- 學位論文
台灣全膝人工關節置換手術醫療效果和醫療資源耗費及術後早期失敗影響因子
Factors affecting outcomes and resource utilization and early failure after total knee arthroplasties in Taiwan
摘要
研究目的： 對末期退化性膝關節炎的患者，目前最有長期療效的治療方式是人工膝關節置換術，台灣每年施行的人工膝關節置換術數量也隨著人口老化而持續增加。本研究目的希望探討台灣人工膝關節置換術之醫療效果、醫療資源耗費和二年內發生早期失敗的影響因子。 研究方法： 研究樣本是以台灣1996年至2010年間全民健保資料庫住院檔作回溯性研究。選取住院中有ICD-9處置碼81.54的病人為研究樣本。排除的病人包括資料登記不全和費用不合理，另外再排除曾在當次人工膝關節置換術前曾接受膝關節再置換術、移除人工膝關節手術及膝關節切開術，共篩選出172,170人次。進行二年內早期失敗病例研究時，再增加排除術後30日內死亡及2009年和2010年之病人，因為這些樣本並沒有完整二年之追蹤，共篩選出131,441人次。 研究變項中自變項包括a.人口學特質(年齡、性別)，b.疾病特質(主診斷類別、合併症、術後併發症)，c.醫療提供者特質(醫院層級別、醫院服務量、醫師服務量)，依變項則包括a.當次手術有無併發症，b.住院30日內死亡，c.當次住院天數，d.當次住院費用，e.術後二年內早期失敗有無發生。 研究結果： 對當次人工膝關節置換術TKA手術有無併發症發生，下列因素有顯著增加的Odds Ratio：年齡小於56歲，男性，術前診斷不屬於骨性關節炎(OA)和類風濕性關節炎(RA)，合併腎臟疾患，Charlson Comorbidity Index ≧1分，區域醫院層級，低手術量醫師(三分位法)。 在住院30日內死亡方面，下列因素有顯著增加的Odds Ratio：年齡≧65歲，男性，合併腎臟疾患，CCI≧1分，地區醫院層級，有術後併發症，低手術量醫師，低手術量醫院，不屬OA和RA診斷。 當次住院天數會受下列因素影響而顯著增加，年齡<56歲，男性，不屬OA和RA診斷，CCI≧1分，合併糖尿病，合併腎臟疾患，非醫學中心，有術後併發症，低服務量醫師，中、低服務量醫院。而當次住院費用會受下列因素影響而顯著增加：年齡小於56歲，非屬OA和RA，合併糖尿病，合併腎臟疾患，CCI≧1分，醫學中心層級，有術後併發症，低服務量醫師。 台灣人工膝關節置換術後二年內早期失敗病例的發生率是1.63% (2,143/131,441)。 Cox存活分析顯示年齡小於56歲，男性，不屬OA和RA診斷，合併糖尿病，非醫學中心，有術後併發症，低服務量醫師，低服務量醫院等因子會顯著增加人工膝關節置換術後二年內早期失敗病例的風險。 結論 1. 全膝置換手術患者在當次醫療效果、當次醫療耗用和術後兩年內發生早期失敗的風險高低證實會受到患者特質、 疾病特質和醫療提供者特質等因素之影響。 2. 屬於全膝置換手術早期失敗高風險的病人，低服務量醫師和低服務量醫院應謹慎篩選以減少早期失敗病例的發生。
並列摘要
Objective Total knee arthroplasty is currently the most effective treatment for those patients with end-stage osteoarthritis of the knee. Due to increased population of aged people, the volume of total knee arthroplasty performed in Taiwan increased steadily over the past decade. This study aimed to find out the factors that affecting the outcomes and resource utilization and early failure within two years of total knee arthroplasty in Taiwan. Methods This study is a retrospective data analysis using the National Health Insurance Research Database (NHIRD) of Taiwan from 1996 to 2010. We first enrolled the patients who had a TKA procedure code 81.54 and a total of 175,711 patients were identified. For the outcomes and resource utilization analysis we excluded the patients with incomplete data, outlier reimbursement and history of revision TKA, removal of knee prosthesis and knee arthrotomy; after exclusion there were 172,170 patients for statistical analysis. For the early failure analysis we further excluded the patients that died within 30 days after TKA and the patients of 2009 and 2010 that not had 2 years of follow up; after exclusion there were 131,441 patients for statistical analysis of early failure. The independent variables of this study include: demographic characters (age, sex), clinical characters (diagnosis, comorbidity and complication) and provider characters (hospital grading, surgeon volume and hospital volume). The dependent variables included: rate of complication after TKA, rate of death within 30 days after TKA, length of hospital stay, reimbursement of index TKA and the risk of early failure (any one of revision TKA, removal of knee prosthesis and knee joint arthrotomy) within 2 years. Results For the rates of complication after index TKA the factors that showed statistically increased odds ratio included age under 56 year old, male, diagnosis other than osteoarthritis and rheumatoid arthritis, with renal failure comorbidity, Charlson Comorbidity Index ≧1, regional hospital, low volume surgeon. In the respect of death within 30 days, the following factors: age equal or above 65 years old, male, with renal failure comorbidity, Charlson Comorbidity Index ≧1, community hospital, low volume surgeon, low volume hospital, associated with statistically increased odds ratio. The length of hospital stay were statistically longer in patients that are age under 56 years old, male, diagnosis other than osteoarthritis and rheumatoid arthritis, with Diabetes Mellitus or renal failure comorbidity, Charlson Comorbidity Index ≧1, not medical center, with complication, low volume surgeon, low and middle volume hospital. In the aspect of reimbursement, statistically higher reimbursement was associated with age under 56 years old, diagnosis other than osteoarthritis and rheumatoid arthritis, with Diabetes Mellitus or renal failure comorbidity, Charlson Comorbidity Index ≧1, medical center, with complication, low volume surgeon. The rate of early failure within 2 years after TKA in Taiwan is 1.63% (2,143/131,441) Cox regression analysis showed statistically higher Hazard Ratio of early failure was found in the factors of age under 56 years old, male, diagnosis other than osteoarthritis and rheumatoid arthritis, with Diabetes Mellitus comorbidity, not medical center, Charlson Comorbidity Index ≧1, with complication, low volume surgeon, low volume hospital. Conclusion and suggestion 1. The outcomes and resource utilization and early failure of TKA in Taiwan were influenced by the factors of demographic characters, clinical characters and provider characters. 2. The low volume surgeon and low volume hospital should avoid performing TKA in the patients that are with risk factors of high early failure after TKA. To prevent the combined risks of detrimental early failure after TKA will be a great relief for the patients and health providers.