階段性雙側人工膝關節置換術手術醫療資源利用之探討

The Medical Utilization of Staged Bilateral Total Knee Replacement: A National Population-Based Study

魯子全(Tzu-Chuan Lu)

指導教授 ： 楊哲銘

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2010年)

https://doi.org/10.6831/TMU.2010.00150

摘要

目的：本研究在探討退化性關節炎 (OA) 以階段性（staged）方式行雙側人工膝關節置換術手術（bilateral TKA）在國內醫療資源利用的現況。以資料庫為基礎探討類似的文章國內外並不多也不及本研究來的完整。期望可由本文提供骨科醫師此種治療方式於醫療資源上利用的概況，並期望由本研究的結果做為衛生政策主管機關擬定政策之參考，適時提供病人更好的醫療照護及完善的醫療品質。
方法：本研究資料來源是國家衛生研究院釋出之「全民健康學術研究資料庫-2005年抽樣歸人檔」選取其中8,0000人。研究時間由1996年至2007年，就其中414人行人工膝關節置換手術(TKA)（ICD-9-CM procedure codes of 815.4)進行分析，選取當中152筆資料因身分證號碼(ID Number)重複出現及主診斷代碼為退化性關節炎（ICD-9-CM codes for primary diagnosis of OA 715, 715.00-715.98）定義為退化性關節炎行階段性雙側人工膝關節手術（staged bilateral TKA）之病人。依變項為各項醫療費用、住院天數、出院後一年內於骨科門診次數及門診醫療費用，控制變項包括疾病特質、病人特質、醫院特質、醫師特質等。對本研究採用SPSS 17 for Windows套裝軟體進行資料的統計與分析。
結果：152筆資料為階段性雙側人工膝關節手術（staged bilateral TKA），病人年齡(由50歲至83歲，平均為68.51歲)，病人合併症之疾病診斷總數(由1至5個，平均為1.89個)，住院天數(由4天至30天，平均為8.95天)，手術醫師年齡(由31歲至68歲，平均為46.98歲)，手術醫院所屬層級(醫學中心50、區域醫院 42、地區醫院60)。兩階段住院相隔時間由20天到4123天，平均為630天（一年九個月），與各依變項及控制變項經過複迴歸分析(multiple regression analysis)加以檢定皆無任何關聯。醫療平均費用為125601元(第一階段：125933.5元，第二階段：121778元；p值＝0.001，有顯著差異)。手術出院後一年內於骨科門診複診率達(150/152=98.68；98.68%)。第一階段術後一年內骨科門診次數(由1至56次，平均為11.14次)，門診醫療利用總金額(由716元至65431元，平均為11302元)；第二階段術後一年內骨科門診次數(由1至70次，平均為7.26次)，門診醫療利用總金額(由640元至41793元，平均為6813元)。
討論：第二階段病人住院期間於診察費、檢查費、特殊材料費、藥費、醫療費用、住院天數皆比第一階段呈現有顯著差異的下降，主因健保局努力控管出現成效，及膝關節置換手術的成熟與普及。病人決定實行第二次手術的時間與依變項及控制變項無任何關聯，主因膝關節置換術手術(TKA)是一個可排程的手術（elective surgery），病人會依實際狀況選擇適當的手術排程。第二階段比第一階段術後一年內骨科門診次數及門診醫療費用都有顯著意義的降低，主因第二階段出院後，兩側膝關節都已經完成置換手術所以骨科門診醫療資源利用自然降低。

關鍵字

退化性關節炎 ； 人工膝關節置換術 ； 全民健康學術研究資料庫 ； 平均住院日數

並列摘要

Significance and purpose：This paper discusses the medical resource utilization by patients with osteoarthritic knees who underwent staged bilateral total knee arthroplasty (TKA). In recent years, papers addressing similar issues through the use of a large population data base are scarcely found either domestically or internationally. In addition to providing orthopedic surgeons a great deal of proper information about the cost effectiveness of staged bilateral TKA, the research results of this paper can hopefully serve as a guideline for the public hygiene regulatory authorities so that they can stipulate quality medical service policies to benefit patients.
Methods：This research drew on the data from National Health Insurance Research Database－2005 Longitudinal Health Insurance Database (LHID) amid which eighty thousand cases were chosen. This research lasted from 1996 to 2007 during which 414 patents who underwent TKA (ICD-9-CM procedure codes of 815.4) were targeted for observation. Among these 414 patients, about 76 cases were selected not only because their ID Numbers were observed to show up in the list more than twice, but also because their codes for primary diagnosis were OA (ICD-9-CM codes for primary diagnosis of OA 715,715.00-715.98). The dependent variables employed by this research are the medical charges for each service, the average length of stay, the number of times visiting the outpatient clinic after the surgery, and the charged incurred for those visits. The control variables include patients’ factors, surgeons’ factors, and hospitals’ factors. Also employed for statistical analysis by this research is the package software SPSS 17 for Windows.
Result：76 patients who underwent staged bilateral TKA and a total of 152 medical records were examined for evaluation. The mean age was 68.51 (range, 50 to 83), the mean diagnosis number of comorbidity was 1.89 (range, 1 to 5), the average length of stay ranged from 4 days to 30 days with a mean of 8.95 days. The mean ages of the surgeons was 46.98 (range, 31 to 68). The hospitals for surgery were equally distributed in medical centers (50), regional hospitals (42) and district hospitals (60). The interval between 1st and 2nd procedure ranged from 20 to 4,123 days with a mean of 630 days. After using multiple regression analysis to evaluate the time interval, there was not any relationship observed between control variables and dependent variables. The average total medical utilization fee was NT$125,601 in the 1st stage and NT$121,778 in the 2nd stage. Since the p value was 0.001, the differences between these two stages were obviously outstanding. During the first year after being discharged from hospital, the visiting rate of orthopedic outpatient department was 98.68%. After the first stage of surgery, the mean times of visiting the outpatient clinic within the first year was 11.14 (range, 1 to 56); the mean total amount of medical fees charged by the services in the outpatient clinic was 11302 (range, 716 to 65431). After the second stage of surgery, the mean times of visiting the outpatient clinic within the first year was 7.26 (range, 1 to 70); the mean total amount of medical fees charged by the services in the outpatient clinic was NT6,813 (range, 640 to 41793).
Conclusion：Although a time interval of 630 days existed between the 1st and the 2nd stage of hospitalization, patients registered an obvious decline in the 2nd stage in examination expenses, inspection expenses, special materials expenses, medicine expenses, total medical expenses, and the average length of stay. This is chiefly caused by the proper control and management of the Bureau of National Health Insurance, as well as by the maturity and widespread acceptance of the staged bilateral TKA in Taiwan. It is observed that the time for the second surgery as determined by patients had nothing to do with the dependent variables and control variables, because TKA is a kind of elective surgery that has more to do with the patients’ subjective perceptions. After the 2nd stage of TKA surgery, it demonstrated a decline in the number of times for outpatient clinic visits and the medical charges incurred by those visits, in comparison with those of the 1st stage. One explainable reason for the decline in medical utilization after the 2nd stage of hospitalization is that patients had already finished the replacement surgery in their bilateral knee joints.

並列關鍵字

Osteoarthritis ； Total Knee Replacement ； National Health Insurance Research Database ； Average Length of Stay

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