某區域醫院冠狀動脈疾病以經皮冠狀動脈氣球擴張術治療與支架治療之成本效果分析

Cost-Effectiveness Analysis of Balloon Angioplasty Versus Coronary Stenting for Patients with Coronary Artery Disease

吳榮州(Jung-Chou Wu)

指導教授 ： 邱亨嘉

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

研究目的: 本研究針對冠狀動脈疾病患(CAD)者比較接受經皮冠狀動脈氣球擴張術(PTCA)或冠狀動脈支架(STENT)植入手術治療之成本效果分析。
研究方法: 針對某區域醫院CAD患者652人接受PTCA或STENT之治療進行回溯性的研究，收集病歷及健保申報電腦檔原使資料，使用SAS及SPSS 10.0統計軟體分析。
研究結果: 在兩組間之人口學及基礎臨床特徵大致相同。接受植入STENT病人的當次平均住院費用(﹩183010 vs. ﹩149117, p<0.001) 比接受PTCA病人的平均住院費用高出﹩33993元﹔追蹤二年之平均醫療費用在兩組已無差異。本研究追蹤六個月至一年平均總費用在醫師間醫療費用有差異，乙醫師費用顯著較高。在術後一年內，接受植入STENT病人的血管再成形術與PTCA病人無差異 (21.1% vs.17.7% , p=0.29)。在術後一年內，接受植入STENT病人死亡率顯著比PTCA病人低 (10.5% vs.15.5% , p=0.028)﹔死亡率下降的主要效果在急性心肌梗塞個案，STENT組 11.7% vs. PTCA組 22.2%。PTCA組急性心肌梗塞的個案裡，在追蹤一年及二年的死亡率時，丙醫師顯著較高。分析第一年成本效果，發現與STENT組比較， PTCA組要增加一個生命年所要增加的醫療費用為917660元﹔以急性心肌梗塞個案內STENT組與PTCA組比較，由PTCA組要增加一個生命年所要增加的費用只需381542元。以累積二年分析成本效果，由PTCA組要增加一個生命年所要增加的費用將隨著追蹤時間而遞減。
討論與建議:本研究結果可讓病患瞭解接受STENT治療的死亡率低, 特別是急性心肌梗塞個案。若經濟條件許可，建議急性心肌梗塞個案採STENT治療。對醫療提供者的而言，本研究追蹤六個月至一年平均總費用在醫師間醫療費用有差異，乙醫師費用較高，在總額預算下或醫院自主管理，可以針對醫療提供者進行管理，以節約成本。PTCA組急性心肌梗塞的個案裡，在追蹤一年及二年的死亡率時，丙醫師顯著較高，建議醫師可以提高STENT使用於急性心肌梗塞的個案。對健保局的建議：本研究追蹤一年及二年，在接受STENT治療的病人不但死亡率顯著低PTCA組，其成本效果分析亦屬合理，且在台灣STENT使用率僅為46.6% ，多數為自費其比率佔74.2%，使用率仍低，建議健保局放寬STENT使用的健保規範，特別是急性心肌梗塞的個案。

關鍵字

支架 ； 冠狀動脈擴張手術 ； 成本效果分析

並列摘要

OBJECTIVES:
The purpose of this study was to compare the cost and effectiveness of coronary stenting (STENT) with those for balloon angioplasty (PTCA) in patients with coronary artery disease.
METHODS:
We retrospectively studied patients with coronary artery disease treated at a regional teaching hospital between January 2000 and August 2003 who received either coronary stent (n =304) or coronary angioplasty (n =348). Detailed cost data were collected initially and up to Feb 2004 following the procedure. Detailed chart reviewed for collecting clinical related data. Five doctors involve the intervention procedures.
RESULTS:
Baseline clinical characteristics were similar beween the two treatment groups. The mean in-hospital cost for stent patients were $ 183010 (P<0.001) significantly higher than those receiving coronary angioplasty $ 149117 by 33993 NT dollars. In the following average 2 years follow-up period, the mean cost became no difference between two groups. There was significant difference among the doctors in the following 6 months and 12 months cost. Doctor B had significant higher cost than the others. The revascularization rate of the target vessel at one year was no difference. But the mortality rate was significant higher in the PTCA group at one year (15.5% vs. 10.5%). The major contribution was in the subgroup of acute myocardial infarction(AMI) patients (PTCA 22.2% vs. STENT group 11.7%, P=0.02). There was significant difference among doctors. In patients with acute myocardial infarction and received PTCA, there was higher mortality at one and two years by doctor C. Analyzing the cost-effectiveness at one year, as presenting with ratio between difference of mean cost group and difference of mortality in the two group, the cost to increase one survival patient per year in the PTCA group as compared with STENT group was 917660 NT dollars. Especially in the AMI group, the cost was only 381542 NT dollars. If extended the follow-up period to two years, the cost to increase one survival patient per year in the PTCA group would further decline.
CONCLUSION:
Although stent is costly, the effect to decrease mortality beyond one year is significant, especially in the AMI patients. From the cost-effectiveness ratio of view, stent should be used more advance especially in the AMI patients.

並列關鍵字

STENT ； PTCA ； Cost-Effectiveness Analysis

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