影響初次剖腹產因素之分析及其醫療資源耗用
適當性之探討－以2003年健保資料庫為例

中文摘要研究目的剖腹產率節節上升已是不爭的事實，以往研究均偏重臨床因素的分析，而對於醫療機構因素及醫療資源耗用適當性之研究則付之闕如。文獻均支持初次剖腹產更能代表醫師之”醫療行為模式”。本研究特以初次剖腹產率及抗生素處方的適當性，來達到以下的研究目的：一. 瞭解台灣地區，初次剖腹產之人口學特徵及分佈情形。二. 瞭解台灣地區，初次剖腹產率及其適應症，併發症的比例。三. 瞭解台灣地區各層級醫療院所，初次剖腹產抗生素處方之使用情形。四. 瞭解台灣地區各層級醫療院所，影響初次剖腹產之因素及其醫療資源耗用情形。研究方法本研究是採回溯性之次級資料分析，研究對像是2003年台灣地區的住院產婦。研究對象以DRG碼，區格為剖腹產(C/S)(0371A)，自然生產(NSD)(0373A)，自願剖腹產(C/S)(0373B)，與剖腹產後嘗試自然生產(VBAC)(0373C)。研究對象區格後，以ICD-9-CM 654.2，654.20~654.23(之前曾剖腹產)，再重新劃分研究對象為初次剖腹產(primary C/S)，曾經剖腹產(previous C/S)及自然生產(NSD)，之後再進行研究。資料來源為「全民健康保險研究資料庫」中的醫事機構基本資料檔(HOSB檔)，醫事人員基本資料檔(PER檔)，住院醫療費用清單明細檔(DD檔)，住院醫療費用醫令清單明細檔(DO檔)。以健保局所提供的一個主診斷碼，四個次診斷碼(ICD-9-CM)，存入統計分析電腦中。刪除資料不全者，極值，曾經剖腹產(previous C/S) 與剖腹產後嘗試自然生產(VBAC)後，初次剖腹產有44340例，自然生產有146383例而進入本研究，以病人的年齡，產科醫師的性別與年齡，醫院層級權屬別、分局別、都市化分級別、教學別，病患產科合併症併內科疾病，來分析初次剖腹產的比例，適應症分佈，住院天數，藥費。在抗生素處方之探討中，以初次剖腹產的個案為樣本，去除資料不全者，並以DD檔的五個ICD-9-CM診斷碼，排除宜使用抗生素之剖腹產個案，之後再進行抗生素處方之探討；包括抗生素費用，品項，數量。並以Cochrane Collaboration剖腹產預防性抗生素的guideline(單一劑量IV第一代cephalosporins)來分析抗生素處方之適當性。最後再以統計套裝軟體SPSS for windows 10.0版進行描述性及推論性統計。研究結果 1. 2003年初次剖腹產率為23.34%。年齡群以18~34歲最多(87.89%)，而高齡產婦佔11.14%。在醫院層級別中，基層診所佔率最高33.0%，而以醫學中心占率最低(16.2%)。藥費方面，以醫學中心最高(NT＄1589.3±3426.7)，住院天數則以基層診所最低(5.0±1.4天)。 2. 單變量分析中，醫學中心有最高的初次剖腹產率(27.1%)，而基層診所卻有最高的”非剖腹產適應症”比例(45.7% V.S 醫學中心7.3%)。校正後之共變量對數回歸分析中顯示基層診所初次剖腹產的機會是其他層級醫院的6.7~7.7倍，而都市初次剖腹產的機會是鄉村的1.93倍(1.81<95% CI for OR <2.06)。 3. 影響初次剖腹產率的三大因素中，病人因素的影響遠大於醫院因素及醫師因素。 4. 初次剖腹產病例中，使用的抗生素有63.46%是靜脈注射(IV)，而36.54%是口服或外用。IV中以cephalosporins佔最多(62.21%)，而僅使用單劑量IV第一代cephalosporins有3728人(佔8.74%)。有65.16%病例併用兩種或兩種以上的抗生素。不適當使用抗生素的病例達91.26%(NT＄26675176，佔抗生素費用的97.16%)。各層級醫院中，以醫學中心”適當使用抗生素”之比例最高(18.94%)，而基層診所最低(0.60%)。討論及建議台灣初次剖腹產率仍然偏高，尤其是基層診所”非必要性”剖腹產率太高。而在影響初次剖腹產的因素中，以病人因素最為重要。在初次剖腹產抗生素處方之研究顯示：台灣抗生素之不適當使用的比例比歐美國家高出太多，而產生的醫療資源浪費亦相當驚人。本研究顯示”知識層面”與”臨床醫療行為模式”有相當落差。建議可由醫師的再教育(包括住院醫師及專科醫師的實証醫學教育，及婦產科醫學會，感染控制醫學會加強宣導剖腹產預防性抗生素治療指引)及實施積極介入措施(如使用臨床路徑，加強健保對第一線抗生素之監控)著手。當然，持續以全國性資料庫追蹤監控是不可或缺的。關鍵詞：剖腹產，預防性抗生素，費用，醫療利用

關鍵字

剖腹產；預防性抗生素；費用；醫療利用

並列摘要

Abstract Purpose of Study: The study was to examine the propriety in primary cesarean section rate and antibiotic prescriptions in Taiwan based on a nationwide database. The impack of patient characteristics, complications, comorbidities, physician factors and institutional factors on the appropriate use of healthcare resources was also evaluated. Materials and Methods: The patients who had given birth in 2003 were studied. After excluding the extreme values, missing values, and previous cesarean section women and vaginal birth after cesarean(VBAC) cases，there were 44340 women received primary cesarean section, and 145617 women received normal spontaneous delivery, who were enrolled into our study from the claim data of the Bureau of National Health Insurance(NHI) in 2003. The different hospital levels were compared by their primary cesarean section rates, health resources usage, and the complication rates. The definition of appropriate use was that the antibiotic prescriptions followed the guideline of Cochrane Collaboration, i.e. intravenous first-generation cephalosporins as a single dose administration for primary cesarean section women. Results:There was higher rate of advanced maternal aged women(11.14%) in 2003 than before data, and these old aged women also had high primary cesarean rate(33.35%) compared to annual average primary cesarean rate(23.34%) in 2003. The clinics had the highest unnecessary cesarean section rate(45.71%) than other hospital levels. Besides, the obstetrics and gynecology clinics had a very high likehood of primary cesarean delivery compared with all categories of hospitals(odds ratios 6.7~7.7), after adjusting for clinical complications and patient, physician and institutional characteristics. Among physician, institutional and patient factors, the patient factors were the most powerful of all. The appropriate used rate of antibiotic prescriptions was only 8.74% by patient number, and 2.87% by prescribed frequency, which was lower than Western countries. In addition, the clinics had the highest inappropriate use of antibiotic prescriptions of all different hospital levels. Conclusions: Taiwan had relatively high primary cesarean section rates, with a particularly high propensity for this procedure at clinics. The primary cesarean section profile in the various clinical complication categories suggested a significantly lower clinical threshold triggering cesarean delivery decisions in Taiwan, especially at obstetrics and gynecology clinics. In the field of antibiotic prescriptions, the results of this study indicated that inappropriate use of antibiotics for primary cesarean section women was very common in Taiwan, which required physician education and aggressive interventions. Key words: cesarean section, cesarean delivery, antibiotics prophylaxis, prophylactic antibiotics, cost, healthcare