髖關節骨折患者接受急性後期照護之成效與成本效果分析

Abstract

研究背景與目的：髖關節骨折（hip fractures）是50歲以上族群常見的骨骼創傷，會造成病人失能、低生活品質與沉重的照護壓力。人口老化與髖關節骨折人數成長使醫療支出持續增加，因此已開發國家實施急性後期照護（post-acute care, PAC）減少急性住院使用與改善病患照護品質。急性後期照護包括住院機構型與居家型，文獻指出兩者皆可顯著改善病患日常生活功能與生活品質，降低再住院與長期照顧需求，減少照護費用。2017年臺灣開始實施髖關節骨折急性後期照護，但缺乏相關文獻探討。本研究的目的是探討髖關節骨折患者接受急性後期照護計畫之成效與成本效果分析。研究方法：本研究為前瞻式世代研究，徵召臺北市立聯合醫院65歲以上髖關節骨折術後患者，分為居家組、住院組，與對照組。出院後進行兩到三週急性後期照護。評估項目包括：疼痛評估、身體功能評估，包含30秒坐站測試、巴氏量表，與Harris髖關節評分（Harris Hip Score）、歐洲五維健康量表（EuroQoL-5D, EQ-5D）、照顧者壓力指標（Caregiver Strain Index）與醫療資源使用狀況。評估時間為急性出院前一日，與急性後期照護結束時。成本效果比值（cost-effectiveness ratio, CER）為計算進步一分日常生活功能（巴氏量表）與生活品質所需花費的金額。統計分析使用SPSS第20.0版（SPSS Inc, Version 20.0. Chicago: SPSS Inc.）進行資料處理與統計分析，組間差異將以卡方（chi-square）分析或費氏精確檢定法（Fisher's exact test）、單因子獨立變異數分析（one-way independent analysis of variance, one-way independent ANOVA）或K-W檢定（Kruskal-Wallis test）。並以概化估計方程式（generalized estimating equations, GEE）比較三組治療過程差異。本研究使用雙尾檢定、顯著水準為α值<0.05。研究結果：本研究有41位受試者同意參加（平均年齡為78.5±7.8歲），分別為對照組12位、居家組17位，住院組12位。三組受試者人口學資料無顯著差異（p>0.05）。初次評估時，住院組的30秒坐站次數與EQ-index都顯著低於對照組（p<0.05），住院組的Harris髖關節評分顯著低於居家組（p=0.018）。經過急性後期照護後，三組受試者的巴氏量表皆有顯著進步，對照組從57.9±10.5分進步至67.5±17.5分（p=0.049）、居家組從56.4±11.5分進步至76.2±12.4分（p<0.001）、住院組從48.8±8.8分進步至63.3±14.8分（p=0.007），居家組改變幅度與對照組有統計上顯著差異（p=0.018）。對照組的Harris髖關節評分從48.1±8.9分進步至56.4±11.5分（p=0.016）、居家組從49.1±6.3分進步至63.5±5.8分（p<0.001）、住院組從40.4±8.8分進步至53.7±10.1分（p=0.003），居家組的改變量與對照組有統計上顯著差異（p=0.029）。介入後，EQ-index生活品質變化為對照組從0.212±0.274分進步至0.271±0.400分（p=0.374）、居家組從0.031±0.294分進步至0.298±0.371分（p=0.008）、住院組從-0.255±0.307分進步至0.146±0.433分（p=0.004），住院組改變量與對照組有顯著差異（p=0.015）。巴氏量表的平均成本效果比值分別為對照組4923元、居家組554元、住院組3165元。生活品質的平均成本效果比值為對照組801017元、居家組41948元、住院組115239元。比較遞增成本效果比值時，居家組有統計上顯著較佳的日常生活功能與生活品質之成本效果。結論：急性後期照護採用居家服務模式可顯著改善髖關節骨折患者的身體功能，住院照護組可顯著改善患者的生活品質。居家照護組的日常生活功能與生活品質之成本效果較佳。未來仍需更多大樣本數的研究瞭解急性後期照護對髖關節骨折病患的療效。

Background and purpose: Hip fracture, a common injury occurred in people aged over 50, may result in disability, poor quality of life, and higher care stress for their families. Aging population and growing number of hip fractures have increased health care costs, so many developed countries implemented post-acute care (PAC) to reduce acute hospitalization, and to improve the quality of care. PAC services can be provided through both hospital/facility-based and home-based services. Previous studies have shown that both services could significantly improve patients’ activities of daily living and quality of life, and reduce readmissions, long-term care and costs. Taiwan has implemented PAC plan for hip fractures since 2017, but relevant studies are scarce. Therefore, the purpose of this study was to analyze the efficacy and cost-effectiveness of PAC for patients with hip fractures. Methods: This was a prospective cohort study which recruited patients aged over 65 with hip fractures underwent surgical treatment in the Taipei City Hospital. They were divided into home group, hospital group, or control group. The timing of PAC was two to three weeks after the acute hospitalization. Assessments included numerical pain rating scale, physical function (30 seconds sit to stand, Barthel index, and Harris Hip Score (HHS)), EuroQol instrument (EQ-5D), Caregiver Strain Index, and using of medical resources. The assessments were performed before and after PAC. The cost-effectiveness ratio (CER) was defined as the NTD paid per unit improvement of functional performance and quality of life. SPSS version 20.0 (SPSS Inc, Version 20.0. Chicago: SPSS Inc.) was used for statistical analysis. The differences of measured variables among groups were analyzed by chi-square test or Fisher's exact test, and one-way independent analysis of variance (ANOVA) or Kruskal-Wallis test. Generalized estimating equations (GEE) was used to examine the effects of variables after intervention among three groups. An alpha level less than 0.05 (two-tailed) was set as statistically significant. Results: In our study, 41 patients agreed to participate (mean age: 78.5±7.8 years), including 12 in the control group, 17 in the home group, and 12 in the hospital group. There were no significant differences in demographic data among groups (p>0.05). At baseline assessment, the hospital group had significantly lower times and scores in the 30-second sit-to-stand test and EQ-index than the control group (p<0.05). The hospital group had significantly lower scores than the home group in the HHS (p=0.018). After PAC, the Barthel index improved in all three groups. The control group improved from 57.9±10.5 to 67.5±17.5 (p=0.049), the home group improved from 56.4±11.5 to 76.2±12.4 (p<0.001), and the hospital group improved from 48.8±8.8 to 63.3±14.8 (p=0.007). There was a significant group and time interaction between the home group and the control group (p=0.018). The change in the HHS was as follows: the control group improved from 48.1±8.9 to 56.4±11.5 (p=0.016), the home group improved from 49.1±6.3 to 63.5±5.8 (p<0.001), and the hospital group increased from 40.4 ±8.8 improved to 53.7±10.1 (p=0.003). There was a significant group and time interaction between the home group and the control group (p=0.029). The change in EQ-index was as follows: the control group improved from 0.212±0.274 to 0.271±0.400 (p=0.374), the home group improved from 0.031±0.294 to 0.298±0.371 (p=0.008), and the hospital group From -0.255±0.307 to 0.146±0.433 (p=0.004). There was a significant group and time interaction between the hospital group and the control group (p=0.015). The average CER of the Barthel index were NTD 4923 in the control group, NTD 554 in the home group, and NTD 3165 in the hospital group. The average CER of the EQ-index were NTD 801017 in the control group, NTD 41948 in the home group, and NTD 115239 in the hospital group. In the comparison of incremental CERs, the home group had better cost-effectiveness for activities of daily living and quality of life. Conclusion: This study showed that home PAC significantly improved the physical function of patients with hip fractures, and hospital PAC can significantly improve the quality of life of patients with hip fractures. The best CER for activities of daily living and quality of life was found with the home PAC. Large-scale, well-controlled, longitudinal studies are needed to further examine the effectiveness of acute post-care on patients with hip fractures.