台灣缺血性中風執行血栓溶解劑治療成效評估

The cost effect of thrombolytic therapy for ischemic stroke using intravenous rt-PA in Taiwan

何憲欽(Hsien-Chin He)

指導教授 ： 張菊惠

長榮大學/健康科學學院/醫務管理學系(所)/碩士(2011年)

https://doi.org/10.6833/CJCU.2011.00151

摘要

目的：血栓溶解劑－合成組織漿胞素原活化劑（rt-PA）已被證實能改善缺血性中風治療結果。台灣80％中風型態為缺血性，因此rt-PA的有效執行應能降低後續醫療成本的消耗，對個人及國家醫療資源均有益處。本研究欲評估rt-PA介入治療對缺血性中風之成效。
材料與方法：使用2005年全民健康保險研究資料庫百萬抽樣歸人檔。研究對象為2005年至2008年間初次發生缺血性中風患者，區辨為接受rt-PA治療與未接受rt-PA治療兩組。rt-PA治療人數23人、非rt-PA治療人數1035人。非rt-PA治療個案針對年齡、性別、檢傷分級、rt-PA禁忌症進行控制並建立配對樣本44人。比較兩組之治療結果與醫療費用，包含存活率、再中風率、併發症、失能程度、後續1年醫療服務利用、復健照護費用。另探討影響rt-PA治療之醫院及醫師因素、成效與rt-PA之關係。
結果：rt-PA治療率2.1％，接近腦中風登錄系統2006至2008年急診中風rt-PA治療比例1.5％。治療結果方面，rt-PA組30天內死亡率（0.0％）與1年內死亡率（0.0％）、半年至1年內再中風率均優於非rt-PA組。住院時併發症的比例rt-PA組與非rt-PA組相同（31.8％），但併發症種數及種類rt-PA組較少。出院後失能方面，rt-PA組40.9％出院後使用中、重度復健比非rt-PA組少，但三管的比例則高於非rt-PA組。當次住院總日數rt-PA治療組19.4日（SD=13.2）較非rt-PA組14.5日（SD=10.5）長，原因為rt-PA組ICU日數較長。成本分析發現，住院費用rt-PA組139,011元高於非rt-PA組85,653元，費用結構中以病房費、藥費最高，且rt-PA組具有顯著差異。復健費則無顯著差異。rt-PA治療可拯救4.47QALY，非rt-PA治療僅4.29QALY。且rt-PA組QALY成本較低，分別為100,834元卅QALY 、138,605元卅QALY。另發現區域醫院與資歷越深的醫師，使用rt-PA的比例較高。
迴歸模式中，影響rt-PA治療的因素為醫院等級、醫師年資、病患性別為最高。死亡率、再中風率、併發症以rt-PA治療及年齡影響最大。住院日則以病患年齡為解釋力最強，且具有顯著性。
結論：在長期觀察下，rt-PA對失能狀況應有較好的成效，並得到較高的QALY。其降低再中風率的效果亦可間接節省中風引發的社會及經濟成本。但對於醫療提供者及病患中風期間，可能需負擔較高的成本進行醫療及照護。

關鍵字

血栓溶解劑 ； 缺血性中風 ； 全民健康保險資料庫 ； 成效評估

並列摘要

Objective: Thrombolytic agent - recombinant tissue plasminogen activator (rt-PA) has been shown to improve the treatment outcome of ischemic stroke. 80% of the type of stroke is ischemic in Taiwan, therefore, the effective application of rt-PA should be able to reduce the consumption of follow-up health care costs, providing benefits for both personal and national medical resources. This study is to assess the effectiveness of the interventional therapy of rt-PA for ischemic stroke.

Materials and methods: The sampling archive of million populations from the 2005 National Health Insurance Research Database was used. The patients with ischemic stroke from 2005 to 2008 for the first time were selected as the study subjects, which were divided into two groups of receiving treatment with rt-PA and non-receiving treatment with rt-PA. The number of rt-PA treatment was 23, and the number of non-rt-PA treatment was 1035. Patients in the non-rt-PA treatment group were controlled based on age, gender, triage, rt-PA contraindications, while 44 paired patients were established. The treatment outcomes and medical expenses, including survival, re-stroke rate, complications, degree of disability, one year follow-up medical care utilization, rehabilitation care costs, impact on employment were compared in the two groups. Moreover, the effects of hospital and physician factors on rt-PA treatment were investigated.

Results: The rt-PA treatment rate was 2.1%, and the rt-PA treatment proportion for patients with emergency stroke who were entered into the cerebral stroke registry system from 2006 to 2008 was 1.5%. For the treatment outcomes, the mortality within 30 days (0.0%) and one year (0.0%), the re-stroke rate within six months to one year in the rt-PA group were better than in the non-rt-PA group. The proportion of complications during hospitalization was the same in rt-PA group with in the non-rt-PA group (31.8%), but the numbers and types of complications in the rt-PA group were less than in the rt-PA group. For the disability after discharge, the proportion using the middle to severe rehabilitation in 40.9% of patients of the rt-PA group was less than in non-rt-PA group, but the proportion of three was higher than in the non-rt-PA group. The cost analysis found that the total number of days of hospitalization for this time of 19.4 days (SD = 13.2) in the rt-PA treatment group was longer than 14.5 days (SD = 10.5) in the non-rt-PA group due to the longer ICU days in the rt-PA group. With the highest of ward fees, medicine fees in the cost structure, the 139,011.2 yuan of hospital costs in the rt-PA group was higher than 85,653.4 yuan in the non-rt-PA group, and there was significant difference in the rt-PA group. There was no significant difference in rehabilitation costs. The rt-PA treatment can save 4.47QALY, and only 4.29 QALY for non-rt-PA treatment. In addition, the QALY costs were lower in the rt-PA group, and the QALY costs were respectively 100,834.3 yuan / QALY and 138,605.7 yuan / QALY. Moreover, it was shown that the local hospitals and the physicians with the more qualifications used a higher proportion of rt-PA treatment.

In the regression model, the greatest influencing factors of rt-PA treatment were the hospital grade, years of physician, and patient gender. For the mortality, re-stroke rate, and complications, the rt-PA treatment and age had the greatest impacts. For days of hospitalization, the patient age was the greatest influencing factor, and was significant.

Conclusion: Under the long-term observation, rt-PA has a good effectiveness for the status of disability, and can achieve a higher QALY. The effect of reducing the re-stroke rate can also save indirectly social and economic costs caused by stroke. However, for the health care providers and during the stroke, it may be required to pay a higher cost of medical and care.

並列關鍵字

Recombinant Human Tissue Plasminogen Activator ； ischemic stroke ； National Health Insurance Research Database ； Cost effect ； Benefit

參考文獻

王惟德、董育瑞、張子瑩、江裕陽（2010）。腦中風後遺症病例報告。北市中醫會刊，16(2)，29-36。

台灣腦中風學會 rt-PA使用規範共識小組（2003）。靜脈血栓溶解劑治療急性缺血性腦中風之一般準則。腦中風會訊，10(3)，4-11。

行政院衛生署（2008）。衛生署死因統計。行政院衛生署統計資料，未出版。

李珮琪（2008）。一個腦住風個案出院準備服務的經驗。榮總護理，25(1)，21-30。

李靜玫、吳肖琪（2005）。市場競爭及其他因素對精神科急診住院病患醫療利用之影響。台灣衛誌，24(4)，296-305。