以診斷關聯群為基礎前瞻性支付制度對於髖部骨折與髖關節置換術的醫療資源利用與照護結果之影響

Abstract

摘要 背景：為了抑制上漲的健康照護費用，美國自1983年實施診斷關聯群/前瞻性支付制度(diagnosis related groups/prospective payment system, DRG/PPS)，其他國家也逐漸採用此支付制度，臺灣於2010年1月實施以診斷關聯群為基礎前瞻性支付制度。很少研究探討DRG為基礎支付制度對於髖部骨折/髖關節置換術之醫療利用及照護結果之影響，且研究結果並不一致。 目的：本研究目的探討DRG為基礎支付制度對於髖部骨折與髖關節置換術之醫療利用與照護結果之影響。 方法：本研究使用2008年至2011年全民健保資料庫，髖部骨折與髖關節置換術病患為研究對象。結果變項包括總住院醫療費用、住院日數、14日再入院、30日再入院、30日死亡。本研究使用廣義估計方程式(generalized estimating equation, GEE)，控制病人特性與醫院特性，以檢測DRG為基礎支付制度實施對於髖部骨折與髖關節置換術之醫療利用與照護結果之影響。 結果：DRG為基礎支付制度實施初期， 30日再入院率上升，之後，30日再入院率逐漸下降。 結論：DRG為基礎支付制度實施初期30日再入院增加，但逐漸下降。DRG為基礎支付制度的推行或許可促使醫療提供者建立較佳診療模式，以減少醫療利用且維持照護結果。 關鍵字：髖部骨折、髖關節置換術、診斷關聯群、照護結果。

Abstract Backgroud：To reduce rising health care costs, diagnosis related groups/prospective payment systems (DRG/PPS) has been introduced since 1983 in the United States followed gradually by other countries. Since January 2010, Taiwan has implemented a DRG-based prospective payment system. Few studies examined the impact of DRG-based payment systems on medical utilization and outcomes of care for hip fracture and hip replacement surgery, and the results were not consistent. Object：The objective of this study was to examine the impact of DRG-based payment systems on medical use and outcomes of care for hip fracture and hip replacement surgery. Method：This study used National Health Insurance Research database of Taiwan between 2008 and 2011. Patients with hip fracture and hip replacement surgery were selected as study objects. Outcome variables were total inpatient expenses, length of stay, 14- and 30-day readmission rates, and 30-day mortality rate. The generalized estimating equation model analysis was used to examine the impact of DRG-based payment systems on medical utilization and outcomes of care for hip fracture and hip replacement surgery after controlling patient and hospital characteristics. Result：In the beginning of implementing DRG-based payment systems, the 30-day readmission rate increased. Afterward, the 30-day readmission rate decreased gradually. Conclussion：The 30-day readmission rate increased at the initial implementation of DRG-based payment systems, but declined gradually. The DRG-based payment systems may encourage health care providers to establish a better care model to reduce medical overuse and maintain outcomes of care. Keywords: hip fracture, hip replacement surgery, diagnosis related groups, outcomes of care