腦中風急性後期照護健康相關生活品質與不同失能程度之成本效用分析：前瞻性兩年世代研究

Health-Related Quality of Life and Cost-Utility Analysis of Various Modified Rankin Scales in Stroke Post-Acute Care Patients：A Two-Year Prospective Cohort Study

鍾若萱(Jo-Hsuan Chung)

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(2020年)

摘要

研究目的
台灣中央健保署自2014年以腦中風為對象推動急性後期照護試辦計畫(Post-Acute Care, PAC)，透過垂直整合轉銜系統的建置與跨專業的整合照護團隊，給予高強度復健訓練，恢復患者功能狀態。因此，本研究探討腦中風患者接受復健後兩年內健康相關生活品質之改變趨勢及影響因子，進而評估在不同照護模式與不同失能程度是否具有成本效用。
研究方法
採用前瞻性世代研究法，針對南部兩家醫學中心(non-PAC組共193位)以及兩家區域醫院與一家地區醫院(PAC組共701位)腦中風患者為研究樣本，於入院時及開始復健後第六週、第十二週、第一年、第二年，評估兩組患者MRS、FOIS、BI、IADL、 EQ-5D、BBS、MMSE、BAI及BDI量表，追蹤其健康相關生活品質與身體功能狀況，醫療照護直接成本由醫院健保申報檔取得，並透過治療權重倒數機率(Inverse Probability of Treatment Weighting, IPTW)進行兩組樣本配對，運用廣義估計方程式(GEE)探討健康相關生活品質改變趨勢及重要影響因子，以SPSS 23.0及STATA 11.0進行統計分析，再採用TreeAge 13.0進行成本效用分析。
研究結果
腦中風患者復健後第六週與第十二週的健康相關生活品質皆有顯著性改善(P<0.05)，第二年則趨近持平，PAC組患者進步幅度顯著優於non-PAC組(P<0.05)；再者，年齡、性別、教育程度、腦中風類型、鼻胃管、導尿管、急性期住院天數、再入院及入院時健康相關生活品質是患者復健後兩年內健康相關生活品質與身體功能狀態之重要影響因子(P<0.05)；整體而言，PAC組患者相較於non-PAC組在復健後兩年內總醫療費用較低(新台幣180,385.79元 vs. 新台幣205,354.70元)，且具有較高的品質調整存活年(0.44 vs. 0.32)，邊際成本效用比(ICUR值)為新台幣-212,430元，PAC試辦計劃為具有成本節省之急性後期照護，且失能程度較嚴重者更具有成本效用。
結論
在黃金治療期間高強度密集的復健治療對於腦中風患者提供了良好的照護成效，與傳統的復健照護模式相比，PAC試辦計劃能在最佳經濟效益的考量下，同時提升患者生活品質與節省成本，且對於中度與中重度失能患者更具成本效用，因此建議腦中風患者應盡早接受PAC復建治療，並期望藉由本研究結果能提供衛政主管機關在未來政策規劃上之建議，提升整體醫療資源之配置與運用，進而提升整體醫療照護品質。

關鍵字

急性後期照護 ； 腦中風 ； 健康相關生活品質 ； 成本效用分析

並列摘要

Objective
In 2014, Bureau of National Health Insurance proposed a Post-Acute Care (PAC) pilot program for stroke patients. The PAC program provided a high-intensity and multidisciplinary integrated rehabilitation according to patients’ personal conditions through seamless transition system to improve their functional recovery. Therefore, this study purposed to explore the trends and impact factors of health-related quality of life (HRQoL) among stroke patients after 2-year rehabilitation and to evaluate the cost utility of various models of the Modified Rankin Scale (MRS) from the health provider perspective.
Methods
A total of 894 stroke patients were recruited into this two-year prospective multicenter study from two medical centers (non-PAC group, n=193) and two district hospitals and one local hospital (PAC group, n=701). All patients completed the BI, FOIS, EQ5D, IADL, BBS, MMSE, BAI, and BDI at the baseline, the 6th week, 12th week, 1st year, and 2nd year after rehabilitation. Medical direct costs are collected from the claims dataset. Health-related quality of life and functional status were calculated using the inverse probability of a treatment weighting-adjusted log-rank test. The generalized estimation equation (GEE) model also was employed to analyze the changing trends and to predict impact factors of HRQoL. A cost-utility analysis finally was performed by using TreeAge decision tree model. Costs, adjusted for inflation, were expressed in 2019 New Taiwan dollars. Costs and QALYs were discounted at 3% per year.
Results
The results show all of HRQoL had a significant improvement from the baseline to the 12th week (P<0.01), and reached to the plateau at the 2nd year after rehabilitation. In geberal, the effect size of PAC group was larger than non-PAC group. Moreover, it also showed that age, gender, education, type of stroke, nasogastric (NG) tube, foly, acute lengths of stay, readmission, and pre-rehabilitation HRQoL were the significant predictors of the 2-year HRQoL after rehabilitation (P<0.05). Additionally, compared to the non-PAC group, PAC group showed lower total costs (NTD$180,385.79 vs. NTD$205,354.70, respectively) and higher QALY (0.44 vs. 0.32, respectively) and the incremental cost-utility ratio was NTD$-212,430/ QALY. Patients with MRS=3 and MRS=4 compared to those with MRS=2 were more cost- utility.
Concludsions
Stroke patients should be adviced that their HRQoL after rehabilitation not only associated with patient attributes, clinical attributes, and quality of care, but also associated with their HRQoL at baseline. The significant predictors identified in the study can also be used to educate the patients with stroke with respect to the course of recovery and health outcomes. Compared to the traditional fee-for-service rehabilitation care, intensive post-stroke rehabilitative care delivered by per-diem payment is effective in terms of improving functional status and saving medical costs simultaneously. It is cost effective in stroke patients with more severe disability spontaneously. Therefore, these findings of this study may be useful for managing the education programs and for developing shared decision-making procedures for stroke patients undergoing early rehabilitation.

並列關鍵字

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

參考文獻

英文文獻

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