術前復健計畫對於全人工關節置換術後醫療耗用與醫療療效 衝擊之探討

The impact of preoperative rehabilitation on total joint replacement medical intervention and outcomes

梁怡芬(I-Fen Liang)

指導教授 ： 許弘毅

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

中文摘要
研究目的
2014年全台因退化性關節炎造成的醫療支出住診費用為38.9 億元、住診費用成長率為3.6%。而術前復健，能夠在全人工髖、膝關節置換手術後，降低復健總需求，進而降低整體的費用。故本研究欲探討術前復健計畫對於全人工關節置換術後醫療耗用與醫療療效的衝擊。本研究探討術前復健計畫對於全人工髖、膝關節置換手術之當次住院日數、當次住院總費用、術後九十天內門診總次數、術後九十天內門診復健總次數、十四日再住院率、以及全人工髖、膝關節置換手術患者死亡相關因素的影響。
研究方法
本研究採回溯性次級資料分析，資料來源為2005年「全民健保學術研究資料庫」之百萬承保抽樣歸人檔，研究樣本為於2005-2012年進行初次人工髖關節置換 (ICD-9-PCS為8151)、初次人工膝關節置換手術 (ICD-9-PCS為8154) 患者共6155人，並串聯門診及住院部分檔案、承保資料檔（ID）與醫事機構基本資料檔（HOSB），以取得手術前8週至手術後90天內，所有門診與住診資料。並以 SPSS 20.0統計套裝軟體，進行描述性統計、T檢定、卡方檢定、複迴歸分析、二元回歸分析、存活分析。
研究結果
研究樣本以平均年齡65-75歲、女性之全人工髖、膝關節置換術患者居多。研究結果發現，接受術前復健計畫的患者，以在醫學中心接受手術者最多。由2005-2012年間，接受術前復健計畫的全人工髖、膝關節置換術患者有增加的趨勢，尤以在醫學中心、高服務量醫院進行手術、CCI指數大於1、高社經地位、75歲以上、女性患者增加的情形最為顯著。接受術前復健計畫者，其當次住院日數(P<0.001)、當次住院總費用(P<0.001)顯著低於未接受者。而接受術前復健計畫與全人工髖、膝關節置換術後十四天再住院率、術後死亡率無關。
結論與建議
接受術前復健計畫以及住院期間復健的患者，在全人工髖、膝關節置換術之當次醫療資源耗用顯著少於未接受者，故建議醫護人員應更重視術前復健計畫。

關鍵字

全人工髖關節置換手術 ； 全人工膝關節置換手術 ； 術前復健計畫

並列摘要

Background:
In 2014, the cost of hospitalization for osteoarthritis was 3.89 billion New Taiwan dollars, which incresed by 3.6% from 2013 to 2014. It seems to be the result of mounting volumes of total joint replacement (TJR). Preoperative rehabilitation, prehabilitation, was known by a mechanisum decreasing demands for physical therapy and overall costs after total TJR. Therefore, the purpose of this study was to determine the impact of preoperative rehabilitation on TJR medical intervention and outcomes in Taiwan. It investigated the effect of prehabilitation on outcomes of primary TJR in the perspective of length of stay, hospitalization-related medical expenditures, post-operative physician visits and outpatient physical therapy utilities. Besides, the study also investigated readimissioin rate and survival rate after total joint replacement.
Methods:
This retrospective study composed of patients undergoing primary TJR from 2005-2012 in Taiwan. Propensity score-based matched subsamples was used to eliminate selection bias. After patients’ age and gender were adjusted, the prehablitation group and the non-prehabilitation group were matched on 1:4. Therfore, a total 1090 patients were enrolled in the study. The nationwide, population-based NHIB administrative data was used to analysis the impact of prehabilitation on medical resource utilization and outcomes 90 days after TJR.
Results:
Patients in the treatment group stayed shorter time in the hospital and reqired less hospital charge than control group. Whereas they had more post-operative physician visits and outpatient physical therapy utilities than control group. Yet the intervention had no effect on readimissioin rate and survival rate after total joint replacement.
Conclusions:
An 8-week preoperative rehabilitation program can significatly decrease LOS and hospital charge of total joint replacement in Taiwan. Further study needs to be done for its effect on post operative health service utilization.

並列關鍵字

Total Hip Replacement ； Total Knee Replacement ； Preoperative Rehabilitation

參考文獻

英文文獻

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Cabilan, C., et al. (2015). "The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review." JBI database of systematic reviews and implementation reports 13(1): 146-187.

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