開立低價值醫療服務的情形及影響因素探討-以6種心臟相關處置為例

Abstract

研究背景：世界各國均面臨著醫療支出逐年成長的情形，臺灣健保也不例外，有部分醫療對於患者而言，其實提供了很少或沒有益處，進而造成傷害和浪費有限的醫療資源，故檢視醫療處置是否均有益於民眾，減少無效或低價值醫療處置的浪費，將資源有效利用是必要的。近年國外許多學會或機構已提出許多低價值醫療清單及倡議Choosing Wisely活動，而相較於台灣醫療體系，對於低價值醫療概念的研究仍屬不足，亦難探究低價值醫療項目對醫療資源的影響。 研究目的：心血管相關的處置或檢驗在國內外的醫療支出均為高佔比，且國外低價值醫療清單提及許多心血管相關項目，故本研究以清單中心血管相關處置或檢驗作為研究項目，選取經皮冠狀動脈介入性治療(PCI)等六項，運用臺灣全民健保資料庫數據直接分析，以了解低價值醫療在心血管相關項目的潛在程度，及開立心血管處置及檢驗項目與低價值醫療相關的重要因素。 研究方法：本研究使用2009年至2018年之門住診就醫資料，研究對象為曾接受過心血管相關處置及檢驗項目之病患，且患者年齡為20歲以上(含)，並採用次級資料以醫師及醫療機構特質，分析醫師為此類病人開立低價值醫療項目之情形。本研究依變項為心血管相關處置及檢驗項目等6項目，分別為「對穩定型冠心病病患予以經皮冠狀動脈介入治療，並採用氣球擴張術或支架置入術治療」、「對穩定型冠心病病患予以壓力測試」、「術前進行心臟超音波」、「術前進行壓力測試」、「對白內障手術進行術前心臟檢查」、「對非心臟手術進行術前心臟檢查」；而自變項為醫師特質及醫療機構特質等兩類，控制變項則使用病人特質做為分析。 研究結果： 1.在穩定型缺血性心臟病病人中，所接受到的低價值醫療服務，在2016-2018期間所接受PCI處置病患之比例為34.18%，而在2010-2018期間接受壓力測試病患之比例則為28.67%；另在非心臟性中低風險手術病人中，在術前30天曾接受心臟超音波及壓力測試之比例為5.65%及6.45%；另排除心臟相關疾病後，檢視在術前30天曾接受過5項心臟相關檢驗項目，白內障手術之比例為4.69%，而非心臟性低風險手術病人則為52.74%。 2.在開立低價值案件比例較高之醫師有較高傾向提供低價值醫療服務，另排除PCI項目後，分別在就診機構開立低價值案件比例較高之醫院、高都市化程度地區之醫院、權屬別為非公立之醫院亦較有高傾向提供低價值醫療服務，而在年紀越大之病人(排除白內障手術)、未裝血管支架之病人(PCI)，接受到的機會顯著較高。 結論：在本研究發現雖各項目之低價值比例不一，但在醫師低價值案件占整體比例越高越易有開立低價值醫療項目之情形，建議政府未來考量針對高占比的機構或醫師進一步檢視其醫療必要性；而在醫療提供者則應以國內實證醫學及臨床狀況為基礎，建置用於臺灣醫療體系的清單，以提供社會大眾更優質之醫療服務；也建議未來研究可以其他低價值醫療項目，佐以臺灣的臨床狀況進行探討，以獲取更適於臺灣的低價值醫療研究。

Background: Medical expenditures around the world are increasing, and Taiwan is no exception. Medical treatments with little or no benefit for the patient are a waste of limited medical resources. Thus, there can be considerable advantages to identifying medical treatments that are truly beneficial to the public. Cardiovascular-related treatments and testing account for a considerable proportion of medical expenditures, and in many counties they are considered low-value. Objective: Our objective in this study was to assess the value of cardiovascular- related treatment/testing within the context of the medical system in Taiwan. Methods: Outpatient and inpatient medical records (2009 to 2018) were used to identify patients (>20 years) that had undergone cardiovascular-related treatment/ testing. Physician characteristics, facility level, and clinical variables were used as independent variables to gain insight into situations in which low-value medical service (six items) are administered. The control variable was patient characteristics. Results: 1. Among patients with stable ischemic heart disease, 34.18% underwent percutaneous coronary intervention (PCI) during 2016 - 2018, whereas 30.32% received stress tests during 2010-2018. Among non-cardiac intermediate or low-risk surgical patients, 5.65% underwent echocardiographic evaluation and 6.45% received stress testing in the 30 days before surgery. Surgery patients that had been examined and cleared of heart-related diseases were subjected to five heart-related tests 30 days prior to their surgeries. Note that among these patients, 4.69% were cataract surgery patients and 52.74% were non-cardiac low-risk surgery patients. 2. Physicians with a higher proportion of low-value cases were more likely to prescribe low-value medical services. After excluding cases of PCI, it was found that hospitals with a high proportion of low-value cases, hospitals in urban areas, and non-public hospitals were more likely to order low-value medical services. The probability of receiving low-value medical services was significantly higher for older patients (excluding cataract surgery patients) and PCI patients who had not yet received coronary stents. Conclusions: Overall, the proportion of low-value services was proportional to the likelihood of ordering low-value medical procedures. The government should consider methods to assess the value of medical services in institutions with a high proportion of low-value medical services. They should also review the actions of doctors who order a high proportion of these services. Bases on empirical medicine and clinical situations, medical service providers should limit the use of low-value medical services in order to improve the overall quality of care. We recommend further research on other forms of low-value care within the context of the Taiwanese medical system.