接受不同經皮冠狀動脈介入性治療術病患之處置後三年醫療資源使用以及療效之探討

雖然國外對於不同冠狀動脈介入性治療術(Percutaneous coronary intervention;以下簡稱PCI)的成本效果相關研究已經發表許多，但因為國際間的保險給付制度、醫療技術水準、臨床照護能力及文化背景等諸多情境的不同，故其研究結果不完全適合推論至國內，而且國內對於跨機構、中長期的不同PCI處置的醫療資源利用及療效比較是很少探討的，因此，本研究透過跨院區病歷回溯追蹤觀察三年的調查，探討不同PCI處置之醫療資源利用和療效的情形，以期能提供相關單位參考。本研究主要在於瞭解個案醫院冠狀動脈疾病(coronary artery disease; CAD)患者接受不同方式之PCI的醫療資源利用及療效，具體研究目的如下： (一)探討個案醫院CAD病患接受不同PCI處置之醫療資源利用及其影響因子。 (二)探討個案醫院CAD病患接受不同PCI處置之療效及其影響因子。 (三)探討個案醫院CAD病患接受不同PCI處置的成本效果。 (四)探討CAD病患接受PCI處置後醫療資源利用與療效在院際間是否有差異。　本研究透過跨院區病歷回溯追蹤觀察自90年1月1日起至92年12月31日止的三年調查，平均追蹤2.46年，追蹤未滿三年的樣本費用以每人平均實際費用估計取得而療效視為沒有發生任何事件。樣本以高屏區三家個案醫院於九十年第一次接受PCI處置的病患為主；包含接受經皮冠狀動脈擴張術(Percutaneous Transluminal Coronary Angioplasty;以下簡稱PTCA)及冠狀動脈支架(Stent)的處置病患，利用病歷抄錄病患的特質、疾病嚴重度及至九十二年底為止之續後療效，再利用全民健康保險資料庫進行樣本個案之住院及門診費用的歸戶串檔，最後以全國死亡檔進行串檔確認樣本個案的存活情形，整合收集的資料以複迴歸、存活分析及成本效果分析探討個案醫院不同PCI處置的醫療資源利用、療效及成本效果的影響因子。　研究結果發現在接受PTCA處置者174人(其中A、B、C三家個案醫院樣本數分別為25人、66人、83人)及接受Stent處置237人(其中A、B、C三家個案醫院樣本數分別為60人、104人、73人)中，在醫療資源利用的結果上，PTCA組及Stent組有以下結果：PTCA組的當次住院費用在統計上顯著低於Stent組($155,468 vs $188,017；P<0.05)，而當次住院天數及追蹤觀察期間的醫療費用二組間沒有顯著差異，若控制其他變項下且資料取對數轉換後，接受PTCA處置較Stent處置者會增加0.2個單位的當次住院天數，而當次住院費用接受PTCA處置較Stent處置者會減少0.14個單位，但追蹤觀察期間的醫療費用並不會受到不同PCI處置而影響。而在醫療結果的個案醫院總樣本在PTCA及Stent二組間，住院中重大心臟血管不良事件(Major Adverse Cardiac Events; MACE)(包含死亡、大量出血、緊急冠狀動脈繞道手術、緊急PCI)在統計上並無顯著差異(17% vs 10%；P>0.05)，追蹤至觀察時間結束時，PTCA組的死亡率約是Stent組的二倍(21.26% vs 11.81%；P<0.05)，其他追蹤的醫療結果(急性心肌梗塞、再冠狀動脈繞道手術、再PCI)在統計上無顯著差異，若控制其他變項下，則接受不同PCI處置不會影響住院中重大不良事件、死亡及追蹤的醫療結果。若以成本效果來看Stent組比PTCA組每增加1天的存活天，追蹤累積至三年的PCI相關醫療資源利用需要增加花費$587。另外值的注意的是三家個案醫院在院際間的比較上，控制其他變項下且資料取對數轉換後，B、C醫院分別較A醫院的當次住院天數減少0.11個單位及0.17個單位，追蹤觀察期間的PCI相關費用B、C醫院分別較A醫院增加0.40個單位及0.43個單位，二年的PCI相關再住院C醫院較A醫院增加0.23次。　本研究的結論是病患在接受處置至追蹤觀察結束後，接受PTCA處置的病患醫療資源利用會低於接受Stent處置者，但死亡是接受Stent處置者的2.02倍，以成本效果來說，接受Stent處置的病患較接受PTCA處置的病患多活一天僅需要增加$587。而院際間在醫療資源利用及療效的比較亦會因為醫師處置行為及病人特質的不同而有差異。　依本研究結論呈現雖然接受PTCA處置的醫療資源利用低於接受Stent處置者，但接受PTCA處置者的死亡率較接受Stent處置者高，而本研究的資料呈現個案的Stent健保給付比率僅佔總樣本的7.55%、自費Stnet比率佔50.12%、僅接受PTCA者佔42.34%，顯現符合健保給付Stent的個案很低，若能放寬健保給付Stent的條件，減少病患因經濟壓力因素無法接受Stent處置的比率，應能減少罹患CAD而死亡的機會。

關鍵字

成本效果評估；醫療資源利用；療效評估；冠狀動脈介入性治療術

並列摘要

Clinical and economic outcome of Percutaneous Coronary Intervention (PCI) has been performed in many studies. These results may not provide for Taiwan. Outcomes might be different due to payment, medical technology, clinical care ability, and culture. Besides, studies on resource utilization and clinical outcome of Percutaneous coronary Intervention (PCI) were limited to a single institution and a short term study in Taiwan. Therefore, a multi-center, three-year follow-up study design will be used to explore the medical resource utilization and clinical outcome after different PCI in order to provide a reference for related units. The main purpose of this study is to explore the medical resource utilization and clinical outcomes for Coronary Artery Disease (CAD) patients receiving different PCI. For this purpose, specific purposes of the study are: 1. To explore medical resource utilization and its determinants for CAD patients receiving different PCI. 2. To explore clinical outcome and its determinants for CAD patients receiving different PCI. 3. To explore cost utilization for CAD patients receiving different PCI. 4. To examine the relationships between different hospital and medical resource utilization and health outcome for CAD patients receiving PCI. This is a retrospective study design and the sample was collected between Jan. 2001 to Dec. 2003, with average 2.46 follow-up year. For whole incomplete sample, the total medical charges were evaluated by using each individual real medical charge. All patients received primary Percutaneous Transluminal Coronary Angioplasty (PTCA) or Bare metal stent (Stent) procedures at three medical centers in Kaohsiung-Ping area between Jan. 2001 to Dec. 2001 were the study sample. Patient characteristics and clinical outcome record were conducted by chart review. Medical resource utilization, such as inpatient and outpatient expenditures, was collected from the claims files of the National Health Insurance (NHI). Mortality record was received from the Department of Health. Multi-variable regression, Cox-regression, and cost effectiveness were used to analyze the medical resource utilization and clinical outcomes and its affective factors after different PCI. The findings of this study were: Patient with PTCA (N=174) and Patient with Stent (N=237) in medical resource utilization: Initial hospital expenditures were lower for PTCA than Stent (NT 155,468 vs NT 188,017；P<0.05). Mean length of stay and follow-up medical resource utilization wasn’t significantly between each group. After adjustment, mean length of stay was higher for PTCA than Stent, and initial hospital expenditures were lower for PTCA than Stent. But medical resource utilization wasn’t significant for different PCI. In clinical outcomes finding: In-hospital Major Adverse Cardiac Events (MACE) wasn’t significant between each group. Mortality within this three-year follow-up study was two times higher for PTCA than Stent (21.26% vs 11.81%；P<0.05), but the results in other outcomes weren’t significant. After adjustment, the results in-hospital MACE, mortality, and other health outcomes were similar within different PCI. By using cost-effectiveness analysis, the expenditure to increase one survival day in the Stent group as compared with PTCA group was NT 587. Mean length of stay was lower for hospital B and C than hospital A. The PCI medical resource utilization was higher for hospital B and C than hospital A. Re-admission of two-year follow-up was higher for hospital C than hospital A. The conclusion of the study was medical resource utilization that patients accept PTCA treatment would be lower than Stent. But the mortality in PTCA group was 2.02 times higher than Stent group. From the cost-effectiveness analysis, the patients accepting Stent in comparison with PTCA only need to add NT587 dollars per a survival day. And Comparing with medical resource utilization and the curative effect between hospitals would be different because of the physicians’ behavior and the patients’ characteristics. According to the results, PTCA treatment had less medical resource utilization but relatively higher mortality than Stent. And the findings for this study also showed that 7.55 % Stent treatment by the payment of NHI、50.12 % by self-pay Stent、42.34 % by PTCA. The fact appeared that fewer Stent patients are fit for the coverage of payment. If NHI could loosen the terms of payment and reduce the pressure to patients who could not accept Stent treatment, it would decrease the mortality of CAD gradually.