國外臨床路徑對本土醫療資源利用與療效之影響-以某醫學中心全人工膝關節置換術為例

本研究的目的在比較國外引進之TKR臨床路徑實施前後，其醫療處置行為、資源利用與療效改變情形，並在療效沒有差異前提下，歸納出最具成本效益之TKR臨床路徑，提供醫療院所參考。研究方法係採回溯性橫斷調查研究，研究對象為某醫學中心接受「全人工膝關節置換術」860位病患，分為其他路徑組260人，本土路徑組443人，國外路徑組157人。研究資料以病歷審查方式收集病患人口學特質、疾病特質、醫療處置行為與負向療效等資料；而醫療費用來源，則為中央健康保險局高屏分局。研究結果顯示，在人口學與疾病特質方面，其他、本土及國外路徑大都無顯著性差異。在醫療處置行為方面，如檢查（驗）項目、手術時間、引流管使用天數、靜脈點滴留置天數、第一次下床行走天數、靜脈抗生素使用天數及出院後三個月複診次數等項目，國外路徑均比本土及其他路徑少；而在復健照會及門診復健次數上，國外路徑明顯較其他及本土路徑高。於醫療資源利用方面，總住院天數，以國外路徑5.24天最短，其次為本土路徑6.53天，其他路徑6.71天最長，三組有達顯著性差異；而於醫療費用部分，在總醫療費用仍以國外路徑121,235元最少，本土路徑122,429元次之，其他路徑123,384元最多，三組有達顯著性差異。而細項目方面，達顯著性差異的，亦以國外路徑費用最少，其中只有一項復健治療費是國外路徑最多，這是因為復健照會多的緣故。雖然國外路徑之醫療資源利用（總住院天數、總醫療費用）都比其他路徑及本土路徑少，而在負向療效方面，就僅一項因關節問題門診比率達顯著性差異，也以國外路徑比率最少，至於大部分項目均無顯著性差異。故將人口學及疾病特質作為控制變項，放入迴歸模式，結果國外路徑是具較少住院天數及較低醫療費用的模式。故本研究之國內外TKR臨床路徑，均有達各自路徑表單上之規範，但在療效不變的情形下，國外路徑是最能達到減少及降低醫療費用的目標，為最具成本效益之TKR臨床路徑，建議可提供相關醫療單位參考。

關鍵字

療效；醫療資源利用；臨床路徑；全人工膝關節置換術

並列摘要

The aim of this study is to compare the difference before and after the introduction of the clinical pathway (CP) of total knee replacement (TKR), in terms of treatment protocols, medical resources utilization, and outcomes. The anticipated results may generalize the most cost-effective clinical pathway for hospital benchmarking. This retrospective cross-sectional study included 860 patients who received TKR at one medical center which further divided into three groups, including other –CP (n=260),Kaohsiung Medical University Hospital（KMUH）-CP (n=443) and University of Virginia Health System（UVAHS）-CP (n=157). The characteristics of patient demography and illness, treatment protocols, resources utilization, and adverse effects were reviewed by charts. Medical expenditures associated with TKR were got from the data files of the Kao-Ping Branch of Bureau of National Health Insurance. The results indicated that there were no significant differences in the patient demography and the characters of the illness among these three groups. In the aspect of treatment protocols, there were less lab tests, surgical time, the time using hemo-vac, the duration of parenteral fluid supplement and antibiotics, and the times of OPD follow-up within 3 months postoperatively and earlier first day of walking in the UVAHS-CP group. Whereas, there were higher percentage of rehabilitation consultation and more times of OPD rehabilitation in the UVAHS-CP group. Significant differences were noted in terms of length of stay and medical cost, the UVAHS –CP group also had better performance than the other two groups. On average, the UVAHS-CP group had the least mean time of hospitalization (5.24 days) and the least cost of 121,235 NT dollars, followed by the KMUH-CP group (6.53 days and 122,429 NT dollars) and the other –CP group (6.71 days and 123,384 NT dollars). After controlling for patient characteristics and severity of illness, the UVAHS-CP group had the least length of stay and medical costs. However, only in the aspect of the cost of rehabilitation was higher in the UVAHS-CP group due to more times of rehabilitation consultation. Though the utilization of medical resource (length of hospitalization and cost) in the UVAHS-CP group was less then the other groups, only in the aspect of ratio of OPD reach significance difference due to the problems related to the joints. No significant difference was noted in the most items. When we set patient demography and the characteristics of illness as control variants and put into regression model, there were less length of hospitalization and cost. All three TKR clinical pathways in this study can be fully accomplished as required on the list. Nonetheless, the UVAHS-CP group provided the equivalent quality of care with minimum resources and costs. Based on this investigation, the most cost-effective UVAHS-CP may be helpful for future development of TKR clinical pathway.