健保總額給付對台灣大腦血管動脈瘤併蛛蜘網膜下腔出血手術趨勢之影響

研究目的：探討健保總額給付對台灣大腦血管動脈瘤併蛛蜘網膜下腔出血手術夾手術前後醫療耗用、處置療效之影響材料與方法：本研究設計採單一組介入時間數列分析(single group interrupted time series design)的類實驗研究法設計。研究對象與資料來源：本研究屬回溯性的次級資料分析，乃彙集2000年-2004年間全國住院檔中的ASAH經手術夾手術的病患為研究對象，總共有2,452例病患，病患來自全國醫學中心及區域教學醫院。本研究中所定義ASAH病患，其疾病主診斷代碼分別為ICD-9 CM：430，疾病處置碼為39.51。研究變項主要自變項有：期間（名義類別變項）、性別（名義類別變項）、年齡層（次序類別變項）、總額給付介入因子（名義類別變項）；主要依變項有總醫療費用、平均住院天數、當次住院死亡率（皆為連續性變項）。統計分析是以電腦套裝軟體SPSS中文第14版為分析工具，進行時間序列分析。結果：總醫療費用時間序列分析的最佳擬合模式為介入模型ARIMA(1,0,2)。研究顯示總額給付介入前、後總醫療費用有顯著的差異存在，亦即總額給付介入後總醫療費用有顯著增加25.76%。平均院天數用時間序列分析的最佳擬合模式為介入模型ARIMA(2,0,2)。研究顯示總額給付介入前、後平均院天數有顯著的差異存在，亦即總額給付介入後平均院天數有顯著增加7.20%。住院死亡率用時間序列分析的最佳擬合模式為介入模型ARIMA(2,0,1)。研究顯示總額給付介入前、後住院死亡率有顯著的差異存在，亦即總額給付介入後住院死亡率有顯著降低10.09%。結論與建議：研究證實總額支付制度的實施不但沒降低台灣大腦血管動脈瘤併蛛蜘網膜下腔出血經手術夾手術醫療資源耗用反而助長了醫療資源耗用，但處置療效卻有改善。時間序列分析Box-Jenkins 的介入分析模型ARIMA有效準確地分析台灣大腦血管動脈瘤併蛛蜘網膜下腔出血經手術夾手術醫療資源耗用及療效的趨勢和評估總額支付制度的影響。希望健保局能了解支付制度的改變會影響醫療資源耗用，但有可能是負面的影響。建議健保局在實施任何新的支付制度需謹慎參考各研究以免造成錯誤。另外，影響醫療資源耗用增長的原因有很多，支付制度的改變並非唯一解決之道。未來研究者如果評估政策干擾醫療資源耗用趨勢的研究仍應以時間序列來分析而且應該擴大研究區間及擴大研究樣本，不宜僅以一般迴歸來分析，以免造成研究結果的不正確。此外，應多方面的分類探討其他重大給付項目受總額給付制度政策的影響，以作為政府制定政策的參考。

關鍵字

健保總額給付；大腦血管動脈瘤；蛛蜘網膜下腔出血；手術夾手術；時間序列分析

並列摘要

Objective: To evaluate the influence of global budget payment on medical utilization and management outcomes in patients of aneurysmal subarachnoid hemorrhage with clipping. Materials and methods: This is a secondary research using single group interrupted time series design to collect data retrospectively from the database of National Bureau of Health Insurance. Totally 2452 cases diagnosed with aneurysmal subarachnoid hemorrhage between Jan. 2000 and Dec. 2004 were collected . We defined cases with aneurysmal subarachnoid hemorrhage as their disease diagnosis code were ICD-9 CM:430 and disease management code were 39.51. The main independent variables include period, sex, age group, and intervention factor (global budget payment). The main dependant variables include total medical expenditure, average of length of stay and hospital mortality rate. A time series analysis was used mainly for the evaluation of the influence of Global Budget Payment on medical utilization and management outcomes of neurysmal subarachnoid hemorrhage with clipping. Results: After a series of trial and error, we found that the interrupted ARIMA(1,0,2), interrupted ARIMA(2,0,2), and interrupted ARIMA(2,0,1) were as the best-fit models for the time series analysis of total medical expenditure, average of length of stay and hospital mortality rate respectively. The study demonstrated that there were remarkable effects of global budget payment on total medical expenditure and average of length of stay by increasing values of 25.76% and 7.20% respectively after its implementation. There was also remarkable effect of hospital mortality rate by decreasing values of 10.09%. Conclusion and suggestion: The implementation of global budget payment didn’t reduce total medical expenditure and average of length of stay for cases of aneurysmal subarachnoid hemorrhage with clipping but encourage their utilization . However, it did reduce the hospital mortality rate of cases of aneurysmal subarachnoid hemorrhage with clipping after its implementation actually. The time series analysis with Box-Jenkins interrupted ARIMA models accurately reveal the effects of global budget payments on the medical utilization and management outcome for cases of aneurysmal subarachnoid hemorrhage with clipping. We hoped that the national health insurance can realize that the change of payment system would probably result in adverse effects for the whole system. It is suggested that any implementation of new payment system should be cautious and discrete in order to avoid the mistakes. There were many reasons for the growth of resources utilization. Change of payment system is by no means the only way of solution. If researchers in the future involve the evaluation of policy intervention for medical service resources, using time series analysis is highly suggested.