全民健康保險慢性阻塞性肺病醫療給付改善方案執行成效初探 – 以嘉義縣某區域醫院為例

Abstract

背景與目的：中央健康保險署自2017年4月開始實施「全民健康保險慢性阻塞性肺病醫療給付改善方案」，藉由導入疾病管理與論質計酬的整合性照護概念，提升慢性阻塞性肺病之照護品質；目前未有研究探討該方案在疾病管理層面對照護結果是否有改善影響，本研究旨在以醫療資源使用及臨床照護成效進行評估，探討方案介入後之影響。 方法：本研究為準實驗設計之病歷回溯性研究，對象為嘉義某區域醫院胸腔內科系接受慢性阻塞性肺病治療之病人，依照病人是否於參加全民健康保險慢性阻塞性肺病醫療給付改善方案分派至對照組及實驗組，透過傾向分數配對法、魏克生符號檢定及差異中之差異法，探討全民健康保險慢性阻塞性肺病醫療給付改善方案實施後，對慢性阻塞性病病人在醫療資源使用狀況、急性發作狀況、肺功能及生活品質狀況之短期成效。 結果：推論性結果顯示，經慢性阻塞性肺病醫療給付改善方案介入，一年內的醫療資源使用狀況呈現下降趨勢，在門診、急診與住院分別減少了0.92次、0.25次與0.25次；一年內的急性發作狀況亦呈現下降趨勢，共減少0.62次；關於用力呼氣肺活量、用力呼氣肺活量預測百分比、用力呼氣一秒率及用力呼氣一秒率預測百分比的肺功能狀況，均呈現改善趨勢，分別增加了0.11公升（5.10%）及0.07公升（4.21%）；生活品質狀況則是在改良式呼吸困難指標、慢性阻塞性肺病評估量表總分、咳嗽構面及活動構面呈現改善趨勢，分別減少了0.44分、1.84分、0.41分及0.59分。 結論：慢性阻塞性肺病醫療給付改善方案的短期介入效果，可有效減緩病人在肺功能受到病程進展的衰退程度，避免病人因不穩定病況或急性發作，而增加額外必須至門診、急診或住院就醫及接受治療的次數，藉此減少醫療成本支出；並能改善病人的整體生活品質及病人活動程度，讓病人免於因疾病影響，造成日常生活進行自主活動上的過多限制。整體而言，慢性阻塞性肺病醫療給付改善方案的短期介入，能實踐提升疾病照護品質及減少醫療成本支出之目的，惟方案長期介入成效，建議於未來進一步進行研究及探討。

Background Purpose: National Health Insurance Administration has been implementing the chronic obstructive pulmonary disease (COPD) disease management and pay-for-performance program under the National Health Insurance since April 2017. The purpose of the program is to improve the clinical care quality of COPD by introducing integrated care into disease management and pay-for-performance, but there is no empirical study exploring whether the program improves the disease management as of 2020. This study aims to evaluate the program on the basis of medical utilization and clinical performance. Method: This study is designed as a quasi-experimental retrospective study of clinical medical records. Study subjects were enrolled by screening the patients who were treated for COPD in department of chest medicine in a regional hospital in Chiayi County, and assigned to control group or experimental group according to whether they participated in the program. Propensity score matching, Wilcoxon signed-rank test and difference-in-difference analysis are used to assess the short-term effectiveness of the program on the basis of the results and conditions of medical utilization, acute exacerbation, pulmonary function test and health-related quality of life. Results: The inferential statistical results indicate that after the intervention of the program, the medical utilization within one year showed a downward trend, with outpatient, emergency and hospitalization decreasing by 0.92, 0.25 and 0.25 times respectively. The acute exacerbation also showed a downward trend, with a total decrease of 0.62 times. The pulmonary function test of forced vital capacity (FVC), percentage of predicted FVC value, forced expiratory volume in one second (FEV1) and percentage of predicted FEV1 value all showed improvement trend, increasing by 0.11 liters (5.10%) and 0.07 liters (4.21%) respectively. The health-related quality of life improved in terms of the mMRC, total CAT score, cough dimension and activity dimension of CAT, which were reduced by 0.44, 1.84, 0.41 and 0.59 points respectively. Conclusions: The short-term intervention of the program effectively slowed down the decline in pulmonary function caused by progression of COPD, and reduced unnecessary additional visiting of outpatient, emergency and hospitalization because of unstable conditions or acute exacerbation, thus lowering unnecessary medical costs. It also improved patients’ health-related quality of life and activity level, and alleviated the restrictions on activities of daily living created by COPD. On the whole, the short-term intervention of the program improved the clinical care quality and reduced medical costs; however, the long-term one needs to be further inspected in future research.