以核心療效指標評估介入計畫對老年髖部骨折病人術後之整體效益

Performance of Intervention Program on Core Outcome Set for Surgical Hip Fractured Patients

陳怡霖(Yi-Lin Chen)

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(2016年)

摘要

研究背景與目的
多數健康照護機構已使用核心療效指標來評估髖部骨折病人之療效，但目前在台灣並無合適的評估指標適用於髖部骨折手術病人。本研究目的主要為三部分：(一)以核心療效指標評估老年髖部骨折病人有無接受手術介入照護計畫之差異、(二)評估病人於當次療效之影響因素、(三)探討當次資源利用之影響因素。
研究方法
本研究屬前瞻性設計，研究對象為在2015年08月01日至2016年05月31日間於南部某醫學中心與區域醫院接受髖部骨折手術治療之病患，樣本依據有無接受髖部骨折照護介入計畫分為介入組與控制組，總樣本數為96人，其中介入組為52人。研究資料來源主要為三部分：1. 病歷審查、2.醫療資源使用、3.核心療效指標測量，核心療效指標於術後住院期間、術後1、3個月進行測量。研究工具為：視覺疼痛類比量表(VAS)、日常生活活動量表(ADL)、歐洲生活品質量表(EQ-5D)以及自擬性問卷(復健、跌倒情形)等量表。統計方法利用SPSS20統計軟體，以卡方檢定、獨立樣本T檢定、變異數檢定、差異中之差異法(DID)、廣義估計方程式(GEE)，統計工具為STATA13.0版、SPSS20.0版進行資料分析與驗證假說。

研究結果
介入組平均年齡為76.52±8.02、控制組平均年齡78.89±7.31，皆以女性居多(70.83%)，手術方式皆以半人工髖關節置換(HA)居多(57.29%)。兩組隨治療時間增長各核心療效指標皆達顯著改善(P<0.001)。整體的效用分數：介入組為0.23、0.58、0.68；控制組為0.23、0.63、0.67，介入組與控制組之五量表隨時間逐漸改善，但兩組並無顯著差異。短期成效在復健率在術後1、3個月：介入組75%、72.09%；控制組65.85%、77.78%。術後1個月內跌倒率：介入組3.85%、2.44%；術後1-3個月內則兩組皆無人跌倒，以上並無顯著差異。使用GEE迴歸模型證實於術後有接受相關復健者在ADL、EQ-5D-Index、EQ-5D-VAS、Utility score比無接受相關復健者分別多16.54分、1.92分、12.64分、0.21分，接受復健者有較佳的療效。

結論和建議
老年髖部骨折手術病患之核心療效指標趨勢皆隨術後三個月內有顯著改善，於出院後有接受相關復健者有較佳的療效(ADL、EQ-5D-Index、EQ-5D-VAS、Utility score)之影響因子
，可見術後復健的重要性。介入組與控制組間在生活品質間並無顯著差異，可能原因為短期追蹤三個月內尚未看出兩組差異變化，建議後續研究需延長追蹤時間加以探討。本研究發現與前瞻性支付制度相比發現Tw-DRG支付制度導致住院天數有顯著改變。

關鍵字

髖部骨折 ； 核心療效指標 ； 骨折照護介入計畫 ； 醫療資源利用

並列摘要

Purpose
Several healthcare systems started to use “Core Outcome Set (COS) to evaluate the outcome of hip fracture patients No comprehensive effectiveness evaluation indicators have been applied for surgical hip fracture patients at Taiwan. The first objective of this study was to use COS to identify outcomes for a hip fracture intervention program as compare with patients without enrolled the programs The second objective was to examine the factors associate with the outcomes The third objective was to analysis the factors affected the healthcare utilization for hip fracture patients underwent surgery.

Methods
The study adopted a prospective study design. The study subjects were hip fractured patient admitted to one medical center and regional hospitals in southern Taiwan , from August 2015 to May 2016. The samples were grouped into interventional group (IG) and comparison group (CG) based on whether received a hip fracture intervention program Totally, 96 patients were included at the study, among them 52 were IG Three data sources used in the study were: patient clinical parameters derived from chart review, medical utilization obtained from hospital in-house claim data, and COS were obtained from patients interview during hospitalization and 1- and 3-month follow up surveys after patients discharge COS indicators included Pain Visual Analogue Scale (VAS), Activities of daily living (ADL), The European Quality of 5 Dimension (EQ-5D) Analytical methods included chi-square test, independent t-test, Difference in Difference (DID), and general linear regressions The statistical tool which we used are STATA 13.0 and SPSS 20.0. 
Results
The mean ages for IG and CG were 76.52 (± 8.02) and 8.89 (± 7.31) respectively. Female gender accounted for 70.83% of the study sample. More than 57.29% patients received semi-artificial hip replacement (HA) procedure. Both groups patients experienced a better COS outcomes after discharged from hospitals. The utility scores for during hospitalization, 1-month, 3 month were was 0.23, 0.58, 0.68 for intervention group and 0.23, 0.63, and 0.67 for comparison group patients. No statistical differences in all COS indicators between groups across times.GEE models demonstrated that patients with rehabilitation after discharge had better outcomes in ADL、EQ-5D-Index、EQ-5D-VAS、Utility score were was. 16.54, 1.92, 12.64,.0.21.

Conclusions
The study confirmed that COS indicators have been improved 3 months after surgery for in elderly hip fracture patients Patients with rehabilitation after discharge experienced a better outcomes in ADL, EQ-5D, Utility score, it suggested that postoperative rehabilitation is very important. To restore the patient quality of life. No significant differences in COS indicators between two groups might be due to the shorter follow-up time (3-month), a long term longitudinal observation is suggested. Our study also identified the impact of DRG on the length of stay of hip fracture patients as we compared with patients prior to the PPS payment system

並列關鍵字

Hip fracture ； Core Outcome Set ； Fracture care Intervention Program ； Medical utilization

參考文獻

英文文獻

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