實施Tw-DRGs支付制度對醫院資源耗用影響－以人工膝關節置換術為例

施麗玲

doi:10.6831/TMU.2012.00190

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實施Tw-DRGs支付制度對醫院資源耗用影響－以人工膝關節置換術為例

The impact of implementation of Tw-DRGs payment system on the hospital resource utilization － A Study of Total Knee Replacement

施麗玲 , Masters　　Advisor：李顯章　　

繁體中文 DOI： 10.6831/TMU.2012.00190

台灣版疾病診斷關聯群(Tw-DRGs) ；雙側人工膝關節置換術；單側人工膝關節置換術；膝關節再置換術；資源耗用； Taiwan Diagnosis Related Groups (Tw-DRGs) ； Bilateral Total Knee Replacement ； Unilateral Total Knee Replacement ； Revision Total Knee Replacement ； Resource utilization

Abstract │ Reference (45) │ Altmetrics

Abstract 〈TOP〉

研究背景與目的：自1995年3月全民健保支付制度實施後，健保局為提升醫療品質，控制醫療費用成本，自2010年1月開始分階段性於住院部門逐步推動Tw-DRGs支付制度，根據健保局統計資料2009年醫療資源利用情形為65歲以上人口占10.54%，醫療費用占33.86%，老年人口為醫療資源耗用較多。研究目的在於探討Tw-DRGs支付制度實施後，以同一次住院置換雙側人工膝關節置換術，在研究期間只置換一側為單側人工膝關節置換術及同一側膝關節再置換術，分析醫院服務量、醫師服務量與照護結果死亡之關聯性，在人工膝關節置換術對醫院醫療資源利用情形及對醫院財務的影響，分別從醫院特質、醫師特質、病患特質進行探討。

研究方法：本研究資料來源為國家衛生研究院全民健康保險研究資料庫2009年至2010年之醫事機構基本資料檔(HOSB)、醫事人員基本資料檔(PER)、住院醫療費用清單明細檔(DD)及承保資料檔(ID)共四個資料檔，再以SAS 9.3版進行資料分析，其研究對象以Tw-DRGs實施前後二年期間，同時置患雙側人工膝關節置換術(ICD-9-CM procedure codes 81.54 + 81.54)，及置換單側人工膝關節置換術(ICD-9-CM procedure codes 81.54)，另在研究期間為膝關節再置換術(ICD-9-CM procedure codes 81.55)之住院患者，統計方法採用t檢定、單因子變異數分析、卡方檢定、複迴歸模型、邏輯斯迴歸，檢視不同Tw-DRGs支付制度實施後對於醫療點數及醫療點數差額所造成之影響，醫院服務量、醫師服務量對死亡之關係。

研究結果：實施Tw-DRGs支付制度後，醫療點數之各變項皆呈現下降趨勢，由醫療點數之複迴歸模式分析結果，雙側人工膝關節置換術之醫療點數，在Tw-DRGs支付制度實施前後時程、患者年齡、主診斷、次診斷指數、層級別及地區別方面，具有統計上顯著性差異(p＜0.05，p＜0.01，p＜0.001)；單側人工膝關節置換術之醫療點數，在Tw-DRGs支付制度實施前後時程、患者性別、患者年齡、主診斷、合併症指數、次診斷指數、權屬別、層級別、地區別及醫師服務量方面，具有統計上顯著性差異(p＜0.05，p＜0.01，p＜0.001)；膝關節再置換術之醫療點數，在患者性別、患者年齡、次診斷指數、權屬別、層級別、地區別及醫師性別方面，具有統計上顯著性差異(p＜0.05，p＜0.01，p＜0.001)；而醫療點數差額之複迴歸模式分析亦有類似結果，由此可知本研究之各變項在資源耗用上有較高的解釋能力，醫療點數與醫療點數差額是非常重要的影響因素。
    在照護結果關係，醫師數量集中在26-74百分位，患者數量集中在≧75百分位，且疾病嚴重度及死亡風險皆有可能會增加死亡率，在置換雙側、單側及膝關節再置換術追蹤出院後90日內死亡方面，以卡方檢定分析結果，主手術死亡率情形，置換雙側為0.54%、置換單側為0.32%、膝關節再置換術為0.43%；邏輯斯迴歸分析結果，膝關節再置換術死亡率為置換雙側的1.93倍(95﹪C.I.= 0.39-9.57)，置換單側死亡率為置換雙側的1.17倍(95﹪C.I.= 0.54-2.53)；醫師服務量26-74百分位影響出院後90日內死亡為≦25百分位的0.76倍(95﹪C.I.=0.26-2.22)，≧75百分位影響出院後90日內死亡為≦25百分位0.97倍(95﹪C.I.=0.34-2.81)，但統計上未達顯著性差異。

結論：實施Tw-DRGs支付制度後，醫院有效控制醫療成本，且獲得合理的給付；此骨科手術在置換雙側、單側及膝關節再置換術之死亡風險較低。

研究建議：(1)衛生主管機關須公開Tw-DRGs醫療品質指標；(2)醫療院所疾病分類人員主動與醫師討論找出有效合併症與併發症，以獲得合理的給付；(3)未來研究者須持續追蹤Tw-DRGs支付制度給付規定，另針對住院期間較長個案，醫療資源耗用較多，進行個案分析，減少不必要的資源耗用。

Parallel Abstract 〈TOP〉

Background and Objectives：
The current national health insurance (NHI) system in Taiwan was adopted by Taiwanese government since March 1995. To control the cost of medial expenses without compromising the quality of medial care, the Bureau of NHI started to use the diagnosis-related group system (Tw-DRGs) in January 2010. According to the statistics of NHI Bureau in 2009, age 65 and over in Taiwan, 10.54 percent of the country’s people, accounted for 33.86% of medical benefit claims for illness or injury. The elderly population consumed more medical resources.
The aims of this study were to investigate the relationships between the hospital service volume, physician service volume and mortality rates in patients had received unilateral total knee replacement, simultaneous bilateral total knee replacement and revision total knee replacement after the implementation of the Tw-DRGs payment system. This study also discover the influence of knee replacement on medial resources and financial of the hospital by the hospital characteristics, physician characteristics and patient characteristics respectively.

Methods：
The data sources are from Contracted Medical Facilities (HOSB), Registry for Medical Personnel (PER), Inpatient Expenditures by Admissions (DD) and Underwriting Data File (ID) of the NHI Research Data Library from 2009 to 2010. The statistic analysis was performed using SAS software (version 9.3). 
The objects of the study were the patients, in two years before and after the implementation of Tw-DRGs, received unilateral total knee replacement (ICD9-CM procedure code 81.54), bilateral total knee replacement (ICD9-CM procedure code 81.54 + 81.54) and revision total knee replacement (ICD9-CM procedure codes 81.55) in the hospital at the same time, and to evaluate the influence of knee replacement on medial resources and financial of the hospital by the hospital characteristics, physician characteristics and patient characteristics respectively. The statistic methods include t-test, one-way analysis of variance, Chi-square test, multiple regression models, and logistic regression.

Results：
The variable of medial charges are shown with a downward trend after the implementation of Tw-DRGs payment system. Analysis of the results from the medial charges of multiple regression models, the medial charges of bilateral total knee replacement has the significance in the Tw-DRGs payment system implementation schedule, patient age, primary diagnosis, secondary diagnosis index, layer level and geographic (p＜0.05, p＜0.01, p＜0.001).
The medial charges of unilateral total knee replacement has the significant ability in the Tw-DRGs payment system implementation schedule, patient age, primary diagnosis, comorbidity index, secondary diagnosis index, ownership, layer level, distinguish, and physician services quantity (p＜0.05, p＜0.01, p＜0.001).
The medial charges of revision total knee replacement has the significance in patient sex, patient age, secondary diagnosis index, ownership, tier level, distinguish, and physician service volume (p＜0.05, p＜0.01, p＜0.001). The multiple regression models analysis also have the similar results. Medical charges and cost difference are important factors. 
In the relationship of care results number of physicians are concentrated in the 26-74th percentile, and number of patients are in the >= 75th percentile.
Both the severity of illness and risk of death may increase the mortality of bilateral, unilateral and revision total knee replacement within 90 days after discharge from hospital. Main surgical mortality are 0.54% in bilateral TKR, 0.32% in unilateral TKR, and 0.43% in revision TKR by Chi-square test.
From the analysis by Logistic Regression, the mortality of revision TKR is 1.93 times then the mortality of bilateral TKR (95% CI = 0.39~9.57). Unilateral TKR is 1.17 times then the mortality of bilateral TKR (95% CI = 0.54~2.53), 26-74th percentile influence of the physician volume is the 0.76 times the death of <= 25th percentile (95% CI = 0.26~2.22), and >= 75th percentile of discharge after 90 days is 0.97 times the death of <= 25th percentile (95% CI = 0.34~2.81) But the statistics have not reached a significant yet.

Conclusion：
After the implementation of the Tw-DRGs payment system, hospitals could effectively control the cost and receive reasonable reimbursement.

Recommendation：
(1) Health official authorities must disclosure the Tw-DRGs quality indicators of health. (2) Medical institutions and certified coders take the initiative to discuss with your doctor to find out the comorbidity and complication have been a reasonable reimbursement. (3) Researchers need to keep track of Tw-DRGs payment system payment provisions in the future, and focus on a longer hospital stay cases and medical resource utilization to do more case studies to reduce unnecessary resource consumption.

Reference ( 45 ) 〈TOP〉

江依倫(2010)。醫師服務量與院內死亡之相關性研究－以葉克膜氧合器為例。未出版碩士論文，臺北醫學大學醫務管理研究所。
連結：
李佳霖、方莉、李聖瑤、蔡桂香、韋有升(2009)。模擬實施新制DRG(Tw-DRGs)對醫療費用之影響及因應之道--以股骨轉子間骨折(210,211)為例。醫務管理期刊，10(3)，153-164。
連結：
邱艷芬、吳巧雲、黃俊雄(1998)。全膝關節置換手術緊要路徑之建立與評估。慈濟醫學雜誌，10(4)，311-325。
連結：
黃凱潔(2011)。模擬Tw-DRGs實施對醫院資源耗用之影響-以Cardiac Cath、PTCA及CABG為例。未出版碩士論文，臺北醫學大學醫務管理研究所。
連結：
張錦文(2005)。醫院總額支付與未來的因應措施。福爾摩莎醫務管理雜誌，1(1)，1-7。
連結：

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