停經後骨質疏鬆婦女運動訓練計畫之效果與成本評估

Abstract

隨著老年人口的快速增加，骨質疏鬆已成為一個全球性的公共衛生課題，亞洲地區及台灣也不例外。骨質疏鬆病患骨密度會降低且骨組織構造會受到破壞，導致骨頭變得較脆弱，容易引發骨折，而骨折後所引發的相關併發症與後遺症往往帶給醫療及社會相當大的成本與負擔。運動治療無副作用，對於這類病患是極被推薦的非藥物性治療方式，運動對於增加骨密度、減緩骨流失、預防跌倒等成效已被很多研究證實，但對於不同運動介入方式所產生之效益的研究則頗為有限。對於醫療提供者而言，如何能達到有效益又可節省成本是重要的考量。因此，本研究之目的為：研究一，探討不同運動介入方式，包含居家運動組、群體運動組及衛教組之療效差異；研究二，比較三種執行方案之成本效益。 研究一設計為前瞻性隨機分組臨床試驗，共徵召87名50歲以上停經後骨質疏鬆婦女以隨機分組介入的方式，探討居家運動組、群體運動組及衛教組之療效差異，運動介入時間為三個月，在介入前、介入停止後及追蹤至一年各有一次評估，評估項目包括：骨密度(於6個月時做第二次評估)、肌力、平衡能力、功能活動、生活品質、與跌倒次數。資料分析以SPSS 11.0版本作為統計分析之工具，所有分析之α值定在0.05。將以敘述性統計呈現三組基本資料的特性；以Kruskal- Wallis test檢測三組在各個不同時間點組間之差異。以Friedman test檢測各組在不同時間點之組內差異。研究二進行上述三方案之成本效益分析：成本為執行方案所需之經費，效益為骨密度、肌力、平衡能力、功能活動、生活品質及跌倒次數之改變；以及與衛教組比較所增加之成本效益比。 研究一結果顯示，各組在運動介入後大部分變數均有進步之趨勢。在各個不同時間點，三組間在各變項均無顯著差異(p> 0.05)。故將三組結果加以整合分析，結果顯示上肢抓握力相較於第一及第二次測試，在第三次之測試有顯著進步；功能活動、平衡及整體生活品質表現，第一次與第二次及第三次之測試間有顯著進步。而跌倒的人次，在介入完成後半年內三種執行方式均有明顯減少。 研究二結果顯示，對於提高病患生活品質而言，居家運動為三種模式中最符合成本效益之方式。而對於跌倒的預防，衛教組最具成本效益。當以不同方式支付治療費用及不考慮產值損失時，敏感度分析結果並未改變。然而不考慮產值損失時，居家運動組幾乎為大部分變項中最具成本效益的介入模式。 由介入結果可提出結論，三種不同運動執行方式對功能活動及減少跌倒的效益是相近的，未來對於此類病患教導其執行居家運動並給予完整的疾病相關衛教應是避免骨質疏鬆及預防跌倒的有效方式。若加入成本之考量，衛教及居家運動皆為較符合成本效益的執行方式。

Elderly population is rapidly increasing in number and proportion, osteoporosis has become a major global public health issue, including Asia and Taiwan. Osteoporosis is a systemic disorder and is characterized by low bone mass, leading to bone fragility and an increased susceptibility to fractures. The complications and sequelae that coming with osteoporotic fractures always cause great burden to the society and medical care system. Many studies have proven that exercise can improve the bone mineral density, decrease bone loss, prevent fall and so on. However, most studies focused on the effects of different types of exercises, few studies compared the therapeutic effects among different delivery modes. To the medical providers, what is the most cost-effective program is important. The purposes of this thesis are as follows: Study 1: To compare the effectiveness of home-based exercise, group exercise and education group. Study 2: To conduct a cost-effectiveness analysis (CEA) for the 3 programs and the incremental cost effectiveness analysis (ICEA) comparing with the education group. Study I was a prospective randomized controlled trial. Eighty seven postmenopausal women with osteoporosis and age older than 50 years old were recruited. They were randomized into home-based exercise, group exercise or education group. The intervention was for 3 months, evaluation was done before and after the intervention and one year after starting the program. The outcome measures included: bone mineral density (BMD: the second evaluation was done at the 6th month), muscle strength, balance, functional mobility, quality of life, and numbers of fall. Data was analysed using the 11.0 version of SPSS and a was set at 0.05 for all analyses. Descriptive statistics was used to show the baseline characteristics of the three groups. Kruskal–Wallis test was used to compare difference among groups. Friedman test was used to analyze the differences among all three time points within the groups. Study II, a CEA and ICEA for the 3 programs was executed. The cost was based on the budget for performing the programs, and the effectiveness was measured including the changes in BMD, muscle strength, balance, functional mobility, quality of life, and numbers of fall. The result of study I showed that three groups had a trend of improvement in most outcomes. There was almost no significant difference among three groups at each time point (p> 0.05). The data of all modes was pooled together, the results showed that grip strength had significant improvement at 12- month follow- up comparing to baseline and 3- month assessments; functional mobility, balance (using one leg standing with eyes opened), and total score of Qualeffo- 31 all showed significant improvements between baseline and 3- month and between baseline and 12- month assessment (p< 0.05). All fall numbers of 3 modes declined till half year after intervention. The results of study II showed that home- based exercise was the most cost effective one among 3 delivery modes of exercise for improving QOL. For fall prevention, education program might be the most cost effectiveness program. The sensitivity analysis was conducted, the results did not change. However, if the productivity cost was neglected, home- based exercise was the most cost- effective option in most variables. We concluded that all 3 modes of exercise could get similar effects on mobility and lowering the fall risk. A comprehensive education program with home exercise program may be an effective way to prevent osteoporosis and fall. When cost effectiveness is considered, education program or home- based exercise may be the better options.