitation and acupuncture are a total of 3,176 people, 3,003 people for the rehabilitation therapy, rehabilitation, acupuncture combined 173 people. Treatment in the rehabilitation group rehabilitation training: during hospitalization and after discharge for physical disabilities receive physical and occupational therapy, if language barriers or swallowing difficulties, speech therapy added; treatment at least twice a week; rehabilitation combined acupuncture group in addition to rehabilitation training, during hospitalization or discharge three months to receive acupuncture treatment three times a week for the inclusion criteria. To reduce selection bias in the findings explain the interference, so using Rosenbaum and Rubin (1983) proposed propensity score (Propensity Score; PS) analysis methods, as amended by propensity score 1:1 paired, two from each of 173 people medical resource use cost-effectiveness analysis of research samples.
Results
Rehabilitation Rehabilitation merged group and the acupuncture group, demographic characteristics and clinical features of the comparison, rehabilitation group age 69.9 ± 12.5 years, rehabilitation combined acupuncture group, age 67.7 ± 13.1 years, with a significant difference (P = .024 ), gender groups are more boys than girls, showed no statistical difference (P = .496); risk factors: hypertension, diabetes, high cholesterol, heart disease, no significant difference; rehabilitation group comorbidity index (CCI) was 1.17 ± 1.26 points, length of stay 16.2 ± 16.5 days, rehabilitation combined acupuncture group comorbidity Index (CCI) was 1.38 ± 1.24 points, length of stay 28.6 ± 20.5 are significantly different (P <.05), intensive care ward days and ventilator days no statistical difference.
After propensity score matching by comparing costs, total cost of hospitalization, medical tests cost a total cost of significant differences (P <.05), no significant difference in the total cost of outpatient; Rehabilitation Acupuncture combined total medical expenses 501,879 ± 421,349 yuan more than the rehabilitation group of 427,752 ± 394,942 yuan. In effect test again no significant difference in the number of strokes, the total length of stay, readmissions, two years survival time (months) all reached significant difference (P <.05).
Incremental cost-effectiveness analysis (ICER) of total hospital days, another stroke frequency, number of readmissions, two years survival time (months) analysis found that acupuncture group rehabilitation combined total health care costs than the rehabilitation group, but better than rehabilitation group, and the ICER value is less than three times the GDP.
Conclusions and proposition
It was found by the study, rehabilitation and rehabilitation combined acupuncture treatment, the cost-effectiveness evaluation indicators (cost-effectiveness ratio, the incremental cost-effectiveness ratio) of the test under the program are worth pursuing, because limited NHRID taken , indirect and overhead costs can not be obtained, then a risk assessment of health and quality of life adjusted person-years (QALY) cost-effectiveness assessment should also consider the quality of life when alive.
Early medical organizations recommend acupuncture treatment of stroke occurs, increase cerebral perfusion, the proposed standard will be included acupuncture treatment. Stroke Center was established to integrate care across teams together to reduce physical disability and improve the quality of life after treatment.

並列關鍵字

ischemic stroke ； rehabilitation combined acupuncture treatment ； cost-effectiveness analysis

參考文獻

Chang, K. C., & Tseng, M. C. (2003). Costs of acute care of first-ever ischemic stroke in Taiwan. Stroke, 34(11), e219-221. doi: 10.1161/01.str.0000095565.12945.18

Chiu, H. C., Lee, L. J., Hsieh, H. M., & Mau, L. W. (2003). Inappropriate hospital utilization for long-stay patients in southern Taiwan. Kaohsiung J Med Sci, 19(5), 225-232. doi: 10.1016/s1607-551x(09)70428-0

Lloyd-Jones, D., Adams, R., Carnethon, M., De Simone, G., Ferguson, T. B., Flegal, K., . . . Hong, Y. (2009). Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 119(3), 480-486. doi: 10.1161/circulationaha.108.191259

Anderson, C., Ni Mhurchu, C., Brown, P. M., & Carter, K. (2002). Stroke rehabilitation services to accelerate hospital discharge and provide home-based care: an overview and cost analysis. Pharmacoeconomics, 20(8), 537-552.

Berlowitz, D. R., Hoenig, H., Cowper, D. C., Duncan, P. W., & Vogel, W. B. (2008). Impact of comorbidities on stroke rehabilitation outcomes: does the method matter? Arch Phys Med Rehabil, 89(10), 1903-1906. doi: 10.1016/j.apmr.2008.03.024