初次診斷憂鬱疾患者追蹤三年之醫療利用與費用分析探討

Three-year follow-up of healthcare utilization and expenditure of patient with first diagnosis depressive disorder

洪瑞屏(Jui-Ping Hung)

指導教授 ： 葉玲玲

亞洲大學/健康學院/健康管理研究所/碩士(2006年)

摘要

本研究希望了解國內初次診斷憂鬱疾患者追蹤三年之醫療利用與醫療服務點數，並分析其影響因素，以供相關單位推動憂鬱疾患者照護政策時之參考。
採次級資料回溯性分析方法，資料來源為1996年至2003年全民健保資料庫承保抽樣歸人檔。以2000年憂鬱疾患者(ICD-9-CM碼 296.2、296.3、300.4、311)，排除之前曾有憂鬱疾患診斷或曾有抗憂鬱劑使用者，初次診斷憂鬱疾患者共875人，各連續追蹤三年之醫療利用、醫療服務點數。
本研究發現，2000年憂鬱疾患之年發生率為0.44％，女性佔60.7％，30歲至59歲佔58.3％，60歲以上佔26.6％，初次診斷為在精神科就診者佔41.8％，追蹤第一年時憂鬱疾患者在精神科就診超過4次以上者僅佔20.5％，第一年時憂鬱疾患者由非精神科轉診至精神科就診比率為3.5％。初次診斷憂鬱疾患者三年間，每年門診、急診與住院就診率，皆超過國人每年平均就診率。初次診斷憂鬱疾患者在與憂鬱疾患無關之門、急、住診醫療服務方面，明顯有較高之利用率及較高的就醫次數；在與憂鬱疾患有關之門診醫療服務，在第二、三年時就診率明顯偏低（29.6％與24.0％）。
重鬱症患者、年齡越大者、第一年精神科就診次數4次以上者，有較高的與憂鬱疾患有關之門診醫療利用。與年齡越大者、女性、初次診斷前一年醫療費用較高者、第一年免部分負擔者，有較高的與憂鬱疾患無關之門診醫療利用。年齡越大者及有重大傷病者，有較高的憂鬱疾患無關之住院醫療利用。
追蹤三年期間，第一年僅55.0％憂鬱疾患者有獲得抗憂鬱劑使用，第二、三年分別遞減為23.7％、21.0％，總開藥日數分別為88.6天、129.1天、139.1天，抗憂鬱劑藥物服務點數分別為3249.9點、4342.3點、4613.7點。重鬱症者、年齡越大者、第一年精神科就診次數4次以上者，有較多的抗憂鬱劑使用。
針對研究結果，本研究發現初次診斷憂鬱疾患者大部分仍尋求非精神科醫師的照護，第一年由非精神科轉診至精神科就診之比率低，第二、三年與憂鬱疾患有關之醫療服務與抗憂鬱劑使用比率，則明顯比第一年低。因此，建議政策決策者增加非精神科醫師將嚴重憂鬱疾患者轉診至精神醫療專業之誘因，及鼓勵醫療院所落實憂鬱疾患者個案管理制度與後續追蹤。

關鍵字

憂鬱疾患 ； 初次診斷 ； 醫療利用 ； 全民健保 ； 醫療費用 ； 歸人檔 ； 就診率 ； 發生率

並列摘要

Objective: This study was to investigate three-year follow-up of healthcare utilization and reimbursement of patient with the first diagnosis depressive disorder and analyz its related factor. Furthermore, providing government the evidence-based data of promoting patients with depressive disorder care in decision-making.
Methods: This was a retrospective study analyzing secondary data. The source of data came from claim data of all set of sampled registry of beneficiaries of National Health Insurance from 1996 to 2003. Patient had the first diagnosis of depressive disorder (ie, ICD-9-CM code 296.2, 296.3, 300.4, 311) in 2000. Patients with previous depressive disorders and/or treatment with an antidepressant were excluded from the analysis. A total of 875 patients with first diagnosis depressive disorders were collected, continuously followed three-year medical utilization and reimbursement.
Results: The incidence of depressive disorder was 0.44% in 2000. There were 60.7% female patients, 58.3% in 30-59 years old and 26.6% in 60 years old and above, 41.8% of patients with the first diagnosis depressive disorder to look for care initially in the psychiatry department . Only 20.5% patients went to psychiatry department over 4 times in the next year, and 3.5% transfer rate from non-psychiatry department to psychiatry department in the first year. In outpatient service, emergency medical treatment and inpatient rate, the medical utilization of patients with the first diagnosis depressive disorder was over the national average utilization rate. Patients with the first diagnosis depressive disorder had significant higher medical use in non-depression-related outpatient, inpatient and emergency service. The utilization of the depression-related outpatient service in the second and third year was obviously lower (29.6% and 24.0%).
There were significant higher depression-related outpatient utilization in major depression, older and the first year psychiatry department rate over 4 times. There were significant higher non-depression-related outpatient utilization in older, female, before first diagnosis year high medical expense and first year no copayment patient. There were significant higher non-depression-related inpatient utilization in older and catastrophic illness.
Follow three years period, only 55% of patients with the first diagnosis depressive disorder used antidepressant in the first year. The second and third year antidepressant utilization was 23.7% and 21% respectively. The total drug day of first diagnosis depressive disorder patients were 88.6 days, 129.1 days and 139.1 days respectively. The antidepressant service points were 3249.9 points, 4342.3 points and 4613.7points. The utilization of antidepressant was significantly related to major depression, older, patients with the first diagnosis depressive disorder went to psychiatry department above 4 times.
Conclusion and recommendation: According to this results, majority of the depressive disorder patients still sought non-psychiatry department services. The transfer rate from non-psychiatry department to psychiatry department were obviously low. The medical utilization and usage of antidepressant of depressive disorder patients in the second and third were obviously lower than the first year. Based on the results of this study, a few suggestions were proposed as the following: The Bureau of National Health Insurance should increase the incentive to the non-psychiatry general physicians to transfer major depression patients to the psychiatry department and encourage hospitals to realize the case management and continuity of care.

並列關鍵字

depressive disorder ； first diagnose ； healthcare utilization

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