急性心肌梗塞住院病人醫療品質與費用關聯性的探討 以東部某區域醫院為例

Association of Medical care Quality and Expenses in Inpatients with Acute Myocardial Infarction: Using A Regional Hospital in Eastern Taiwan as Expample

彭奕欣(Yi-Hsin Peng)

指導教授 ： 張永源

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(2007年)

摘要

目的：
心臟疾病在我國近年十大死因排名第三，而又以急性心肌梗塞死亡率最高，若能在適當的時機給予適當的醫療處置，可降低急性心肌梗塞病人死亡的風險，故本研究目的：
一、探討東部某區域醫院急性心肌梗塞住院病人符合臨床指引項目多寡與平均住院日、併發症、死亡率、30天再住院率、醫療費用之相關。
二、探討急性心肌梗塞病人年齡與費用之相關、及住院天數在性別上之差異。
三、探討東部某區域醫院急性心肌梗塞住院病人急病嚴重度、平均住院日、死亡率、30天再住院率、醫療費用與同體系其他院區之比較。
方法：
本研究採回溯性病歷審查方式，搜集同體系不同院區三家醫院急性心肌梗塞住院個案，以美國ACC/HA (American College of Cardiology/American Heart Association)實證的臨床醫療處置指引，看其臨床指引項目符合項次與醫療品質(平均住院日、死亡率、併發症、30天再住院率)及費醫療費用等之相關，以SPSS10.0套裝軟體進行次數分配、百分比、平均數等描述性統計，再以t-test、one-way ANOVA、迥歸分析進行推論性統計。
結果：
一、 急性心肌梗塞住院病人符合臨床指引項目多寡與併發症、死亡率、30天再住院率有統計上的差異，與住院天數、醫療費用沒有顯著差異。
二、急性心肌梗塞病人年齡與費用有顯著正相關，住院天數在性別上有顯著差異，女性住院天數高於男性。
三、急性心肌梗塞住院病人平均住院天數、醫療費用、有無併發症與同體系其他院區有顯住差異，在死亡、30天再住院與同體系其他院區無顯著性差異。

結論與建議：
一、實證證實依臨床指引執行醫療處置可降低急性心肌梗塞病人死亡率，並減少醫療費用花費。
二、以經濟誘因的論質計酬獎勵方案可有效提高醫療品質，且可誘發醫院參與方案的意願，推動計畫的普遍化達到整體品質的提昇。
三、國內疾病論質計酬方案應大力推動，並增加更多疾病論質計酬方案。
四、建議從支付制度面改革，依醫療品質不同而有不同給付，拉大經濟誘因級距促使醫院做的更好。

關鍵字

急性心肌梗塞 ； 醫療品質 ； 臨床指引

並列摘要

Objective:
Heart disease has been the third place of the top ten cause-of-death of our country in recent years. Amongst the acute myocardial infarction has the highest mortality rate. However, the mortality rate of AMI can be lowered should the appropriate medical treatments could be given in appropriate time. Therefore, the purpose of this study is firstly, to investigate the relation between the compliance of clinical indicators of AMI inpatient cases and length of stay, complications, mortality rate, readmission rate in 30 days, and medical expenses; secondly, to explore the relation of the age of AMI patients and medical expenses; and the differences between length of stay and gender; and thirdly, to compare the variation of AMI patients’ average length of stay, mortality rate, readmission rate in 30 days, and medical expenses of a regional hospital and other hospitals in the multi-hospital system.
Methods:
The retrospective medical review method was adopted in collecting the hospitalized AMI patients from three hospitals in a multi-hospital system. Seven evidence-based AMI clinical guidelines from the Hospital Quality Incentive Demonstration project by the Centers of Medicare and Medicaid, USA were used to justify the relationships with clinical quality indicators, such as ALOS, Mortality rate, and readmission in 30 days, and medical expenses. Statistical analyses were performed using computer package software SPSS version 10.0, including descriptive statistical, and inferential statistical procedures such as frequency, percentile, means, t-test, and one-way ANOVA.
Results:
We found that the numbers of compliance items in clinical guidelines are statistically significant in association with the complications, mortality rate, and readmission in 30 days. And we did not find the significance in length of stay and medical expenses. The age of AMI patients is significantly associated with expenses. And the female is significantly higher than the male patients in length of stay. The average length of stay, medical expenses, and complications in the study hospital are significantly different from other hospitals in the same multi-hospital. However there are no significant difference in mortality rate and readmission in 30 days compared with other hospitals in the system.
Conclusion and Suggestion:
Complying with evidence-based AMI clinical guideline can reduce the mortality of AMI patients and medical expenses. Using financial incentives in rewarding for the better quality of care can effectively improve the quality of care, and raise the willingness of participation in order to reach the improvements in overall quality. The pay for performance programs should be intensively promoted by increase the numbers of pay for performance projects. It is recommended that the reformation of the fee schedule structure in providing incentives to have hospitals providing better of care in order to get higher reimbursements.

並列關鍵字

acute myocardial infarction ； medical quality ； clinical guidelines

參考文獻

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