臨床指引遵從性對急性心肌梗塞住院病患之效益研究

Benefits of the Clinical Guidelines Adherence for Hospitalized Patients with Acute Myocardial Infarction

陳世卿(Shih-Ching 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在職專班/碩士(2016年)

摘要

摘 要
目的
急性心肌梗塞病患住院過程面照護之臨床指引，包括檢查（LDL_C）及用藥（DAPT_雙重血小板抑制劑治療(Aspirin+ADP受體拮抗劑)、ACEI&ARB、β_Bloker、Statin、4_Combine），本研究目的包括：
目的一：探討急性心肌梗塞病人住院期間臨床指引遵從情形、
目的二：探討急性心肌梗塞病人住院期間臨床指引遵從度之影響因素
目的三：、探討急性心肌梗塞病人住院臨床指引遵從情形不同對治療結果之影響
目的四：、探討急性心肌梗塞病人住院臨床指引遵從情形不同，對醫療資源使用之影響。
研究之重要性
本研究嘗試以美國2013 ACCF/AHA之急性心肌梗塞治療臨床指引、衛生福利部及台灣臨床成效指標(TCPI)對急性心肌梗塞病人住院期間所建議的治療(包括檢查及用藥項目)，與全民健康保險研究資料庫台灣本土大型資料庫進行其效益評估，期待本研究結果能提供政策及臨床執行之改善參考。
研究方法
本研究為縱貫性研究設計，資料期間：1997~2010年，資料檔：以全民健康保險研究資料庫2000年百萬抽樣人檔，資料樣本為擷取主診斷ICD-9 CM 前三碼為410.xx或 A-code碼為A270之所有住院病患之住院所有病患相關資料及病患承保加退保期間、投保金額等，醫事機構、及醫師檔相關資料。
研究結果
樣本數共5,175人次之急性心肌梗塞住院病人，臨床指引遵從率自1997年起逐年上升，且達統計顯著差異，結果一：研究期間14年，臨床指引遵從率自1997年起逐年上升，且達統計顯著差異，2010年遵從率為：遵從情況，LDL_C檢查：63.6544.85%；用藥情形：、DAPT：85.2056.54%、ACEI/ARB：68.8568.85%、β_Bloker：59.1759.17%、Statin：59.8036.41%、4_Combine：30.8016.08%。
結果二：對數迴歸分析遵從臨床指影響引因子包括：，人口學特質之年齡層、共病指數(CCI分數)、疾病治療特徵、醫院特質之分局別、權屬別、特約類別、醫師特質之是否有心內(外)專科醫師及其服醫師服務量，為主要影響急性心肌梗塞病患住院期間遵從臨床指引之因素。
治療結果指標包括當次住院死亡，30日內、60日內、180日內死亡，結果三：有遵從急臨床指之檢查及用藥對治療結果30日內死亡減少20%~58%、有接受ACEI/ARB,β-blocker, statins, 4_combine 用藥之180日內死亡減少30%~55%之死亡(含當次住院死亡，30日、60日、180日院內+院外死亡)之風險降低，達統計顯著差異；對14日14日內再入院及30日30日內再入院無影響。
結果四: 有遵從急臨床指引之檢查(LDL_C)及用藥(Statine)對醫療資源使用之住院天數有減少之影響，校正後整體迴歸解釋力為26.6%；對ICU住院天數無顯著影響；對醫療費用影響差異極小，校正後解釋力低解釋力低於1%，，臨床指引檢查及用藥非影響ICU天數、醫療費用之主要因子。
結論與建議
臨床指引可降低醫療上無法接受或不需要的變異，醫師以更有效益的方式來提供高品質的照護，對於醫療設置及健保給付與臨床指引相佐部分，建議與專業團體通分溝通，並尋求更適合本土現況的治療方式及給付規定。

關鍵詞：急性心肌梗塞、臨床指引、治療結果、醫療資源使用

關鍵字

急性心肌梗塞 ； 臨床指引 ； 治療結果 ； 醫療資源使用

並列摘要

Abstract
Objectives：
The clinical guidelines for inpatient care with acute myocardial infaction, including examination ( LDL_C) and medication(DAPT_ dual platelet inhibitor therapy (Aspirin + ADP receptor antagonist), ACEI or ARB, β_Bloker, Statin, 4_Combine), the objectives of this study: Explore the performance of clinical guidelines adherence for hospitalized with acute myocardial infarction, Investigate the impact factor of clinical guidelines adherence for hospitalized with acute myocardial infarction, Explore the effect of treatment outcome in clinical guidelines adherence for hospitalized with acute myocardial infarction, Explore the effect of medical resources usage in clinical guidelines adherence for hospitalized with acute myocardial infarction.
Significance：
This study attempts to assess the benefits of the 2013 ACCF / AHA guidelines and Ministry of Health and Welfare, Taiwan Clinical Performance Indicators (TCPI) recommended (including examination and medication) for acute myocardial infarction, and Taiwan National Health Insurance Research Database, expected results of this study provide policies and implementation of clinical practice guidelines to improve.
Methods：
This is a longitudinal study design, the Longitudinal Health Insurance Database 2000 (LHID2000) from NHIRD in 1997 to 2010，Selected all hospitalized patients with a primary discharge diagnosis code of ICD_9-CM 410.xx.

Results：
Inpatients 5175 with acute myocardial infarction. Clinical guidelines compliance increased year by year since, and amounted statistical significance, The compliance rate, Examination of LDL_C were used to 44.85% of patients, 56.54% of the entire group received dual anti-platelet therapy (DAPT), ACEI/ARB were prescribed to 68.85%,β_Bloker were prescribed to 59.17%, Statin were prescribed to 36.41% and 4_Combine were prescribed to 16.08% of patient.
Logistic Regression analysis was used to investigate the impact factor of compliance with clinical guidelines , We found that age, CCI comorbidity index, Characteristics of disease treatment（PCI,CABG,CATH, etc）, Different hospital contract type, Whether cardiologist, physician volume, are main impact factors.
Outcome indicators include in-30 day, in-60 day, in-180 day mortality; readmission within 14 days, readmission within 30 days. In-30 day mortality reduced by 20%~58% in patients receiving examine or medications, In-180 day mortality reduced by 30%~55% in patients receiving medications(ACEI/ARB,β-blocker, statins, 4_combine), and amounted statistical significance. It is no influence for readmission within 14 days, readmission within 30 days. Medical resource of hospital stay were reduced for Inpatient used LDL_C examine and receiving Statins. It is no influence for medical expenditure and ICU stay.
Conclusion：
Clinical guidelines have the potential to reduce inappropriate practice variation, Physician to improve quality of patient healthcare.It recommends that the insurance payment provisions should fully communicate with professional organizations, and to seek more appropriate treatment.
Key words：acute myocardial infarction、clinical guidelines、 treatment outcome、medical resources

並列關鍵字

acute myocardial infarction ； clinical guidelines ； treatment outcome ； medical resources

參考文獻

英文文獻

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