探討膝退化性關節炎病患以玻尿酸關節內注射之療效分析

Therapeutic Effect of Hyaluronic Acid Intraarticular Injection for Degenerative Osteoarthritis of Knee

江秀珠(Hsiu-Chu Chiang)

指導教授 ： 鄭裕民

共同指導教授 ： 邱亨嘉(herng-chia chiu)

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2009年)

摘要

研究背景與目的
依據內政部2009年統計資料顯示，2008年底台灣65歲以上老年人口已達10.4％；其醫療費用，占健保總醫療支出的31%，醫療利用率為65歲以下人口的4-5倍；老年人常見的慢性病膝部骨性關節炎，其發生率與盛行率均隨著年齡而增加，膝部骨性關節炎對老年生活影響甚鉅，對醫療成本的花費也是一大衝擊；退化性關節炎（Degenerative Osteoarthritis, 簡稱OA）是老化引申的肌肉骨骼問題（最常見之老年行動失能慢性病），因為疼痛，導致僵硬與肌肉無力等症狀，也是造成高齡者功能性限制與依賴的原因，亦造成社會成本之耗用。本研究以某醫學中心初次診斷膝退化性關節炎之病患，以關節內注射玻尿酸治療和一般藥物治療進行研究分析，主要探討不同治療方式對中長期治療療效及醫療資源利用之差異性，以評估玻尿酸治療膝關節炎之效益。

研究方法
本研究以回溯性調查2002-2004年某醫學中心初次診斷為膝退化性關節炎之門診病人共有1032人，依其治療方式將未完成完整療程者予以排除後，共計609人納入研究對象，分為關節內注射劑治療者(Hyaluronic Acid Intraarticular Injection, 簡稱HA) 167人，一般藥物治療者442人。以描述性統計分別描述病患特質、疾病特質、醫師特質及中長期膝關節治療療效與醫療資源利用情形，並依據本研究所提出之研究架構，分別以中長期膝關節治療療效為依變項，病患特質、疾病特質、OA診斷治療情形、醫師特質為自變項，進行Logistic regression分析，再利用上述檢定具顯著之變項，進行Multiple logistic regression分析以預測主要之影響因子。

研究結果
609名研究個案之基本資料分析，HA療法佔27.4%，一般藥物治療者佔72.6%，年齡分層皆以45-64歲者且女性較多，HA治療者以OA退化程度stage I、II 較多，以一般藥物治療者則半數以上為stage I。施行HA治療者醫師年資均較輕，因其他疾病因素須住院治療者比率較低；以一般藥物治療者，就診科別皆以復健科居多，但因疾病嚴重度較高，所以住院次數、住院費用、住院天數以及手術次數、手術費用也相對較高。以OA診斷後至施行TKR手術平均時間，以HA治療者為30.47個月，一般藥物治療者為19.10個月。

在Multiple Logistic regression分析中長期年資較輕的醫師及OA退化程度為Stage III和IV者較stage I者均有較高機率持續接受HA療法，但年齡、疾病嚴重度等無達到顯著差異。在接受OA相關手術之顯著預測因子為OA退化程度和初次診斷科別，顯示OA退化程度愈嚴重接受手術治療之比率相對提高，而初次診斷為復健科者有較低之機率在五年內接受骨科相關手術治療。

結論
本研究證實治療方式對年齡、醫師年資、疾病嚴重度、OA退化程度及診斷科別有關；OA退化程度及病患選擇診斷治療科別為治療療效及醫療醫源利用影響的變項。整體而言，以HA治療者較一般藥物治療者有較高的醫療資源利用，亦有較高的機率施行骨科相關手術手術，但比較不同治療方式其施行人工關節置換的時間，HA療法較一般藥物治療者確有延緩之趨勢。

關鍵字

膝退化性關節炎 ； 玻尿酸關節內注射 ； 療效分析

並列摘要

Background
The old population in Taiwan had reached 10.4% in the end of 2008 according to the 2009 statistical data of the Interior Ministry Department. The medical cost of senile population(over 65 years old) in Taiwan is 31% of the total National Health Insurance disbursement and is 4-5 times of the population of younger than 65 years old. The occurrence and prevalence of degenerative osteoarthritis of knee (the most common chronic ambulation disabling illness of senile people) is increasing with the age processing. It has a great influence on the senile daily life and also an impact on the medical cost experditure. Osteoarthritis of knee, the degenerative musculoskeletal problem which cause the pain, stiff and weakness of the extremity and leads to senile disabling and dependence that also increase the social cost. The materials were the patients who was diagnosed as osteoarthritis for the first time in a medical center, and were derived into 2 groups for study: one is ordinary medicine treatment and the other is intraarticular injection of Hyaluronic Acid. To compare the difference of therapeutic effectiveness and medical resource consumption between these two groups in long term, and trying to evaluate the value of HA in the treatment of OA knee.

Material & Method
This is a retrospective study of 1032 patients treated in a medical center during 2000-2004 who has diagnosed as osteoarthritis of knee for the first time. Excluding those who the treatment course was interrupted, there were totally 609 cases were studied and divided into 2 groups: 167 of intra-articular injection of Hyaluronic Acid (HA), and 442 of ordinary medicine conservative medical treatment. The described statistic analysis was used on patients, diseases & physician’s characters and long term clinical result and medical resource consumption, and by using logistic regression and multiple logistic regression analysis to find out the significant factors among the variables mentioned above.

Results
Of the 609 researched cases, the HA group accounts for 27.4% and the ordinary medicine group accounts for 72.6%. The patients’ age are range from 45 to 64 years old and the female are dominant. HA group mainly are OA degree of stage I and II while ordinary medicine group is mainly (more than 50%) are stage I. HA group had been treated by younger physician and had a lower percentage to admitted for other disease. As for the group of ordinary medicine, they mainly managed by Rehabilitation department, but their disease severity was higher so frequency of admission. Hospitalization length and cost are higher, never the less, they have more operation and more surgical cost. The average time interval between diagnosis of osteoarthritis and undergo surgery of total knee replacement is 30.47 months in HA group versus 19.10 months in ordinary medicine group.
The multiple logistic regression for long term result, shows that the younger physicians prefer the HA therapy, and Stage III, IV OA has a higher percentage receiving continuous HA therapy. But age and difference of disease severity has no significant concerned with the treatment options. As for the osteoarthritis related surgery, the factors concerned are degenerative degree and the primary diagnosis department. It shows that the more severe the OA degree is, the higher percentage will receive surgery, and for the cases diagnosed in rehabilitation department, there is a lower possibility to receive related orthopaedic surgery within 5 years.

Conclusion
This study shows that treatment option for the degenerative osteoarthritis is concerned with the patients age, illness severity, OA degenerative degree and diagnosed department. Degenerative degree and treated department alternatives influenced the treatment effectiveness and medial resource consumption. The HA group has higher resource consumption and more possible to undergo related orthopaedic surgery, but the time interval for total knee replacement is longer and postponed comparing to patients, received ordinary medicine therapy.

並列關鍵字

Degenerative Osteoarthritis of Knee ； Hyaluronic Acid Intraarticular

參考文獻

英文部分

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