消化性潰瘍病人幽門螺旋桿菌根除與否醫療耗用的比較與分析

Resources Utilization of Helicobacter pylori Eradication in Peptic Ulcer Disease Patients

吳登強(Deng-Chyang Wu)

指導教授 ： 楊俊毓

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2007年)

https://doi.org/10.6832/KMU.2007.00119

摘要

研究背景
消化性潰瘍是一種十分常見的消化系統疾病，全世界約有5-10﹪的人口在其一生中曾有消化性潰瘍的問題。在全美國每年因為有症狀性潰瘍而損失2900萬人口的工作量，而且每年接近300萬人次的就醫，估計在涵括工作損失、住院費用及門診費用，消化性潰瘍疾病的花費，每年約為美金34億到57億之間。根據健保局的統計資料，在台灣，符合消化性潰瘍定義且有相關用藥之人數，在92~93 年皆超過百萬人，申報件數約355~391萬件，費用更是高達百億，而且有上升之趨勢，其背後潛藏的危機與龐大的醫療負擔，值得深入探討。
有很多的原因都會導致消化性潰瘍，但是幽門螺旋桿菌的感染卻是最主要的原因。相當多的研究結果都指出，消化性潰瘍病人在根除幽門螺旋桿菌後，會顯著的降低潰瘍再發及併發症的產生。消化性潰瘍的相關治療研究更明確的指出有幽門螺旋桿菌感染之十二指腸潰瘍及胃潰瘍，停藥後的潰瘍復發率，在根除幽門螺旋桿菌後分別降至6%及4%，但是未殺菌組潰瘍復發率，則分別高達65%及95%。
本研究針對消化性潰瘍病患進行整體性評估，除分析其相關就醫與用藥外，並針對消化性潰瘍新病患執行幽門螺旋桿菌清除治療的情形及疾病嚴重度的醫療花費狀況，相關醫療耗用情形進行分析。
因此本研究的目的為
一、 瞭解國內消化性潰瘍病患之醫療利用狀況。
二、 瞭解消化性潰瘍病患(PU)執行幽門螺旋桿菌(Hp)根除治療之狀況。
三、 瞭解消化性潰瘍病人幽門螺旋桿菌根除與否醫療耗用的狀況。
四、 瞭解消化性潰瘍病人在不同疾病嚴重度時幽門螺旋桿菌根除與否醫療耗用的狀況
研究方法
以全民健康保險局86-93年門住診費用明細與醫令檔、藥品主檔、藥價歷史檔、以2300萬人口中，隨機取樣抽出的200,000人的健保歸人檔、抽樣檔進行有關PU病患之醫療利用狀況、Hp根除治療之狀況及根除與否醫療耗用(包括門診次數及總診察費等)狀況的回溯性分析及統計。幽門螺旋桿菌根除治療的定義為2種或2種以上特定抗生素使用7或14天以上。
研究結果
研究結果顯示自86年到93年中消化性潰瘍的盛行率為61,588人(30.79%)，其中有44,360人符合新消化性潰瘍的定義。消化性潰瘍病人殺菌後門診次數由第一年的3.1次/人年降到第六年的0.4次/人年但是未殺菌組則由第一年的3.1次/人年只能降到第六年的1.7次/人年，這種差異在嚴重性消化性潰瘍病人更明顯。至於消化性潰瘍病人執行幽門螺旋桿菌根除治療執行比率在醫學中心20.3%、區域醫院14.9%、地區醫院8.4%、基層院所3.9%間呈現逐漸下降的趨勢，在整個醫療資源的耗用情形分析結果呈現，當Hp根除組在殺菌開始時的醫療費用(殺菌：未殺菌為2066元：1513元)及門診次數(殺菌：未殺菌為3.1：3.1)並未下降反而上升，但是當長期追蹤後發現殺菌組的門診次數(第六年治療比未治療=0.4：1.7)及整體醫療耗用較未殺菌組少(治療比未治療=299元：1000元)。
討論與建議
消化性潰瘍是醫療耗用的一個重要問題。在全美國每年因為有症狀性潰瘍而損失57億美元(涵括工作損失、住院費用及門診費用)，本研究的結果顯示當幽門螺旋桿菌治療後不論在門診次數及總體醫療費用都顯著下降。根據本研究的結果，我們建議幽門螺旋桿菌治療應該做為將來個別醫院評鑑中醫療品質評估的標準之一。

關鍵字

消化性潰瘍 ； 幽門螺旋桿菌根除 ； 門診次數 ； 醫療耗用

並列摘要

Background: Peptic ulcer disease continues to be a common problem. Peptic ulcers are defects in the gastrointestinal mucosa that extend through the muscularis mucosae. The lifetime prevalence is 5 to 10 percent in the general population. It is estimated that symptomatic ulcer disease results in 29 million days of restricted activity per year in the United States, and accounts for more than three million physician office visits per year. Estimates of expenditures related to work loss, hospitalization, and outpatient care have ranged from $3.4 to $5.7 billion per year. In Taiwan, according to National Health Insurance’s reports, there were million peoples suffered from peptic ulcer disease at the year 2003 and 2004. About 3.55 to 3.91 million applicant under the diagnosis of peptic ulcer disease and the expenditure around ten billion or more and it’s going up gradually. There were crisis and economic burden behind the phenomenon. It needs to be further study!
Different factors have been implicated as etiologies for DU, including diet, stress, smoking, and overproduction of gastric acid. However, it is now clear that Helicobacter pylori infection is the primary cause of DU disease. Overwhelming data showing that cure of H. pylori infection reduces ulcer recurrence and complications. Recurrence of DU and GU occurred in 6 and 4 percent of patients following H. pylori eradication versus 65 to 95 percent in those who remained infected. In clinical view, all patients with DUs associated with H. pylori infection should undergo therapy to eradicate the organism. This study estimate of expenditures related to outpatient care, medication etc and further analyzed by stratified these patients with Helicobacter pylori treat or not, disease severity and its related cost.

Aims of this study:
1. Understanding the physician office visits condition in peptic ulcer patients
2. Understanding the Hp treatment status in peptic ulcer patients
3. Understanding the medical cost with/without Hp treatment in PU patients
4. Understanding the medical cost with/without Hp treatment in different disease severity of PU patients

Methods: This study retrospectively evaluated peptic ulcer disease patients from 200,000 cases that randomized sampling from the 23,000,000 cases National Health Insurance data bank. Clinical outcomes and resources utilization included physician office visits and medical cost etc were assessed for all peptic ulcer patients from year 1997 to year 2004. These patients were stratified by Helicobacter pylori treatment and diseases severity and analyzed their resource utilization condition.

Results: There were 200,000 cases in this data file. Prevalence rate of peptic ulcer is 61,588 cases (30.79%) and 44,360 cases fulfill the criteria of new peptic ulcer patients. Helicobacter pylori treatment was defined as two of special antibiotics used for 7 or 14 days. Post Hp treatment, physician office visits of PU patients dropped from 3.1 per year per case in first year to 0.4 per year per case in sixth year. However the un-treatment group, the physician office visits dropped from 3.1 to 1.7 per year per case. These differences appeared even more obviously in complicated peptic ulcer patients. The Hp treatment rate goes down from medical center gradually to general partition from 20.3%, 14.9%, 8.4% to 3.9%. In view of medical expenditure and physician office visits, going up, when Hp treatment began, but after 5 to 6 years followed, the medical cost below the non-Hp-treatment group.

Conclusion and Suggestion: Peptic ulcer disease (PUD) is an important cause of morbidity and health care costs; estimates of expenditures related to work loss, hospitalization, and outpatient care (excluding medication costs) are $5.7 billion per year in the United States. The results of this study revealed resource utilization goes down since Helicobacter pylori treatment. However, it maintain at high level if Hp persisted presented in PU patients. According above results, we suggested, Hp treatment or not should be as quality indicator of individual hospital.

並列關鍵字

Peptic ulcer ； Helicobacter pylori eradication ； resources utilization

參考文獻

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