全國施行冠狀動脈繞道術及冠狀動脈介入性治療 之醫療品質與資源利用探討

The Medical Quality and Resource Utilization of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in Taiwan.

侯美夙(Mei-Su Hou)

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(2008年)

摘要

研究背景與目的
根據行政院衛生署95年統計，心臟疾病每十萬人口的死亡率為53.82，為十大死因中排行第三。因此健康照護的研究焦點就放在過去二十年來兩種被廣泛使用治療心臟的療程:冠狀動脈遶道術(Coronary Artery Bypass Grafting)及冠狀動脈介入性治療(Percutaneous Coronary Intervention)。過去雖然心臟相關的研究不算少，但綜觀國內文獻尚未同時對CABG及PCI做醫療品質與資源利用做探討，特別是針對疾病的嚴重度、醫療服務量、CABG手術方式及術後的情形。因此本研究運用全國性資料庫，探討CABG及PCI從1996-2004年長期醫療品質及資源利用之趨勢，找出醫療品質及資源利用之相關因子，將重點放在疾病嚴重度、醫療服務量、手術方式和術後情形對醫療品質及資源利用之影響。
研究方法
本研究為橫斷性研究。資料來源為1996~2004年國家衛生研究院「全民健康保險研究資料庫」。利用「住院醫療費用清單明細檔」之主手術(處置)一~四碼五個欄位截取CABG及PCI之病患。全國施行CABG及PCI九年共計筆數為152,295筆。進一步合併「醫事機構基本資料檔」、「專科醫師證書主檔」後，利用SPSS分析。
研究結果
一.CABG及PCI之醫療品質與資源利用之趨勢
以1996年為基礎，CABG直至2004年成長率達2倍；PCI成長率更是直逼5倍。CABG及PCI除了住院天數皆呈現遞減趨勢外，當次住院死亡及醫療費用則呈現波動情形。
二.疾病嚴重度、醫療服務量、手術方式、術後情形對CABG醫療品質與資源利用之影響
控制其他變項後，處置血管條數愈多，當次住院死亡風險愈低，但住院天數及醫
療費用則隨處置條數愈多而愈高。合併症則隨著分數愈高，其當次住院死亡及住院天
數及醫療費用則顯著愈高。控制其他變項後，醫師服務量愈高，其當次住院死亡風險
及住院天數、醫療費用則顯著愈低，醫院服務量則無此情形。高服務量醫師其當次住院
死亡風險為低服務量醫師的0.49倍，且會減少1.76天及32,702元的醫療費用。控制其他變
項後，手術方式採動脈做移植其當次住院死亡風險為採靜脈移植之0.46倍，且會減少
2.33天的住院天數以及減少47,143元的醫療費用。控制其他變項後有併發症其死亡風
險為無併發症之6.98倍，且會增加14.29天的住院天數及227,255元的醫療費用。
三.探討疾病嚴重度、醫療服務量、術後情形對PCI醫療品質與資源利用之影響
控制其他變項後，合併症分數愈高，其當次住院死亡、住院天數、醫療費用也愈
高。控制其他變項後，醫師服務量愈高，其當次住院死亡風險及住院天數、醫療費用
則顯著愈低，但醫院服務量則無此情形。高服務量醫師其當次住院死亡風險為低服務量
醫師的0.63倍，且會減少2.74天及17,182元的醫療費用。控制其他變項後，術後有併發
症、感染及當次住院併行CABG會有較高的當次住院死亡、住院天數及醫療費用。
有併發症其死亡風險為沒有併發症的11.02倍，且會增加12.13天的住院天數及
133,237元的醫療費用。而當次住院併行CABG其死亡風險為沒有併行的6.35倍，且
會增加15.14天的住院天數及340,280元的醫療費用。
結論
九年期間CABG及PCI都有成長趨勢，但是當次住院死亡及醫療費用卻沒有隨時間而有減少趨勢，顯示醫療院所及衛生機關要注意此一現象。本研究發現CABG或是PCI其醫師的經驗比醫院更能影響醫療品質及資源利用，顯示醫師之貢獻大過於醫院。此外有併發症及當次住院有併行CABG對整個住院死亡及資源利用影響甚巨，故想要改善死亡及資源利用，首重避免併發症及當次住院併行CABG之發生。最後建議醫師在病患許可情況下，可多使用動脈做移植，以期會有較好的預後。

關鍵字

冠狀動脈遶道術 ； 冠狀動脈介入性治療 ； 醫療品質 ； 資源利用

並列摘要

Background and Objective

According to the statistic number from Dpeartment of Health, Executive Yuan in 2006, the death rate out of 100,000 populations of Cardiovascular Disease (CVD) is 53.82, which is No.3 cause of death in Taiwan. Therefore, the research focus of health care in the past twenty years is on the CABG and the PCI. There are many researches regarding cardiopathy in the past few years, but few studies discussed about CABG and PCI, especially in severity of illness, medial volume, method of surgery and postoperative situation. Hence, this study discusses the trend of CABG and PCI base on a huge number of databases from 1996 to 2004. It concentrates on the affection of severity of illness, medial volume, method of surgery and postoperative situation.
Methods
152,295 CABG and PCI cases were conducted from National Health Insurance Research Database of the National Health Research Institutes in Taiwan during Jan. 1996 through Dec. 2004. The data are analysed by SPSS.
Results
一.The trend of medical quality and resource utilization in CABG and PCI.
The growth rate of CABG has increased to twice in 2004 than in 1996. The growth rate of PCI is 5 times than before. The length of stay (L0S) is decreasing but in hospital death and the medical charge is unsteady.
二.The severity of illness, medial volume, method of surgery and perioperative complication of CABG.
After adjusted other variables, the more number of vessels bypassed the less in hospital death. However, the LOS and Medical charge will be higher. The higher the scores of comorbidities, the higher the risk of in hospital death and the LOS and the medical charge.After adjusted other variables, the higher surgeon volume, the lower the risk of in hospital death and the LOS and the medical charge.However, the hospital volume will not have this trend. After adjusted other variables, the death risk of high volume surgeon is 0.49 times more than the low volume surgeon. Moreover, it is 1.76 days of the LOS and 32,702 NT dollars of the medical charge less than low volume one. After adjusted other variables, the death risk of artery graft is 0.46 times more than venous graft.Moreover, it is 2.33 days of the LOS and 47,143 NT dollars of the medical charge less than venous graft one.After adjusted other variables, the death risk of patients who has complication is 6.98 times more than who has no complication. Moreover, there will be additional 14.29 days in the LOS and 227,255 NT dollars in charge for the patients with complication.
三.The severity of illness, medial volume and perioperative complication of PCI
After adjusted other variables the higher the scores of comorbidities, the higher the risk of in hospital death and the LOS and the medical charge.After adjusted other variables, the higher surgeon volume, the lower the risk of in hospital death and the LOS and the medical charge .However, the hospital volume will not have this trend. The death risk of high volume surgeon is 0.63 times more than the low volume surgeon. Moreover, it is 2.74 days of the LOS and 17,182 NT dollars of the medical charge less than low volume one.After adjusted other variables, the death risk of patients who has complication is 11.02 times more than who has no complication. Moreover, there will be additional 12.13 days in LOS and 133,237 NT dollars in charge for the patients with complication. After adjusted other variables, the death risk of patients who has in-hospital CABG is 6.35 times more than who has no complication. Moreover, there will be additional 15.14 days in LOS and 340,280 NT dollars in charge for the patients who have in-hospital CABG.
Conclusions
CABG and PCI increased during past 9 years. However, in-hospital death and medical
charge did not decrease in this period of time. It deserves attention from all health care
stakeholders in Taiwan.The experience of surgeons is a more critical factor than
hospital in medical quality and resource utilization. Itshows that surgeons’ contributions
are more than hospital. In addition, avoiding complication and in-hospital CABG will help
reducing death rate and resource utilization.Last but not the least, surgeons should use
arterial graft more than venous graft for better postoperation.

並列關鍵字

CABG ； PCI ； Medical quality ； Resource utilization

參考文獻

參考文獻

英文文獻

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