急性腦中風病人住院復健強度之照護結果與成本效果分析—以某醫學中心為例

Abstract

研究背景與目的：過往研究發現腦中風病患住院期間接受高強度復健，可改善身體功能與中風相關併發症，或許能降低醫療費用，而非計畫再住院與急診亦可反映住院復健成效，然目前尚未有研究探討住院復健強度與住院醫療費用、非計畫再住院以及急診的相關性。此外，目前也未有研究探討住院復健強度之成本效果。因此，本研究目的為探討住院復健強度與住院期間醫療費用、非計畫再住院以及急診的相關性，並以健保署觀點，探討住院復健強度之成本效果。 研究方法：本研究資料取自「臺大醫療體系醫療整合資料庫」與「P4P病人層級指標登錄表」，研究對象為2015年10月到2017年9月出院且有接受住院復健之腦中風病人，透過多元線性迴歸與多元邏輯斯迴歸分析不同復健強度對住院醫療費用、非計畫再住院以及急診之影響，並以遞增成本效果比值(Incremental cost effectiveness ratio, ICER)進行成本效果分析。 研究結果：本研究共納入1,166人，經過傾向分數配對後兩組人數各為378人，經過迴歸分析後，於住院期間接受高強度復健的腦中風病人之出院後30日內非計劃性再入院勝算比為0.49 (95％信賴區間：0.27-0.86)、30日內急診利用勝算比為0.36 (95％信賴區間：0.22-0.61)、90日內急診利用勝算比為0.55 (95％信賴區間：0.37-0.82)，在住院醫療費用的部分則節省了32,707元(p=0.026)；進行成本效果計算後，發現高強度復健為較具優勢的治療策略。 結論：腦中風病人於住院期間接受高強度復健之住院醫療費用較低，同時也能改善照護結果，為具成本效果的治療策略。

Objectives: Previous studies have explored that stroke patients who received high intensity inpatient stroke rehabilitation, may result in the improvement of functional outcomes and the reduction of stroke-related complications, and might reduce medical costs. Furthermore, the outcomes of unplanned readmission and emergency department(ED) visit reflected the quality and effectiveness of care. However, the relation between inpatient rehabilitation intensity and medical costs, unplanned readmissions and ED visits are unknown. In addition, the economic evaluation of different intensities of rehabilitation is also unknown. Thus, the aim of the study is to assess the difference in medical costs , return emergency department visits and unplanned readmissions after receiving different intensities of stroke rehabilitation during hospitalization; moreover, to examine the cost-effectiveness of different intensities of rehabilitation. Methods: The database derived from Hospital Healthcare system and pay-for-performance documents of National Taiwan University Hospital, and we incuded stroke patients who discharged from October 2015 to September 2017. Multiple logistic regression analysis and multiple linear regression were used to discover the effects of different intensities on unplanned readmission, emergency department visit and medical costs. The Incremental cost effectiveness ratio was calculated as the difference in costs divided by the difference in the rate of return emergency department visits and unplanned readmissions. Results: We recruited 1,166 patients, and 378 pairs of subjects were selected after propensity score matching. After adjustment by regression model, the odds ratio of receiving high intensity therapy of 30-day unplanned readmission, 30-and 90-day emergency department visit were 0.49 (95% confidence interval [CI], 0.27-0.86), 0.36 (95% CI, 0.22-0.61) and 0.55 (95% CI, 0.37-0.82), respectively. In addition, it saved NT$32,707(p=0.026) in medical costs. According to the result of cost-effectiveness analysis, high intensity of rehabilitation therapy was a dominant strategy. Conclusions: For stroke patients who receive high intensity rehabilitation therapy can not only reduce medical costs, but also decrease hospital utilization after discharge, and which is a cost-effectiveness strategy.