探討腦中風病人急性後期照護生活品質及成本效用分析

Quality of Life and Cost-Utility Analysis in Post-Acute Care among Stroke Patients

葉宇柔(Yu-Jo Yeh)

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(2018年)

摘要

研究目的
中央健保署自2014年以腦中風病人為實施對象推動提升急性後期照護(Post-Acute Care, PAC)試辦計畫，目的是為了能夠透過跨團隊的整合照護，建構病人垂直轉銜系統，依個別失能程度，在黃金治療期間內給予積極性之照護，使其恢復功能。因此，本研究欲探討PAC計畫實施至今，其參與病人之健康相關生活品質及重要影響因子，並評估計畫醫療照護成本與生活品質之改善是否具有成本效用。
研究方法
採用前瞻性研究設計，以南部兩間醫學中心、兩間區域醫院及一間地區醫院之腦中風病人為研究樣本，共收案1,476人，研究期間依序追蹤入院前、入院後第六周、第十二周及第一年，共四個時間點。病人功能狀態、吞嚥、姿勢平衡等健康相關生活品質由下面問卷收集：MRS、BI、FOIS、EQ5D、IADL、BBS、MMSE、BAI與BDI，以廣義估計方程式(GEE)等統計方法進行趨勢及重要因子之探討；醫療照護費用由醫院住院費用檔與成本結構問卷獲得，成本效用分析以TreeAge軟體協助研究假說之驗證。
研究結果
BI、EQ5D、IADL及BBS量表在入院後第六周、第十二周及入院後第一年均呈現顯著性的進步(P<0.01)，且PAC組優於non-PAC組，而入院前生活品質初評分數是入院後第一年生活品質的最佳預測指標(P<0.001)。在成本效用分析上，PAC組的平均醫療花費較non-PAC組少(新台幣131,430元Vs. 161,866元)，且兩者的品質調整存活年分別為(0.73 Vs. 0.66)；以遞增成本效果(ICER)計算，每增加一個有品質的存活年，PAC組的花費較non-PAC組節省新台幣434,800元，以2017年台灣人均GDP做比較，大約為0.59倍GDP，顯示PAC組與non-PAC組相比是非常具有成本效用的急性後期照護治療選擇。
結論與建議
PAC組在生活品質方面之進步幅度較non-PAC組大，顯示了與目前腦中風復健系統相比，在急性後期後接受政府所推動之PAC計畫，其身體功能狀態的恢復是更顯著的。而在考量醫療花費的同時， PAC也是具有成本效用的治療選擇，因此，除了希望研究結果能給予衛生主管機關反饋，檢視該計畫自2014年執行迄今頗具成效，也希冀能夠提供政府在未來政策規劃上之建議、擁有更適當的決策，以提升整體醫療資源分配之效率、有效減少醫療花費，讓全民健保永續經營。

關鍵字

腦中風 ； 急性後期照護 ； 醫療花費 ； 生活品質 ； 成本效用分析

並列摘要

Objective
It has started ‘the demonstration on improving the quality of post-acute care (PAC)’ in 2014 to enhance the overall quality of life (QOL) of stroke patients and to provide better quality of cares. Therefore, the study purposed to explore the impact of PAC on quality of life among stroke patients and in order to evaluate wheather the PAC program can grasp the balance between cost and utility.
Methods
A total of 1,476 stroke patients completed the Modified Rankin Scale (MRS), Barthel index (BI), Functional Oral Intake Scale (FOIS), EuroQol-5D (EQ5D), Instrumental Activities of Daily Living (IADL), Berg Balance Scale (BBS), Mini-mental state examination (MMSE), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) at the baseline, the 6th week, the 12th week and the 1st year after rehabilitation. The generalized estimation equation (GEE) model was employed to analyze the change trends and to predict impact factors of QOL and a cost-utility analysis was performed by using TreeAge decision tree model.
Results
The results showed that BI, EQ5D, IADL and BBS had a dramatic improvement from the baseline to the 6th week, the 12th week and the 1st year (P<0.01). Moreover, it also showed that pre-rehabilitation QOL was the best predictors of the 1st year QOL after rehabilitation (P<0.001). The cost-utility analysis reveals the cost of PAC group was lower than non-PAC group; the incremental cost-effectiveness ratio for PAC group against non-PAC group was calculated as NTD$-434,800 for per utility gained. Overall, PAC is a better choice for cost-utility.
Concludsions
PAC group increased QOL in stroke patients and the improvement was better compared with non-PAC group. Additionally, PAC is still the better choice for cost-utility when considering all medicial expenses during acute and post-acute phase. Therefore, we hope that the authorities can realize the demonstration is productive executed to this day. Meanwhile, expected the government can distribute the medical resources more appropriate in the future.

並列關鍵字

Stroke ； Post-Acute Care ； Cost ； Quality of Life ； Cost-Utility Analysis

參考文獻

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