冠狀動脈繞道手術病人術後五年醫療服務
利用與醫療品質評估

研究背景及目的：在國內心血管疾病死亡人口攀增的情況下，其相關治療手術的費用也節節上升，而在所有心血管疾病治療處置中，又以心臟外科之冠狀動脈繞道手術為較常實施處置之一，其屬於一項高成本、高危險性之處置。目前國內對於長期追蹤冠狀動脈繞道手術病人的費用結果分析之研究較為缺乏，本研究期望針對國內執行冠狀動脈繞道手術的病人之治療結果進行回溯性分析，作為臨床處置及醫療決策的參考。因此本研究以接受冠狀動脈繞道手術之病人為研究對象，長期追蹤其術後的醫療服務利用及品質，讓健保局、醫院明瞭術後醫療服務的利用情形，並以此做為參考依據，及提供病人明瞭術後的品質及結果。研究方法：研究時間為民國86 年1 月到91 年12 月，研究對象為全台灣地區醫院向健保局申報冠狀動脈繞道手術之個案，並使用SPSS 統計軟體分析。主要分析重點在探討人口特質因素（年齡、性別、血管阻塞條數、當次手術合併經皮氣球擴張術、使用內乳動脈移植、合併症）、機構因素（手術醫院權屬別、層級別、服務量別、分區別及醫師年資別）對於實施冠狀動脈繞道手術病人之當次手術醫療服務利用（當次手術醫療費用、當次手術住院天數）、當次手術醫療品質（住院間死亡率、14 天再住院率、30 天再住院率）及長期醫療服務利用（5 年門住診醫療費用、5 年心臟相關門住診醫療費用）、結果（5 年內死亡）之影響。研究結果：1.當次手術醫療服務利用方面，每人平均住院天數為25.44 天，每人平均當次手術費用則為434709 元。年齡、充血性心臟衰竭、周邊血管疾病、慢性肺疾病、糖尿病、腎臟疾病、地區分局皆為住院天數之預測因子。而當次手術有合併經皮冠狀動脈氣球擴張術、當次手術使用內乳動脈移植、心肌梗塞、消化性潰瘍、轉移性腫瘤、醫院層級、地區分局、醫師年資、院內死亡、住院天數皆為醫療費用之預測因子。 2.當次手術醫療品質方面，院內死亡者佔了9.57％；14 天內再入院者佔了9.49 ％；30 天內再入院者佔了15.69％。年齡、當次手術有合併經皮冠狀動脈氣球擴 ii 張術、心肌梗塞、充血性心臟衰竭、腎臟疾病、地區分局、醫師年資為院內死亡之預測因子。消化性潰瘍、糖尿病、地區分局、醫師年資為14 天內再入院之預測因子。而慢性肺疾病、糖尿病、腎臟疾病、地區分局、醫師年資則為30 天內再入院之預測因子。 3.就長期醫療服務利用方面，平均每年每人心臟相關住院費用範圍為7603 到 17148 元；住院費用範圍則為61720 到36953 元；心臟相關門診費用範圍則為 10936 到12324 元；門診費用範圍為51046 到60067 元；總心臟相關費用範圍則為19762 到28084 元；總費用範圍為95371 到112766 元，心臟相關費用大約都佔總費用之20％。至於血管阻塞條數、當次手術使用內乳動脈移植者、當次手術醫療費用、腎臟疾病、術後追蹤5 年內死亡、有再做經皮冠狀動脈氣球擴張術、總住院天數及總就醫次數、追蹤天數為5 年門診費用之預測因子。而年齡、術後追蹤5 年內死亡、有再做經皮冠狀動脈氣球擴張術、有再做過冠狀動脈繞道手術、總住院天數、追蹤天數為5 年住院費用之預測因子。另外當次手術醫療費用、腎臟疾病、術後追蹤5 年內死亡、再做經皮冠狀動脈氣球擴張術、有再做過冠狀動脈繞道手術、總住院天數以及總就醫次數為5 年門住診總費用之預測因子。此外年齡、當次手術使用內乳動脈移植者、慢性肺疾病、再做經皮冠狀動脈氣球擴張術、追蹤天數為5 年心臟相關門診費用之預測因子。而年齡、性別、當次手術住院天數、腦血管疾病、再做經皮冠狀動脈氣球擴張術、再做冠狀動脈繞道手術、總住院天數為5 年心臟相關住院費用之預測因子。最後，年齡、性別、再做經皮冠狀動脈氣球擴張術、再做過冠狀動脈繞道手術、總就醫次數及總住院天數為5 年心臟相關總費用之預測因子。 4. 就追蹤期間發生事件方面，再做經皮冠狀動脈氣球擴張術者佔了7.18％；而有再做冠狀動脈繞道手術者佔了0.8％；在追蹤期間內死亡者佔了23.75％，而病人術後5 年死亡率則為33.3％。而年齡、充血性心臟衰竭、慢性肺疾病、糖尿病、腎臟疾病、總就醫次數、總住院天數為術後5 年死亡之預測因子。 iii 討論與建議：就病人特質而言，年齡、當次手術合併經皮氣球擴張術、血管阻塞條數、使用內乳動脈移植、心肌梗塞、充血性心臟衰竭、周邊血管疾病、慢性肺疾病、消化性潰瘍、糖尿病、腎臟疾病、轉移性腫瘤皆會影響到當次手術醫療服務利用及醫療品質以及5 年長期醫療服務利用及結果。就醫療機構而言，醫院層級、醫院地區、醫師年資也都會影響到當次手術醫療服務利用及醫療品質。至於追蹤5 年內發生事件更是會顯著影響到長期醫療服務利用及結果的發生。因此建議醫療提供者，對具有高醫療資源耗用、高死亡率或高再住院率特質之病人，於醫療照護過程中應特別留意，以降低其死亡率、再住院率及醫療資源利用，並需長期追蹤病人固定回診，定期檢查及多方面教導病人健康觀念，以確保病人術後之健康生活，減少不良事件之發生及醫療資源之耗用。另外也建議衛生政策與健保機構對於高醫療資源耗用、高死亡率或高再住院率之醫療機構特質，需加強監控及審查，以改善其醫療品質及結果。

關鍵字

醫療服務利用；醫療品質；長期追蹤；冠狀動脈繞道手術；風險因子

並列摘要

Background and Objective：The death numbers due to cardiovascular disease is increasing in Taiwan ; therefore their related cost are also increasing. The most frequently used therapy for cardiovascular disease is coronary artery bypass graft (CABG) , which is high cost procedure with high mortality. Most of the studies on CABG in Taiwan are cross-sectional, but not longitudinal studies on medical expenditure and outcome of CABG patients. The present study focused on CABG patients data derived from the National Health Insurance Database. The findings may be helpful for the Bureau of National Health Insurance , hospital providers and CABG patients. Methods：All patients who underwent CABG from January 1 to December 31, 1997 were study sample of follow-up for five years. The major focus of analyses was to determine the effects of patient characteristics (age, gender, numbers of vessel, CABG plus PTCA, use IMA, comorbidity), hospital characteristics (hospital ownership, hospital level, annual CABG volume, hospital area, physician experience) on CABG health service utilization (hospital expenditure and length of stay), and surgery quality of care (in-hospital mortality, 14,30 days readmission); long-term health service utilization (outpatient, inpatient, total expenditure in five years and outpatient, inpatient, total cardio-related expenditure in five years) and outcome (mortality in five years) were all examined. Results : 1. For surgery hospitalization, average length of stay (LOS) was 25.44 days, and average CABG hospital expenditure was 434709 NT dollars. Significant factors for LOS was age, congestive heart failure, peripheral vascular disease, chronic pulmonary disease, diabetes, renal disease, hospital area. And significant factors for CABG hospital expenditure was CABG plus PTCA, use IMA, myocardial infarction, peptic ulcer disease, metastatic solid tumor, hospital level, hospital area, physician experience, in-hospital death, LOS. 2. For surgery quality of care, in-hospital mortality rate was 9.57%, 14 days readmission rate was 9.49%, 30 days readmission rate was 15.69%. Significant risk factors for in-hospital mortality was age, CABG plus PTCA, myocardial infarction, congestive heart failure, renal disease, hospital level, hospital area. Significant risk factors for 14 days readmission was peptic ulcer disease, diabetes, hospital level, hospital area. Significant risk factors for 30 days readmission was chronic pulmonary disease, diabetes, renal disease, hospital level, hospital area. 3.Longitudinal, average cardio-related expenditure of inpatient per year was coverage 7603 to 17148 NT dollars, average expenditure of inpatient per year was coverage 36953 to 61720 NT dollars, average cardio-related expenditure of outpatient per year was coverage 10936 to 12324 NT dollars, average expenditure of outpatient per year v was coverage 51046 to 60067 NT dollars, average cardio-related expenditure of all patients per year was coverage 19762 to 28084 NT dollars, average expenditure of all patients per year was coverage 95371 to 112766 NT dollars, the cardio-related expenditure was almost 20% of total expenditure. However, the significant factors for outpatient expenditure in five years was numbers of vessel, use IMA, CABG hospital expenditure, renal disease, post-surgery mortality in five years, repeat PTCA, total hospitalization in five years, total hospital visits in five years, follow-up days. And the significant factors for inpatient expenditure in five years was age, post-surgery mortality in five years, repeat PTCA, repeat CABG, total hospitalization in five years, follow-up days. CABG hospital expenditure, renal disease, post-surgery mortality in five years, post-surgery mortality in five years, repeat PTCA, repeat CABG, total hospitalization in five years, total hospital visits in five years was significant factor for total expenditure in five years. Further, age, use IMA, chronic pulmonary disease, repeat PTCA, follow-up days was significant factor for outpatient cardio-related expenditure in five years. And the significant factors for inpatient cardio-related expenditure in five years was age, female, CABG LOS, cerebrovascular disease, repeat PTCA, repeat CABG, total hospitalization in five years. Final, the significant factors for total cardio-related expenditure in five years was age, female, repeat PTCA, repeat CABG, total hospitalization in five years, total hospital visits in five years. 4.For long-term outcome, all patients in follow-up period who received repeat PTCA was 7.18%, repeat CABG was 0.8%, mortality in follow-up period was 23.75%, post-surgery mortality in five years was 33.3%, and age, congestive heart failure, chronic pulmonary disease, diabetes, renal disease, total hospitalization in five years, total hospital visits in five years was significant factor for post-surgery mortality in five years. Discussion and suggestion：The results indicated that age, CABG plus PTCA, use IMA, myocardial infarction, congestive heart failure, peripheral vascular disease, chronic pulmonary disease, peptic ulcer disease, diabetes, renal disease, and metastatic solid tumor significant influenced CABG health service utilization, CABG health service quality, long-term health service utilization, and long-term outcome. In additional, hospital level, hospital area, and physician experience also affected CABG health service utilization, CABG health service quality. Follow-up event in five years is the most important factor for long-term health service utilization and outcome. Let’s suggested that health care providers should be pay more attention to these patients with risk factors of higher mortality or of higher readmission in order to reduce medical service utilization and improve quality of care as well. Moreover, CABG patients need to be followed regularly for teach health concept multilateral health education to reduce adverse event and health service utilization. Besides, health vi policy makers and bureau of national health insurance must enhance to monitoring hospitals with abnormal health service utilization, higher mortality or higher readmission to improve the health care quality and outcome.