到院前心電圖對於ST波段上升型急性心肌梗塞(STEMI)病人之經濟評估

Abstract

研究背景 台灣每年約有兩萬人發生心肌梗塞，且發生率逐年增加，每年因急性心肌梗塞搶救不及，造成疾病惡化或死亡所產生的龐大醫療花費與社會經濟損失極為極為龐大。近年來隨著資訊科技發展，在台灣已有城市發展到院前心電圖系統提供救護人員及早偵測疑似心肌梗塞病人，並通知醫院預做準備，以便儘速完成緊急導管手術。目前台灣研究尚無以使用到院前心電圖與否對醫療品質與醫療利用之影響與經濟評估研究。 研究目的 本研究目的在比較使用到院前心電圖對ST波段上升型心肌梗塞(STEMI)病人在醫療品質與醫療利用方面是否有差異。再以中央健康保險署、政府觀點與社會觀點進行使用到院前心電圖系統之成本效果分析與經濟評估。 研究方法 本研究以2012年2月至2017年7月台灣南部某醫學中心心導管室資料庫，探討經由救護車送醫之STEMI病人，並進行心導管手術治療者進行回溯性研究。觀察使用「到院前心電圖系統」與未使用「到院前心電圖系統」兩組病人，探討兩組對於到達醫院後到接受血管重新灌流的時間（door-to-balloon time, D2B time）與症狀發生到接受血管重新灌流的時間（Ischaemic-to-balloon time, I2B time）、到達醫院後到接受血管重新灌流的時間（door-to-balloon time, D2B time）小於90分鐘達成率和當次住院病人出院時的死亡率等之差異，以及當次住院日數、當次ICU使用日數、健保申報點數和實際醫療費用等之差異。本研究結果以卡方檢定、無母數獨立樣本曼惠特尼(Mann-Whitney)U檢定、羅吉斯迴歸（Logistic regression）、線性迴歸（Linear regression）進行分析，在成本效果分析以遞增成本效果比（Incremental Cost Effectiveness Ratio,ICER）呈現。最後再根據中央健康保險署觀點、高雄市政府觀點與社會觀點分別進行經濟評估，呈現成本效果分析結果。 研究結果 本研究樣本共68人，其中到院前心電圖在介入組26人與未實施到院前心電圖之對照組42人。在醫療品質方面比較，在平均D2B 時間，介入組47.2分鐘，對照組86.6分鐘，在統計上有顯著差異(p<0.001)。在D2B小於90分鐘的達成率，在介入組有25人(96.1％) ，對照組有31人(73.8%)在統計上有顯著差異(p＝0.022)。另外對於症狀發生到接受血管重新灌流的時間I2B時間、在當次住院死亡率 、當次平均住院日數、當次平均使用ICU日數、當次平均健保申報點數與當次實際醫療費用等在兩組均無統計上差異。經濟評估結果顯示在搶救人命方面，每多搶救一位人命所需多投入的金額，以社會觀點、高雄市政府觀點、健保署觀點估計的ICER值分別為477,234元、75,905、及24,135元。平均餘命方面，每多搶救STEMI心肌梗塞病人一年壽命所需投入的金額，以社會觀點、高雄市政府、健保署觀點估計的ICER值分別為30,969元、4,926元、及1,566元。 結論 本研究在發現使用到院前心電圖對於的D2B時間縮短有的效果，對於D2B小於90分鐘達成率方面也具有顯著的提昇，且其醫療費用也較未使用者低，因此使用到院前心電圖在ST波段上升型心肌梗塞病人是較具成本效果優勢(dominant)的方式。推估高雄市全面推動後可每年可減少14.2人死亡。

Background: In Taiwan, approximately 20,000 people a year experienced acute myocardial infarction (AMI) and the incidence rate is increasing year by year. Some patients suffering from this condition cannot be saved. The medical expenses and social and economic losses caused by the worsening or death from the disease are enormous. In recent years, with the development of information technology, some cities in Taiwan have implemented pre-hospital electrocardiogram systems (PHECG) to detect suspected myocardial infarction patients as early as possible and notify emergency departments to prepare for emergent catheterization before patients arrived at the hospital. At present, there is no research focusing on the effects of using PHECG on medical quality, medical care utilization and economic assessment. Objective: The aim of this study was to compare the differences in medical quality and medical care utilization between ST-segment elevation myocardial infarction (STEMI) patients who used PHECG and those who didn't. And to analyze the cost effectiveness and economic assessment of using PHECG. Methods: This study used the cardiac catheterization database of a medical center in southern Taiwan. We enrolled patients who used PHECG and were found to be suffering from STEMI and those who did not use PHECG from January 2012 to July 2017. We compared the difference of the door-to-balloon time (D2B time), the Ischemic-to-balloon time (I2B time), the rate of D2B time less than the 90mins, the death rate, the number of ICU days, the number of hospital days, the costs of health insurance payments and the costs of actual medical expenses. The chi-square test, Mann-Whitney U test, Logistic regression and Linear regression were used to compare the difference in outcomes and costs. Incremental cost-effectiveness ratio (ICER) was calculated from the perspectives of society, the city government, and National Health Insurance Administration (NHIA) with regard to the cost per life saved and per life year saved. Result: There were 68 patients of this study, including PHECG group of 26 and Non-PHECG group of 42 people. There were no differences in the baseline characteristics between these two groups. The mean D2B time was 47.2 minutes in the intervention group, 86.6 minutes in the control group (p< 0.001). The rate of D2B time less than the 90mins was 25 (96.1%) for the intervention group and 31(73.8%) for the control group (p = 0.022). In addition, there was no statistically significant difference in the in-hospital mortality rate, the I2B time, the number of ICU days, the number of hospital days, the costs of health insurance payments and the costs of actual medical expenses in the two groups. Conclusion: This study found that the use of PHECG group for the D2B time and the D2B time has less than 90 minutes had better outcomes, and also lower medical costs than Non-PHECG group. Therefore, the use of PHECG was a dominant modality in patients with STEMI. It is estimated that a total reduction of 14.2 deaths annually will be achieved in Kaohsiung City. The results of economic evaluation show that in terms of incremental cost for per live saves, the ICER for the perspectives of the society, the city government, and the NHIA were NT$477,234, 75,905, and 24,135 respectively. In terms of the incremental cost per life year saved, the ICER for the perspectives of the society, the city government, and the NHIA were NT$30,969, 4,926, and 1,566 respectively.