慢性阻塞性肺病臨床診療指引遵從度與療效及醫療資源耗用的關係

研究目的：探討臺灣的醫師在診治慢性阻塞性肺病患者時，對於臨床診療指引的遵從度。研究是否接受臨床診療指引所建議的治療方式的病患，有較佳的效果？同時探討影響慢性阻塞性肺病臨床診療指引遵從度的因素。研究方法：以國家衛生研究院釋出的「全民健康保險資料庫」二十萬人抽樣資料，選取在醫院門診規則追蹤治療的慢性阻塞性肺病病患。以＂慢性阻塞性肺病診療指引＂所轉換而來的八項操作型定義訂定診療指引的遵從度；以縱斷面、回溯性的分析2001 年1 月至2004 年12 月之「醫療費用清單明細檔」與「醫事機構基本資料檔」。以探討不同臨床診療指引的遵從度對臨床治療結果、醫療利用以及醫療費用的影響。研究結果：臺灣的醫師對於＂慢性阻塞性肺病診療指引＂的各項建議有不同的遵從度：僅6.3％的病患接受了肺量計檢查；但高達92％的病患不曾接受長期系統性類固醇治療。醫院層級越高，對臨床診療指引遵從度也越高；胸腔科專科醫師對該臨床診療指引的遵從度較高；臨床診療指引高度遵從組的病患，平均年齡及其Charlson Index 高於對臨床診療指引低度遵從組的病患。兩組慢性阻塞性肺病病患臨床的存活時間，經校正年齡及Charlson Index 後，並無統計學上的差異。臨床診療指引高度遵從組的病患有較高的醫療利用及較高的醫療費用。討論和建議：醫院層級越高，各項資源較多，較易達成臨床診療指引的建議。胸腔科專科醫師對自己專科的疾病有較豐富的診療經驗，對於源自實證醫學的臨床診療指引有較高的遵從度。臺灣醫師對於慢性阻塞性肺病臨床診療指引中，各 III 項建議的遵從度差異很大，從6.3%到92.0%不等。臨床診療指引高度遵從組的病患，其平均年齡較高且有較多的合併症，因而有較高的醫療利用及醫療費用。但在本研究中，兩組慢性阻塞性肺病病患臨床的存活時間，經校正年齡及 Charlson Index 後，並無統計學上的差異。應進一步探討為何同一臨床診療指引中，醫師對不同的建議的遵從度有極大的差異的原因；以做為將來再度制定臨床診療指引時的參考。相關單位宜了解不同層級醫院對臨床診療指引遵從度不同的原因，以縮小照護的差異性並提高效率。

關鍵字

臨床診療指引；臨床療效；慢性阻塞性肺病

並列摘要

Objective: To understand adherence to the Global Initiative for Chronic Obstructive Lung Disease（GOLD）guideline of the physician who managed chronic obstructive pulmonary disease（COPD）in Taiwan, whether adherence to the GOLD guideline is associated with a long term benefit, and understand the factors that influence the guideline adherence. Methods: We used the claim data of the Bureau of National Health Insurance (BNHI) from hospitals throughout Taiwan between January 2001 and December 2004 for secondary data analysis. One thousand and two hundred thirty patients with the diagnosis of COPD who were regularly followed up at one hospital between January 2001 and December 2001 were eligible for the guideline intervention phase of the study. The follow-up lasted 3 years. Primary end point was survival. A rating of compliance with the guideline recommendations was calculated for each patient. The Cox regression method was used to estimate and compare survival curves between groups. The independent t test was used to compare the utilization of medical resource and the medical expenditure. Results: The adherence of each component of the GOLD guideline varies, ranging from 6.3%（spirometry）to 92%（not to use systemic steroid regularly in patients with stable COPD）. Generally, the adherence of GOLD guideline in Taiwan is lower than other countries. Survival was not directly correlated with guideline adherence. The variation of adherence of GOLD guideline is large among hospitals. The adherence is highest in medical center and is lowest in the district hospital. Among the physicians, the guideline adherence is higher in chest specialist and is lower in other specialist or V general physician. Conclusion: In Taiwan, the survival of the patients with COPD was not directly correlated with guideline adherence. The COPD patients in the high guidelineadherence group , were older then the low guideline-adherence group. They also had more comorbid illness and higher health resource utility and the higher health expenditure.