『高血壓個案管理』之介入對高血壓病患併發症發生率與醫療費用之影響

The Effect of Intervention in “Hypertensive Case Management” To the Complication Rate and Medical Costs in Hypertension Patient

陳俊彰(Chang-Chen Chun)

指導教授 ： 張肇松

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(2012年)

摘要

研究目的高血壓是一高盛行率、多併發症的慢性病。常見高血壓患者，因不瞭解，而輕忽長期血壓控制不良可能造成的傷害。它的致命併發症包括：急性心肌梗塞、自發性腦出血、梗塞性腦中風、主動脈剝離、周邊動脈阻塞、腎衰竭、高血壓眼底病變等，常造成龐大醫療費用支出。健保局於民國95年推出『全民健康保險高血壓醫療給付改善方案』之試辦計畫，希望藉由這樣的個案管理而改善病患血壓控制情況，減少併發症的發生率，降低醫療費用的支出。 本研究之目的就在探討，經由這樣的個案管理，成效如何？是否可確實減少高血壓患者之併發症發生率、死亡率以及醫療費用的支出？ 研究方法 本研究藉由健保資料庫所提供之百萬歸人檔，篩選新發生之高血壓個案，排除：收案前曾有心肌梗塞或腦中風病史，接受過心臟冠狀動脈介入性治療或繞道手術之病人。由母群體分出未曾接受高血壓個案管理收案者，與接受高血壓個案管理一至三階段收案者，比較其急性心肌梗塞發生率、急性腦中風發生率、死亡率、門診與住院醫療費用之差異。研究結果
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1. 併發症發生率（包括急性心肌梗塞及急性梗塞性腦中風）：『未接受高血壓個案管理收案者』，高於『接受高血壓個案管理收案者』，P=0.001，有顯著性差異。
2. 死亡率：『未接受收案者』相較於『接受收案者』，有較高的死亡率(all causes of death)，然而，單變量線性回歸分析的結果，P=0.220，無統計上的差異。
3. 醫療費用比較：
平均每人門診總醫療費用：『未接受收案者』，高於『接受收案者』（P<0.001） 平均每人住院總醫療費用：『未接受收案者』，高於『接受收案者』( P<0.001） 結論和建議研究結果顯示，接受高血壓個案管理者，有較低之併發症發生率；及較低之住院與門診醫療費用。因此，我們合理的相信若有更多的患者接受個案管理與衛教後，整體醫療費用與病患死亡率極有可能因併發症減少而大幅降低。建議衛生主管機關，及健保局應繼續推行此試辦計劃，以達更全面之果效。

關鍵字

高血壓 ； 急性梗塞性腦中風 ； 急性心肌梗塞 ； 高血壓個案管理 ； 門診總醫療費用 ； 住院醫療總費用

並列摘要

Introduction
Hypertension is a chronic disease with high prevalence and complication rate. The majority of patients suffering from high blood pressure does not know, or understands, the characteristics and complications of this disease, and thus underestimate the harm it may cause. Poor blood pressure management can result in target organ damage or fatal complications such as: spontaneous intracranial hemorrhage, cerebral infarction, acute myocardial infarction, aortic dissection, peripheral arterial obstructive disease, renal failure, hypertensive retinopathy, etc. Such complications can result in greater health care costs.
The National Health Insurance Bureau has been promoting a program titled: “Improvement Program of Medical Payments for Hypertension by National Health Insurance” since 2006. The purpose of the program is to encourage/promote lifestyle modification in patients with hypertension in order to decrease complication rates and medical costs.
The purpose of this study is to examine the effectiveness of this program. Has this program helped to improve patients’ blood pressure, decreased complication rates, and reduced their medical expenses?

Sample and methods
The data used in this study was obtained from the database provided by the National Health Insurance Bureau. Subjects used in this study include patients with: chronic hypertension, stroke, and history of acute myocardial infarction or percutaneous coronary intervention or coronary artery bypass graft surgery. This population was then divided into four subgroups, according to the respective stages of hypertensive management, (G0, G1, G2 & G3). The rates of acute myocardial infarction, acute stroke, mortality and medical expense in OPD and hospitalization were compared among the four subgroups.

Results
1. Patients who received the program of hypertensive case management had lower complication rates than those who refused this program.
2. Patients who received the program of hypertensive case management had lower mortality rates than those who refused this program, although the P value of 0.220 does not show a significant difference between the two groups.
3. The medical expenses of both OPD and hospitalization are higher in patients who refused the program of hypertensive case management than those who received it.

Conclusion
According to the results of this study, hypertensive management has shown to lower complication rates and lower medical costs for the patient. Therefore we believe that medical cost and mortality rates of hypertension may be significantly reduced if more patients receive hypertensive management. We suggested that the program, “Improvement Program of Medical Payments for Hypertension by National Health Insurance” be widely promoted because of its benefits to patients and government alike.

並列關鍵字

Hypertension ； acute cerebral infarction ； acute myocardial infarction ； hypertensive case management

參考文獻

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