探討醫師開立低價值醫療利用之相關因素—以高階影像檢查為例

Abstract

研究背景: 低價值醫療僅能帶來有限的益處並且可能對病患造成醫源性之傷害，因此如何減少低價值醫療對全球醫療體系仍然是一項艱鉅的挑戰。台灣全民健康保險每年支出約台幣260億元在電腦斷層、磁振造影及超音波檢查上，然而上述檢查中有多少屬於低價值醫療？又低價值醫療影響影像檢查的利用與病人之看診醫師的因素是否有關？這方面的研究仍然很有限。 研究目的: 本研究是採用衛生福利資料科學中心全民健康保險資料庫，來檢視非複雜頭痛及暈厥病患在低價值影像利用與醫療提供者特質之間的關係。 研究方法: 本研究為橫斷性研究，透過2010~2014年全民健保資料庫進行次級資料分析，研究對象為健保承保20歲以上之人口，此研究包含「非複雜性頭痛開立低價值頭部影像檢查」、「暈厥開立低價值頭部影像檢查」及「簡單性暈厥開立低價值頸動脈超音波檢查」三項低價值影像利用，並且使用多階層邏輯斯回歸來探討控制醫療機構因素及病患因素後，探討病人之看診醫師的因素與低價值醫療利用的關係。病人之看診醫師的因素包含年齡、性別、就醫科別及病人之看診醫師該年影像檢查總費用佔所有申報費用的佔率。 研究結果: 2011~2014年「非複雜性頭痛開立低價值頭部影像檢查」、「暈厥開立低價值頭部影像檢查」及「簡單性暈厥開立低價值頸動脈超音波檢查」利用率分別為8.98%、14.08%及5.80%。在控制病患及醫療機構因素後，此研究發現病人之看診醫師該年影像檢查費用佔所有申報費用的佔率高 (OR:1.342-4.690)、男性 (簡單性暈厥開立低價值頸動脈超音波檢查OR=0.825)、醫師年齡較小 (OR:1.198-1.410) 及就醫科別為急診醫學科 (OR:2.746-4.127，簡單性暈厥開立低價值頸動脈超音波檢查除外) 與低價值影像利用顯著正向相關。 結論: 此研究發現在控制病患因素及醫療機構因素後，低價值影像利用與病人之看診醫師的因素有關聯，且影像檢查中的低價值利用可能與財務誘因有關。目前國際上許多改善低價值醫療利用的措施皆是針對需求面進行，但本研究凸顯了針對醫療服務提供者進行介入干預的重要性。

Background: One of the primary challenges in healthcare management is the elimination of low-value care, which is of limited benefit and can actually cause iatrogenic harm to patients. Taiwan’s National Health Insurance annually spends around 860 million U.S dollars in CT, MRI, and ultrasound. Unfortunately, little is known about the effectiveness of advanced imaging tests and whether the utilization of low-value imaging test is associated with physician characteristics. Objective: This population-based study obtained data from the Taiwan National Health Insurance (NHI) database for the years 2010 - 2014 to characterize the relationship between the use of low-value imaging tests and the characteristics of healthcare providers. Patients who were diagnosed with uncomplicated headache or syncope were included in the analysis. Methods: Three types of imaging tests were defined as low-value: head imaging for uncomplicated headache, head imaging for the evaluation of syncope, and carotid ultrasound imaging for simple syncope. Multilevel logistic regression was used to identify physician characteristics associated with the use of low-value imaging modalities. Physician characteristics included age, gender, specialty, charges for advanced imaging as a proportion of annual reimbursements for disease/symptom claims, and the number of consultations claimed per year. The models were controlled for hospital characteristics and patient characteristics. Results: The utilization of the three low-value diagnostic procedures was as follows: head imaging for uncomplicated headache (8.98%), head imaging for the evaluation of syncope (14.08%), and carotid ultrasound imaging for simple syncope (5.80%). After controlling for patient and hospital factors, our study revealed that the proportion of charges for advanced imaging in annual reimbursements (OR: 1.342-4.690) , gender (OR:0.825), age (OR:1.198-1.410) and Emergency department (OR: OR:2.746-4.127, except for carotid ultrasound imaging for simple syncope) were positively associated with the use of low-value imaging tests. Conclusions: This study revealed that after controlling for patient characteristics and hospital characteristics, the utilization of low-value imaging tests was associated with physician characteristics. The proportion of annual reimbursements attributed to advanced imaging was positively associated with the use of low-value imaging tests, which implies that the utilization of low-value care might be driven by financial incentives. Many interventions could be implemented to limit the use of low-value care, such as the Choosing Wisely scheme advocated in many countries. This study sheds light on important issues regarding the need for interventions aimed at reducing the use of low-value care options.