全民健保成人預防保健服務對於疾病早期治療及降低全死因死亡的效果分析

The effectiveness of Adult Preventive Care Service under National Health Insurance on early disease treatment and reduction of all-cause mortality

林承昌(Cheng-Chang Lin)

指導教授 ： 季瑋珠

共同指導教授 ： 李永凌

國立臺灣大學/公共衛生學院/預防醫學研究所/碩士(2009年)

https://doi.org/10.6342/NTU.2009.00545

摘要

背景：
疾病預防的觀念自二十世紀初期開始蓬勃發展，同時也促成了各類型週期性健康檢查計畫的實行。我國全民健康保險自從民國85年開始全面支付成人預防保健服務，服務內容包含生活型態及病史調查、物理檢查及實驗室檢查，其檢查項目涵蓋大部分我國國民主要死因的疾病篩檢，每年約有三成民眾接受此項服務。然而至今少有足夠之證據和文獻有效的評估成人預防保健服務的效用，尤其是在臨床上結果的分析。目的：本研究的目的在探討對於高血壓、糖尿病及高血脂疾病病程，接受成人預防保健服務可以達成早期治療和降低全死因死亡率的效果。材料與方法：本研究為回溯性世代研究，採用具有全國代表性的全民健康保險研究資料庫20萬人抽樣歸人檔進行次級資料分析，研究材料採用抽樣歸人檔資料中第一及第二組資料，以民國89年為基準，擷取年齡40到100歲的保險對象做為追蹤世代，追蹤時間自民國90年1月1日至96年12月31日。由次級資料庫中擷取目標族群於87至89年間接受預防保健服務的資料,及其追蹤期間所有門、住、急診及治療記錄。本研究使用multiple logistic regression 及Cox proportional hazard regression 分析曾接受此項服務對於新發生高血壓、糖尿病、高血脂治療及全死因死亡事件的勝算比(odds ratio)及風險比(hazard ratio)，本研究亦採用時間相依Cox模型進行分析。結果：本研究世代樣本共包含16,080位男性 (50.2%) 及15,959位女性(49.8%) ，平均年齡分別是55.6±11.9歲和56.0±11.9歲。在7年追蹤期間，原先沒有高血壓、糖尿病及高血脂的族群，各有32.1%, 9.1%和14.5%的比例發生目標疾病的治療。 研究結果發現，每次接受成人預防保健服務後1年，在40-54歲、55-64歲和65-100歲的族群，其發生高血壓治療之風險比(hazard ratio)為1.80(95% confidence interval, CI: 1.64-1.97)、1.67(95%CI: 1.50-1.85) 和1.56 (95%CI: 1.43-1.72)；發生糖尿病治療的風險比為1.59(95%CI: 1.19-2.13)、2.21(95%CI: 1.87-2.61) 和1.76(95%CI: 1.50-2.05) ；發生高血脂治療的風險比則是3.97 (95%CI: 3.59-4.38)、3.21(2.85-3.63)和2.82(95%CI: 2.49-3.20)。這些估計值都具統計上顯著意義 (p< 0.001)。
每次接受成人預防保健服務後1年內及7年內，其發生全死因死亡的風險比僅在65至100歲的族群達到統計上顯著(p<0.001)，其風險比分別0.74(95%CI: 0.67-0.84) 及0.80(95% CI: 0.72-0.89)。結論：本研究有效證實成人預防保健服務對於健康結果的影響。研究結果顯示使用成人預防保健服務，對於高血壓、糖尿病和高血脂三種影響國人健康的主要慢性病，能達到早期治療的效果, 且在65至100歲的族群，有降低全死因死亡風險的保護效果。

關鍵字

成人預防保健服務 ； 週期性健康檢查

並列摘要

Introduction：Chronic diseases prevention became more important in the first decades of the 20th century, which stimulated the implementation of screening programs. The National Health Insurance (NHI) reimbursed the adult preventive care service package for beneficiaries aged 40 and older in Taiwan since 1996. About one-third of its target population utilized this service periodically. However, there has been little evidence for the effectiveness of the service, particular in clinical outcomes. Purpose：The purpose of this study is to assess effectiveness of the adult preventive service on early treatment of chronic disease and the reduction of mortality. Material and methods：A total of 32,039 subjects aged 40-100 years by the year 2000 were identified from the representative 200,000-person sample in the reimbursement database of the National Health Insurance in Taiwan. Uptakes of preventive service during 1998-2000 were retrieved, and subjects were followed from Jan 1, 2001 to Dec 31, 2007, information about ambulatory visits and inpatient care during this period was also collected. Multiple logistic regression and Cox proportional hazard regression were applied to estimate the odds ratio and hazard ratio on newly treated hypertension, diabetes, hyperlipidemia and all-cause mortality for those who ever utilize the service. Extended Cox model with counting process was implemented to treat the time-dependent covariate and assess the effectiveness of each uptake. Results：There were 16,080 male (50.2%) and 15,959 female(49.8%) in the study population and the average age of each group were 55.6±11.9 years and 56.0±11.9 years. During the seven years follow-up, 32.1%, 9.1% and 14.5% of each defined cohort developed newly treated hypertension, diabetes and hyperlipidemia. The hazard ratios (HR) of each uptake on newly treated hypertension within one year were 1.80(95% confidence interval, CI: 1.64-1.97), 1.67(95%CI: 1.50-1.85) and 1.56 (95%CI: 1.43-1.72) among subjects aged 40-54, 55-64 and 65-100. For newly treated diabetes, the hazard ratios were 1.59(95%CI: 1.19-2.13), 2.21(95%CI: 1.87-2.61) and 1.76(95%CI: 1.50-2.05) among subjects aged 40-54, 55-64 and 65-100. For newly treated hyperlipidemia, the hazard ratios were 3.97(95%CI: 3.59-4.38), 3.21(2.85-3.63) and 2.82(95%CI: 2.49-3.20) among subjects aged 40-54, 55-64 and 65-100. All of these estimates were statistically significant (p< 0.001).
The hazard ratio of each uptake on all-cause mortality within one and within seven years were statistically significant only among subjects aged 65-100 (HR: 0.74, 95%CI: 0.67-0.84; HR: 0.80, 95% CI: 0.72-0.89, p<0.001).
Conclusion：This study provides strong evidence for impact of adult preventive care service on major health outcomes. The results indicated the effectiveness of the service on early treatment of hypertension, diabetes and hyperlipidemia, and finally, reduction of all-cause mortality, especially in subjects aged 65-100.

並列關鍵字

adult preventive care service ； periodic health examination

參考文獻

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