膝退化性關節炎病患接受治療情形和長期之治療與資源使用

Treatment and long-term resource utilization for knee Osteoarthritis

陳政陽(Cheng-Yaung Chen)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理學研究所/碩士(2009年)

摘要

退化性關節炎（OA）是老化引申的肌肉骨骼問題，相當普遍且高罹患率存在老年族群，依據2007年全民健康保險醫療統計年報顯示，關節病變及有關疾患之總患者約佔2007年全國人口數12.1％，其中65歲以上佔30%、盛行率為35.8%；並且門診就醫總醫療費用約佔總門診之2.7%，顯見關節相關疾患人數比例及費用之高。關節內注射玻尿酸(HA)為主要治療方式之一，研究顯示治療有效率高達七成以上且沒有明顯副作用發生。台灣醫療環境執行OA病患HA已十年，目前仍無對此實施十年期間的研究，也沒有任何針對已施行於健保之不同HA劑型治療的研究，更何況是利用全台灣健保資料庫分析長達三年半時期的研究。因此，本研究利用健保申報資料庫，探討2005-2008年六月OA病患接受HA治療情形與醫療資源利用情形
研究方法
本研究回橫斷性研究。資料來源以中央健保局2005~2008年曾施打HA之OA病患就醫資料，包含「門診服務點數清單檔」與「門診醫療服務醫令清單檔」。研究樣本以2005年期間曾利用健保至醫療機構執行HA之OA病患為對象，分析OA病患接受HA治療情形與醫療資源利用情形。
研究結果
一、 OA病患接受HA治療情形
六成以上病患接受完整HA 療程，三成以上未完成療程及超量施打。男性、嚴重合併症、五劑、復健科皆嚴重影響未完成療程與超量施打情形。完成療程之病患中，55.3%療程內併用止痛劑、12.3%併用復健、8.8%兩者皆有；4.5%跨院注射HA、24.5%為可能違規或違規多打HA。後續治療趨勢中，只有一成病患持續進行四次HA 療程，以女性、五劑、施打科別為骨科、復健科、風濕免疫科、外科、醫院層級為區域醫院及地區醫院、分局別為台北及高屏區為顯著影響因子；然而在持續服用止痛劑方面，將近六成七之病患持續服用四階段之止痛劑，以女性、CCI 1分及2分、骨科、醫院層級為區域醫院、地區醫院及一般診所、分局別為中區、南區、高屏及東區為顯著影響因子。
二、 完成HA療程之OA病患醫療資源利用情形
OA病患平均每人每年門診與骨科門診次數預測模式中，年齡越長、CCI1分及2分以上、五劑、診所，會增加較多的門診與骨科門診次數；然而在OA病患平均每人每年門診與骨科門診費用預測模式中，年齡與CCI1分、2分以上有相同較高的門診與骨科門診費用情形。
不同劑型之直接與間接成本比較，五劑(14,523元、10,263元)平均HA 成本及掛號費顯著高於三劑(11,899元、1,723元)(P<0.001、P=0.004)，但在X光檢驗成本上以三劑顯著高於五劑(1,685 VS 1,568，P<0.001)。
結論
此三年半期的分析研究，發現年齡、性別、劑型、施打科別與分局別皆部分影響OA病患接受HA治療情形與中長期醫療資源，並且以不同劑型接受HA治療趨勢情形與直接、間接成本推斷，採用五劑療程治療不只有較高的經濟壓力負擔，也有較高的醫療資源的耗用情形。

關鍵字

膝退化性關節炎 ； 關節注射玻尿酸 ； 治療情形 ； 醫療資源利用

並列摘要

Background and objective
Osteoarthritis which is generally turned up in the aged is induced by ageing muscle and bones problem. According to the 2007 annual report by the National Health Insurance, the arthropathies and related disorders is about 12.1%. Plus, 30% among them is over 65 years old. In addition, the prevalence of the disorder is 35.8%. Furthermore, patients who undergo medical treatment in arthropathies and related department are up to 2.7%. Therefore, the cost of arthropathies and related patients are obviously more than other diseases. So far intra-articular Hyaluronic Acid is the only effective treatment by 70% cases without side effect. In Taiwan, patients have been treated by intra-articular Hyaluronic Acid more than a decade. However, up to now there is no study related to the HA treatment even the three-year study used by Taiwan’s National Insurance. As a result, this research is made of the database of Taiwan National Insurance to discover the condition of medical resources of OA patients with HA treatment from 2005 to 2008 June.
Method
The research is cross-sectional study. The resource is based on the information of OA patients with HA treatment from 2005 to 2008 which include the points of outpatient service and medical orders of outpatient service. During 2005, the study has been used to analyze the condition of treatment and medical resources in OA patients accept HA treatment.
Result
The condition of OA patients accept HA treatment
Up to 60% patients totally accept HA treatment, and over 30% patients haven’t finished the treatment and over-dosage. Male, serious syndrome, five dosages, and department of Rehabilitation are affected by unfinished treatment and over-used injection. There are some patients who finish the treatment, and 55.3% patients with analgesic, 12.3% with rehabilitation, and 8.8% both have done; otherwise, 4.5% patients have HA injections in other hospitals, and 24.5% patients are illegally over-used with HA. During the later treatment, 10% patients keep using four-time HA treatment, including female, five- dosage, departments of Orthopedics, Rehabilitation, and Rheumatic, metropolitan hospitals, local community hospitals, Kao-ping and Taipei Branch of Bureau of National Health Insurance are significant. However, in the condition of using analgesic, nearly 67% patients keep using fourth step analgesic. Female, CCI 1 point and 2 points, departments of Orthopedics, metropolitan hospitals, local community hospitals, clinics, and Bureau of National Health Insurance of Central Region, Southern Region, Kao-ping, and Eastern Region Branches are significant.
The condition of OA patients finish the HA treatment resources
In forecasting model of OA patients with annual average outpatient and Orthopedics outpatient, the people who are older, get one point and up to two points at CCI, five-dosage, and clinics cause the outpatient frequency to increase. In addition, you could discover the same costing condition between them.
Compare the direct and indirect cost of different dosages, five-dosage(14,523 dollars, 10,263 dollars) average HA cost and registration fee are more significant than three-dosage(11,899 dollars, 1,723 dollars)( P<0.001、P=0.004). But, X-ray cost on three-dosage is more then five-dosage(1,685 dollars, 1,568 dollars)( P<0.001).
Conclution
The outcome of the research discover the age, the gender, the dosage, the medical department and organization have a great effect upon the OA patient with HA treatment, middle-term and long-term medical resources. Moreover, with different HA dosage and the huge expense, 5-dosage treatment has higher financial burden and higher medical resource consumption.

並列關鍵字

knee osteoarthritis ； intra-articular Hyaluronic Acid ； medical resources

參考文獻

參考文獻

英文部分

1. Alan G. W., Howard G. B., Carmela J., Sharon B., & Jeff S. (2008). Direct and Indirect Costs of Pain Therapy for Osteoarthritis in an Insured Population in the United States. JOEM, 50( 9).

2. Altizer, L. L. (1998). Degenerative disorders. In A. B. Maher, S. W. Salmond, & T. A. Pellino (Eds.), Orthopaedic nursing, 2, 480-534.

3. American Academy of Orthopaedic Surgeons (2002). Viscosupplementation Treatment for Arthritis. Patient Education Web Site of the American Academy of Orthopaedic Surgeons.