膝退化性關節炎糖尿病病患進行膝關節置換術醫療成效與醫療資源耗用分析

Analysis of medical effect and medical resource consumption of knee arthroplasty in diabetic patients with knee degenerative arthritis

蔡佩玲(Pei-Ling Tsai)

指導教授 ： 李金德

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2018年)

摘要

中文摘要
研究目的：
隨著人口老化和國人平均壽命延長，未來同時合併糖尿病和退化性關節炎的人數將增加，預計需接受全膝關節置換術的患者也將增多。本研究目的主要探討有無糖尿病共病患者行關節置換術治療方式對中長期治療療效及醫療資源利用之差異性。
研究方法：
本研究採用2005年健保資料庫百萬人承保抽樣檔資料庫住院檔作回溯性及資料的縱貫研究。選取初次診斷膝退化性關節炎(ICD-9處置碼81.54)之病患為研究樣本。排除住院天數資料不完整，性別資料不完整，年齡小於20歲以下，共計5897人。再利用傾向分數配對（Propensity Score Matching, PSM）1:3將人口學特性的性別、年齡與疾病特性最後分成兩組，前一組有糖尿病711人另一組無糖尿病2133人。
研究結果：
一、初次全膝關節置換術發生率長期趨勢有上升情形，由2000年0.03%到2010年0.06%增加2倍。年平均總醫療費用 (由144,511元降為127,037元)與住院天數(由平均10.04天降為7.14天)卻逐年趨勢往下減少。
二、影響退化性膝關節炎糖尿病患者初次全膝關節置換術當次醫療利用的因子中，次族群分析其中糖尿病組女性、選擇區域醫院開刀、心血管疾病、沒有慢性腎臟疾病或沒有慢性肺阻塞疾病者當次住院天數較高。而女性、≧65歲、醫院中等手術量、合併有慢性肺阻塞疾病、CCI=0者糖尿病組比非糖尿病組當次醫療費用較高。
三、影響次族群分析發現初次全膝關節置換術出院後三十天後近期再入院因素發現，初次人工膝關節置換術患者有慢性腎臟病糖尿病組比沒糖尿病組出院後30天再入院率趨勢多3.46倍。其餘無顯著差異。
結論與建議：
初次行人工膝關節置換術病人的發生率長期趨勢是明顯逐年上升。衛福部雖然採事先審核制，但整體醫療利用率佔健保比例也一直增加，但對於日益增加的自費衛材，這在健保資料庫中無法得知，如何讓病患選擇合適的耗材不致花冤妄錢損害病人權益未來可以再關注。在極短的住院天數中如何讓病人與家屬學會照顧自我照顧，未來或許可以結合正在推行的長照2.0的服務，讓醫院出服個管師轉介適合的長照服務項目介入協助病人，讓病人有更好的生活品質。

關鍵字

人工膝關節置換術 ； 發生率 ； 醫療資源成效 ； 醫療資源耗用

並列摘要

ABSTRACT
Introduction:
As the population ages and the average life expectancy of the country increases, the number of people with diabetes and degenerative arthritis will increase, and patients that are expected to undergo total knee arthroplasty will also increase. The purpose of this study was to investigate the difference between the treatment of patients with or without diabetes comorbidity, the effectiveness of mid- and long-term treatments, and the utilization of medical resources.
Methods and materials:
This study used the 2005 health insurance database for millions of people to obtain the sample file database for the retrospective inspection and longitudinal data study. Patients initially diagnosed with knee degenerative arthritis (ICD-9 treatment code 81.54) were selected as the study sample, excluding data with incomplete records on number of hospitalization days, gender, and patients of less than 20 years of age.
Results:
First, the long-term trend of the incidence of primary total knee arthroplasty has increased, from 0.03% in 2000 to 0.06% in 2010. The annual average total medical expenses (from 144,511 yuan to 127,037 yuan) and the number of hospital stays (from an average of 10.04 days to 7.14 days) decreased year by year.
Second, among the factors affecting the primary total knee arthroplasty in patients with degenerative knee arthritis, the subgroup analysis revealed that women of the diabetes group, the choice of regional hospitals, cardiovascular disease, no chronic kidney disease or no chronic lung obstruction increased the number of days of hospitalization for the disease. Females, >65 years old, hospitals with moderate surgery, combined with chronic lung obstruction, CCI = 0 in the diabetes group had higher medical expenses than non-diabetic group.
Third, the impact of subgroup analysis found that the initial artificial knee replacement surgery patients with chronic kidney disease in the diabetic group manifested a readmission tendency of more than 3.46 times, as compared with the no diabetes group. There are no significant differences in the other factors.
Fourth, subgroup analysis for all the variables found that, by using complex linear regression after the postoperative rehabilitation clinic, the above factors had no impact on the use of rehabilitation clinics.
conclusions:
The long-term trend of the incidence of patients undergoing artificial knee arthroplasty for the first time is significantly increasing year by year. Although the Department of Health and Welfare adopted the pre-audit system, the overall medical utilization rate as a proportion of health insurance has also increased. However, the increasing usage of self-funded materials is not recognized in the health insurance database. How to make patients choose the right consumables, avoid unnecessary expense, as well as protect the rights of patients should be addressed in the future. In the future, to let patients and their families learn to take care of themselves in a very short hospital stay, it may be possible to combine the ongoing Long Photo 2.0 service to allow the hospital to introduce a suitable long-serving service project to assist patients, aiming at a better quality of life for the patients.

並列關鍵字

Total knee replacement (TKR) ； Performance of medical resource ； Medical resource utilization

參考文獻

參考文獻

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2. 吳輝秋(2005)。退化性關節炎。高雄縣醫師會誌，16，31-37。

3. 許幼青(2001)。不同臨床路徑對醫療資源品質之影響-以全髖關節置換術為例。高雄醫學大學公共衛生研究所，未出版，高雄市。

4. 衛生福利部國民健康署。2007 年台灣地區高血壓 、高血糖、高血脂之追蹤調查研究。取自：http://www.bhp.doh.gov.tw/BHPNet/Portal/File/ThemeDocFile/ 201102140310199776/2007%e4%b8%89%e9%ab%98%e5%b0%88%e8%bc%af_%e7%b0%a1%e5%96%ae%e7%89%88_20121218%e4%bf%ae.pdf，取得日期：2017.6.7。