醫療服務量與醫療品質關聯性之探討--以經皮冠狀動脈擴張術為例

Associations Between Medical Service Volume and Quality With The Example of Percutaneous Transluminal Coronary Angioplasty

張崴棣(Wei-Di Chang)

指導教授 ： 毛莉雯

高雄醫學大學/健康科學院/公共衛生學研究所碩士在職專班/碩士(2004年)

摘要

本研究主要目的係整體探討台灣經皮冠狀動脈擴張術醫療服務量與醫療品質之相關研究。納入分析之醫療品質指標包括：(1)住院天數；(2)住院期間死亡情況；(3)自動出院情況；(4)住院中冠狀動脈繞道手術率；及(5)十四天再住院率。分別依病患檔案、醫師檔案及醫院檔案三個不同分析單位份進行探討。假設在控制病患、醫師、醫院特質後，醫院服務量分組間與醫療品質應應顯著呈負關聯性之差異。
本研究設計採回溯性之次級資料分析，其資料來源為國家衛生研就院所提供之中央健康保險局九十年一月至十二月全國醫院向健保局以住院方式申報住院處置醫令碼（ICD-9-CM碼為3601、3602、3605）為經皮冠狀動脈氣球擴張術之案件共15,598例。經由資料整理比對除誤後，以Microsoft® Excel 2000與SPSS® for Windows 10.07C套裝軟體進行描述性及推論性分析比較。
研究結果發現：(一)四分位數服務量組別分析中，在自動出院與十四日內同科再住院有顯著趨勢關聯(p<0.05)，住院天數有顯著差異(p<0.05)，亦即服務量越高其自動出院率、十四日內同科再住院率越低。(二)女性病患有較高之自動出院率與住院天數。（三）公立醫院較私立醫院有顯著較高之死亡率（1.0% vs. 0.5%）；但公立醫院收治病患之年齡較高且次診斷數也較多。(四)醫學中心、公立醫院、低年資醫師組之對照組有較高之同次住院併行冠狀動脈繞道手術率。(五)次高服務量組較其他服務量組有較短之住院天數（4.59天）。曾有不良品質指標發生之病患確實較未發生病患呈現顯著較長之住院天數。
就本研究之各項品質指標而言，經迴歸分析後得知，在自動出院與十四日同科再住院兩項指標確實有依服務量之增加而減少發生率之趨勢；但在住院期間死亡率，同次住院併行冠狀動脈繞道手術率與住院天數，皆以次高服務量組之勝算比或迴歸係數較其他分組低，再次印證次高服務量與醫療品質間之相關性。
簡言之，服務量之高低對經皮冠狀動脈擴張術之醫療品質成果確有影響，故建議健保局應可依醫院服務量建立品質監控指標並配合衛生主管機關儘速建立健全之品質評鑑制度。本研究主要限制為次級資料分析，缺乏個別醫院之病人資料以進行校正，未來個別專業醫學會應將各醫院之臨床資料予以登錄分析，以實證資訊維持良好之醫療品質。

關鍵字

醫療品質 ； 醫療服務量 ； 經皮冠狀動脈擴張術

並列摘要

The major purpose of this study is to investigate the associations between medical service volume and quality with the example of percutaneous transluminal coronary angioplasty (PTCA). According to previous researches that hospital and/or physician had higher volume of practice led to less complications and better outcome. After the introduction of PTCA was introduced in Taiwan for more than 20 years, there is no study on PTCA quality assessment and its relation to PTCA volume. PTCA is an expensive procedure compared with other medical procedures. Thus, medical quality is a more important issue for public makers and hospital mangers, especially facing the global budget of national health insurance (NHI). In this study, there were 5 quality indicators examined among the hospital samples. They were: (1) in-hospital mortality, (2) against advice discharge rate, (3) Same admission coronary artery bypass graft rate, (4) Readmission within 14 days, (5) length of stay. Moreover, the quality differences in PTCA will be compared by hospital ownership and level of care.
The study design was a retrospective secondary data analysis. The study sample consisted of a total number of 15,598 PTCA cases (ICD-9-CM code 3601, 3602, 3605) who received the procedures by all NHI contracted hospitals from January 2001 to December 2001). These NHI claim data sets were released from the National Health Research Institutes. The computer software SPSS® 10.07C for Windows and Microsoft® Excel 2000 were used to conduct descriptive and theoretical comparison and analysis.
The total volume of PTCA procedures divided into four groups by quartile method. The four groups of service volume were named into high, sub-high, sub-low, and low volume. According to planned statistical analyses, the results indicated that: (1) By trend analysis, significant negative association was found in advice discharge (AAD) rate (p<0.001) and readmission rate within 14 days (p<0.05) among the four groups of service volume. (2) The same admission CABG rate of medical center (1.5%) is significantly higher than the proportion of regional hospital (0.6%) (p<0.05). The highest volume hospital had the highest CABG rate (p<0.05). (3) The mortality rates of public hospitals were higher than private hospitals (1.0% vs. 0.5%), which may be due to the mean age of PTCA patients at public hospitals are older than the patients at private hospitals. (4) Female patients had higher AAD incidence (OR=1.4) and longer length of stay (4.86 vs. 5.56) (5) The sub-high volume hospital had the shortest length of stay as compared with other 3 quartile groups (4.59days). All adverse outcome patients had longer length of stay than those PTCA patients without poor outcome.
In conclusion, low volume hospitals (≤338 cases/year) produced poor outcome as shown by selected adverse quality indictors in the present study. It is suggested that the Bureau of NHI should collaborate healthcare administrative office to develop a quality management and accreditation system by the volume of hospital or physician practice. However the research database is from NHRI secondary data. The major limitation of this research was no information on severity of coronary artery disease and clinical data of patients to adjust different patient characteristics among hospitals. For future research, the clinical registry database may conduct by specific medical society to review their members’ practice volumes and related medical quality.

並列關鍵字

Medical service volume ； Medical quality of care ； Percutaneous transluminal coronary angioplasty

參考文獻

中文部份

1.衛生署；全民健康保險-醫療統計年報，2000

2.衛生署；中華民國台灣地區2002全民健保主要疾病就診率統計，2004

3.中央健康保險局；全民健康保險醫療費用支付標準，2004

4.盧瑞芬、謝啟瑞；醫療經濟學，學富文化事業有限公司，2000