心導管檢查或治療在不同醫院屬性下之醫療資源耗用 、死亡率及重返心導管室率之分析、探討與比較

Abstract

研究目的： 本研究主要目的在探討心導管檢查或治療在不同醫院屬性下之醫療資源耗用情況、死亡率及重返心導管室率之分析、探討與比較。納入分析之醫療資源耗用及醫療品質指標包括：(1)總醫療費用；(2)住院天數；(3)死亡率；(4)重返心導管室率。為了滿足研究目的的需要，本研究進行了下列的假說，在控制其他因素之下，(1)不同醫院屬性因素會影響心導管檢查或治療的醫療資源耗用(總醫療費用、住院日數)有所不同。(2)不同醫院屬性因素會影響心導管檢查或治療的病患死亡情形有所不同。(3)不同醫院屬性因素會影響心導管檢查或治療的病患重返心導管室情形有所不同。 研究方法： 以上述研究假說為研究基礎，本研究採用橫斷式(Cross-sectional)事後回溯次級資料分析研究法。本研究所採用的資料為民國89、90、91年全國性健保申報資料，經過篩選、整理、比對並除錯後，共83,547案件數，其中論病例計酬案件72,325筆，非論病例計酬案件11,222筆，以SAS 8.2&reg; for Windows套裝軟體進行分析。 研究結果： 一、不同醫院屬性因素會影響心導管檢查或治療的醫療資源耗用(總醫療費用、住院日數)有所不同。心導管檢查類者申報之總醫療費用平均值最高者皆為財團法人區域醫院；心導管治療類者申報之總醫療費用最高者分別是為財團法人區域醫院、公立醫學中心、財團法人醫學中心。 二、各種論病例計酬項目之住院日數平均值在迴歸分析模式中皆呈現顯著的差異(p<.0001)，但更深入探討發現屬於心導管治療的項目只有私立區域醫院的住院日數與公立醫學中心(參考組)有顯著差異(p<0.0001)，而且是住院日數顯著減少。若以住院日數的平均值由高而低排列依序可知財團法人醫學中心、公立醫學中心、公立區域醫院、財團法人區域醫院、私立區域醫院。 三、在不同醫院屬性之醫院對於心導管檢查或治療的死亡率的確有顯著的不同(p=0.0003)。各種論病例計酬項目與醫院屬性在30天的死亡率在屬於論病例計酬項目者，不同醫院屬性的死亡率都沒有顯著的不同。但是，若屬於脫離論病例計酬核實申報者則不同醫院屬性的死亡率則有顯著的差異(p<0.01)，特別是私立區域醫院的死亡率高達3.62%是最低者(公立區域醫院,0.82%)的4.41倍。以30天內死亡的人和30天內沒有死亡的人相比，私立區域醫院病人的死亡機率是公立醫學中心(參考組)病人的2.09倍，且呈現統計上的顯著差異(p=0.0002)。 四、本研究結果顯示不同醫院屬性因素會影響心導管檢查或治療的病患重返心導管室情形有所不同是成立的，其中以財團法人醫學中心的重返心導管室率最低(0.90%)，財團法人區域醫院最高(2.20%)。 研究建議： 一、對衛生主管機關的建議： 1.主管機關應建立更嚴謹的審查機制與罰則來導引醫院應照實填報。 2.主管機關應訂定基本訓練標準與考核標準，從嚴審核施做醫師在訓練時的過程與結果，以保障民眾就醫的安全性。 二、對醫療機構管理者的建議： 1.建議醫院本身應提供其醫師完整的教育訓練(well-training)。 2.應加強低手術量醫師之品質監控，以提升醫院整體醫療水準。 3.醫療品質之良窳，不僅攸關病患健康問題更是醫院營運之命脈，醫院應以專責醫療品質單位與專業人員監測不良之併發症與療效，致力改善以增進醫療品質。 三、對後續研究者的建議 因為無法由健保資料庫的資料中直接判讀病患心臟血管阻塞的疾病嚴重程度，需藉由病歷回顧檢視法加以認定，且病歷之判讀需有專業人員經標準化訓練，採用較嚴謹之研究設計如雙盲研究並將判讀結果進行交叉比對，以降低個人判定誤差。

Research Objectives: The objectives of this research were to analyze and to explore the catheterization examinations or treatments of medical resources utilization, mortality rate and return rate among with different hospital groups. The essential factors of medical resource utilization and medical quality were included: (1) General medical payment, (2) the length of stay, (3) mortality rate, and (4) the return rate of catheterization. To approach the research objectives, one makes the following three hypotheses under controlling other related factors. The hypotheses were proceeded (1) different hospital groups factors affect the outcomes on catheterization examinations or treatments of medical resources utilization (General medical payment/the length of stay), (2) different hospital groups factors result in different mortality rate outcomes on catheterization examinations or treatments, (3) different hospital groups factors influence the patients return catheterization rate on catheterization examinations or treatments. Method: The cross-sectional research analysis was conducted by adopting the selective National Health Insurance data of 83,547 cases (72,325 case payment, 11,222 non-case payment) from 2000 to 2002. Results: 1.The impacts of different hospital groups affect the outcomes on catheterization examinations or treatments of medical resources utilization (General medical payment/the length of stay). The highest Mean value of General medical payment on catheterization examinations declare are attributed to Non-profit Metropolitan Hospital. Moreover, in terms of catheterization treatments, the highest of General Medical payment s are attributed to Non-profit Metropolitan Hospitals、Public Medical Centers、Non-Profit Medical Centers respectively. 2.The means o f the length of stay on various case payment items in multiple regression model are all shown significant(p＜.0001). However, considering catheterization treatments, one found there were merely the Private Metropolitan Hospitals and Public Medical Centers (Reference Group) showed significant(p＜.0001), meanwhile, the length of stay are shown significant decline as well. Concerning the means of the length of stay from high to low are ranked as Non-Profit Medical Centers、Public Medical Centers、Public Metropolitan Hospitals、Non-profit Metropolitan Hospital、Private Metropolitan Hospitals in order. 3.The mortality rates on catheterization examinations or treatments in different hospital groups are shown significant (p=0.0003). Two situations are discussed. There is no significant of 30-day mortality rate in the case payment items among with different hospital groups. On the other hand, there is significant (p＜0.01) in the non-case payment. Accordingly, the mortality rate of Private Metropolitan Hospitals was 3.62%, which was 441% higher by comparison Public Metropolitan Hospitals (0.82%). In comparison with 30-day mortality rate or above 30-day mortality rate, the mortality rate of Private Metropolitan Hospitals was 209% higher than Public Medical Centers (Reference Group), and the result showed significant (p=0.0002) as well. 4.The results of this research revealed that different hospital groups indeed affected patients return rate on catheterization examinations or treatments. Accordingly, the lowest return rate of Non-Profit Medical Centers was 0.90%, and the highest return rate of Non-profit Metropolitan Hospital was 2.20%. Suggestions: A. To public health policy makers 1.The public health bureau needs establish strictly investigate system and penalty stipulation for guiding hospitals to declare in accordance with rules. 2.The public health bureau needs stipulate basic training and access criterion to evaluate on-training physicians to secure patients health. B. To medical institute manager 1.The hospitals need provide well-training physicians. 2.The hospitals need monitor the quality of low-operation physicians to raise the medical care standard. 3.The hospitals should cooperate with professional to observe the effects of treatments and prevent any harmful complication from being occurred. C.To further researchers In this study, one can not obtain the detail information of severity of patients’ heart blood vessel blocked in National Health Insurance database, consequently, it needs access by Chart-review studies. Thus, one suggests a well-understanding anamnesis needs well-training professional groups to access and to explain by applying double-blinded studies model to improve the further research result accurately.