中老年人多重慢性病集群型態與醫療服務使用之相關研究

Influence of Multiple Morbidity Combinations on Health Care Utilization of Taiwanese Older Adults

紀玫如(Mei-Ju Chi)

指導教授 ： 吳淑瓊

國立臺灣大學/公共衛生學院/衛生政策與管理研究所/博士(2008年)

https://doi.org/10.6342/NTU.2008.02571

摘要

目的：慢性病已是世界已開發國家的主要疾病型態，人口快速老化的結果使老人延續的生命卻必須伴隨慢性病所帶來的健康問題。但多數老人的慢性病問題經常不只一種，使得老人面臨多重慢性病所造成的更大的健康負擔；醫療提供面也未對多重慢性病老人提供有效的整合性照護，更可能導致醫療利用和醫療費用的急速攀升。本研究希望以全國代表性中老年人之樣本，首先瞭解全國中老年人多重慢性病以及其所罹患慢性病類型之集群型態的盛行狀況，幫助釐清目前台灣中老年人多重慢性病問題的嚴重程度；其次則是分析不同多重慢性病集群之間的中老年人之醫療利用，以瞭解不同的醫療服務需求，並提出高醫療利用風險的目標族群，提供衛生政策決策單位先針對醫療服務高利用者規劃介入計畫，以降低後續醫療利用與費用的增長，減輕健保財務負擔。
方法：本研究採用2000年行政院衛生署「全國長期照護需要評估」計畫資料，以全國50歲以上中老年人為母群體進行不等機率抽樣，並採事後加權方式使樣本具有全國中老年人代表性，第一階段樣本共計239,861人。第二階段將對樣本中有長期照護需要者進行深入的後續評估，包括身體功能、認知功能、社會支持與家庭照顧資源、心理健康、復健需求、長期照護服務使用、護理需求專業評估以及社會人口學資料等，此階段納入分析之中老年人失能樣本共計14,094人；並將上述兩階段之中老年人樣本串連2000-2002年全民健保檔，包括門診處方及治療明細檔與住院醫療費用清單明細檔，以高血壓、糖尿病、心臟病、失智症、中風、癌症、關節炎、慢性阻塞性肺病等八種中老年人常見之慢性疾病進行多重慢性病集群盛行率之描述性分析；其次套用Andersen Behavioral Model進行各種罹病集群與醫療服務使用及門診就醫行為之相關分析。
結果：全國中老年人代表性樣本中（N=239,861）有92.2%（N=221,256）在受訪後一年內有使用過至少一次的全民健保資源。在有使用過健保資源的中老年人中，有50.6%的中老年人有一種以上的慢性疾病，27.4%有兩種以上的多重慢性病，平均每人年醫療費用為30,234元。將納入分析之八種慢性病的組合方式（共有255種）分別列出後發現，僅罹患有高血壓者為所有樣本中盛行率最高者，佔7.5%；其次為僅罹患有關節炎者，佔6.2%；第三為合併有高血壓和心臟病者，佔3.4%。在前15種高盛行率之組合中，平均醫療費用最高者為合併有五種慢性病以上者，平均年醫療費用為147,351元；第二為合併有高血壓、糖尿病、心臟病及關節炎者，平均費用為89,208元；第三為合併有高血壓、糖尿病和心臟病者，平均費用為84,143元；第四為僅罹患癌症者，平均費用為82,059元。
上述研究另外發現，罹患有癌症或失智症或連續住院超過90天以上之長期住院患者，平均年醫療費用明顯提高。為避免此族群之過高費用稀釋其他慢性疾病對醫療費用的影響，後續套用Andersen Behavioral Model對失能樣本的分析，將先剔除上述三類超高醫療費用族群。
經第一階段評估後，具有長期照護需要之中老年人共有17,191人，完訪14,094名個案。而所有完訪之失能中老年人樣本中，有95.2%（N=11,617）曾在完訪後一年內使用過健保資源。有76.9%的失能中老年人有一種以上的慢性疾病，57.2%有兩種以上的多重慢性病。觀察失能中老年人主要罹患之慢性病組合（六種慢性病之組合共有63種）發現，合併有高血壓及中風者之盛行率最高，達6.2%；其次為僅罹患有關節炎者，佔5.6%；第三為僅罹患有高血壓者，佔5.4%。
失能中老年人之醫療利用方面，平均每人年醫療費用為78,623元，年門診次數為27.6次，年住院率為35.0%，平均每次住院天數為7天；年急診使用率為33.6%。考慮失能中老年人之前傾、使能及需要因素，及自變項間的交互作用後，以複迴歸比較各慢性病集群與醫療費用遞增的相關發現，對費用增加影響最大的慢性病集群為高血壓合併糖尿病（R2=0.581），其次為合併高血壓、糖尿病及中風（R2=0.578），第三為合併有高血壓、糖尿病、中風及心臟病（R2=0.577）。將所有慢性病集群與上述可能影響醫療費用之因素納入多變項分析後發現，前傾因素中，女性、教育程度較高、有偶者；使能因素中，居住偏城區、具有免部分負擔身份者；需要因素中，有身體功能依賴、任一類慢性病集群；以及中老年人的長期照護安排為「由看護照顧」者，均與醫療費用增加具有顯著相關。
失能中老年人之門診就醫行為則發現，其至基層診所看門診的比例為37.8%，亦即每100次的門診使用中，約有38次在一般基層診所看門診，其他62次則在地區醫院以上之層級使用。若以門診就醫之醫療院所數來看，平均一年會在3.75家不同的醫療院所使用門診；以門診就醫之醫師數來看，失能中老年人平均一年約看6.59位不同的醫師。依個案之就醫層級與就醫醫師數區分就醫行為固定與否，並考慮失能中老年人之前傾、使能及需要因素及自變項間的交互作用後，以邏輯斯迴歸比較各慢性病集群對就醫行為固定的發生機會。合併高血壓和中風者以及僅罹患高血壓者的固定就醫行為發生機會最高；合併有關節炎和慢性阻塞性肺病之固定就醫行為發生機會最低。當所有自變項進入迴歸模式後，和固定就醫行為有顯著相關的因素包括前傾因素中的男性、年齡較輕、教育程度較高、無偶者；使能因素中的居住偏城區、不具有免部分負擔身份者；需要因素中身體功能依賴程度越嚴重、沒有慢性病者；以及中老年人的長期照護安排為「由家人照顧」者。
結論：本研究為台灣第一篇全國中老年人多重慢性病的相關研究。面對越來越多老年人口及其伴隨的多重慢性病問題，加上有限的健保資源，我們應該開始著手規劃整合性的照護管理模式，以單一窗口提供老人多元的醫療需求。因此本研究可提供目前台灣中老年人的多重慢性病狀況以及其醫療需求相關數據，凸顯多重慢性病中老年人的問題重要性以及醫療資源耗用的嚴重性；並經由相關影響因素的分析找出高資源耗用的主要族群。

關鍵字

多重慢性病集群形態 ； 中老年人 ； 醫療服務利用

並列摘要

Purpose: Co-morbidity among the elderly is caused by aging population and disease transition. These medical conditions lower quality of life for the elderly and increase their chances of becoming inactive and dysfunctional. From a social perspective, co-morbidity leads to high medical needs and costs which cause the elderly to become an economically disadvantaged group in society. Hence, this study aims to explore the medical needs of patients who have different combinations of multiple chronic diseases in order to improve care strategy for chronic patients.
Method: This study was based on a two-phase “National Long-term Care Evaluation” program of the Department of Health, Executive Yuan. Probability Proportional to Size (PPS) sampling was conducted from the national population, and over 50 years old, for each county/city, respectively. There were 239,861 people completed interviews. During the second-stage evaluation, it was found 14,094 disabled older adults completed interviews. This study collaborated the files of the 2000-2001 health insurance claims and selected 8 types of common chronic diseases among seniors, for the discussion of multiple constellations of chronic diseases, including high blood pressure, diabetes, heart disease, stroke, dementia, cancer, arthritis and chronic obstructive pulmonary disease.
Results: Among 239,861 cases, 221,256 people used one of the National Health Insurance services in 2001, accounting for 92.24% of the total cases. Among the NHI users, there are 50.1% of the cases suffering from at least one chronic disease, 27.4% suffering from two types of chronic diseases and above. As a whole, the average medical expense nationwide for middle-aged and seniors is $30,234 NTD. From possible combinations of eight common chronic diseases, it is found hypertension has the highest prevalence rate, 7.5%; arthritis ranks the next (6.2%); the combination of hypertension and heart disease ranks the third (3.4%). In the 22 types of major chronic disease clusters, the average total medical expense for people who have five or more chronic diseases ranks the highest, $147,350.8 NTD; the combination of hypertension, diabetes, heart disease, and arthritis ranks the next, $89,208.3 NTD; the combination of hypertension, diabetes, and heart disease ranks the third, $84,143.0 NTD; cancer ranks the fourth, $82,058.9 NTD.
According to our analysis, the cases with cancer or dementia, or long-term hospitalization were super-highly user in NHI. In order to understand the impact to medical expenditures of other common chronic diseases, we only consider the cases without the situation above.
During the second-stage evaluation, it was found that 14,094 disabled older adults completed interviews, and 11,617 people (95.2%) used one of the National Health Insurance services in 2001. Among them, there are 76.9% of the cases suffering from at least one chronic disease, 57.2% suffering from co-morbidity. In the major chronic disease constellations, hypertension and stroke was the most prevalent combination (6.2%); the next was arthritis only (5.6%); and the third was hypertension only (5.4%).
The average medical expense nationwide for the disabled was $78,623 NTD. The average utilization of outpatient was 27.6 times. There ware 35.0% disabled had at least one hospitalization, and the average length of stay was 7 days. There were 33.6% used at least one emergency service. Comparing with other possible combinations, the greatest impact to medical expenditures was the combination of hypertension with diabetes (R2=0.581). After controlling the predisposing, enabling, need factors and their interactions, the multiple regression showed that female, higher education, coupled, lived in town area, had social welfare, with severe disability, had at least one chronic disease and cared in home by a foreigner worker increased the total medical expenditures.
Only 37.8% disabled older adults used outpatient in clinics, most of cases used outpatient in hospitals. They went to 3.75 different clinics or hospitals, and 6.59 different physicians for outpatient services per year. Comparing with possible chronic disease combinations, two combinations of hypertension with stroke and hypertension only were more likely to fix their clinics or physicians, and the combination of arthritis with COPD were more likely to shop around different hospitals and doctors. After controlling the predisposing, enabling, need factors and their interactions, the logistic regression showed that male, younger adults, higher educated, singled, lived in town area, without social welfare, more severe disability, without any chronic disease and cared in home by family members were more likely to fix their doctor-seeking behavior when they need medical services.
Conclusions: With the rising aging population, and the accompanying issue of co-morbidity, policy makers in Taiwan should plan an integrated care management model in an environment with limited health insurance resources, which satisfy diverse medical needs for seniors through a single window. This study may provide statistical data concerning co-morbidity among middle-aged and seniors in Taiwan, and their medical needs. It can also present the significance of the issues with regard to seniors with co-morbidity and the exhaustion of medical resources. Through our analysis, the major population that exhausts the medical resources may be discovered.

並列關鍵字

Multiple Morbidity Combinations ； Taiwanese Older Adults ； Health service utilizations

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