疾病管理對高血壓病人臨床結果及費用的影響－一家區域醫院的經驗

Abstract

背景：疾病管理近年來逐漸受到重視，被認為是提昇醫療照護品質及效率的重要方法。由於高血壓為目前已開發國家中引起心臟血管疾病及死亡的重要原因，根據高血壓的流行病學研究報告，顯示其發生率約佔國人成年人的百分之十五到二十之間，與高血壓有關的中風、心臟病、糖尿病等疾病又名列國人十大死因的前五名。從文獻資料，可知良好的控制血壓，可以降低中風、心臟病、腎衰竭及週邊動脈疾病等的發生率。 目的：探討疾病管理對於高血壓病人治療的臨床結果以及醫療費用的影響。 方法：本研究乃藉由疾病管理的理念，對一家區域醫院心臟內科門診就診的高血壓病人，以類研究的方法觀察疾病管理的執行前及執行後是否有不一樣的結果。高血壓的定義，是以The JNC 7 Report (The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure)為準。實驗組為接受JNC-7 Report所定的臨床指引及衛教方法(JNC-7 高血壓管理的生活型態調整)，並以未執行疾病管理的同一醫院裡面同一科別內的高血壓病人作為對照組。 研究結果：實驗組共77例，對照組共66例。在實驗組裡面，疾病管理之後，血壓控制良好的病例從50.65% 升到 62.33%，相對而言，對照組則由63.63% 升到 65.15%。以疾病管理介入前後的比較，對照組的心血管併發症高於實驗組(心衰竭：6.06 % 比 1.30%，高血壓危象：6.06% 比 1.30%，出血性中風：1.52% 比 0%)。以門診的醫療費用而言，實驗組的醫療費用低於對照組。以上各項發現雖在統計學上並無顯著差異，但其趨勢相當一致，實驗組比對照組結果較佳，費用較低。 結論：高血壓的疾病管理在一家區域醫院門診病人的介入，顯示有較好的血壓控制以及降低心血管併發症，在門診醫療費用方面，短期內實驗組及對照組在統計學上沒有明顯的差異。依據上述的結果，疾病管理的介入對於高血壓病人的應用及發展是符合我國醫療社會經濟狀況的，疾病管理的政策是可提供衛生主管單位作為慢性疾病需要長期治療的政策參考。

Background: Disease Management refers to the use of an explicit systematic population-based approach to identify people at risk, intervene with specific programs of care, and measure clinical and other outcomes. Hypertension affects approximately 15~20% of adult individuals in Taiwan, The relationship between BP and risk of cardiovascular disease events is continuous, consistent, and independent of other risk factors. Purpose: To investigate the impacts of Disease Management on clinical outcomes and costs for patients with hypertension. Methods: This study was carried out in a community hospital in Taipei City. Individuals of hypertension were defined, according to JNC-7 definition. The intervention group received scheduled screening tests and education (JNC-7 Lifestyle modifications to manage hypertension), provided by cardiologist, nurses and dietician. The control group was given usual medical care. Results: There were a total of 77 subjects in intervention group and 66 subjects in control group. In the intervention group, BP with well control changed from 50.65% to 62.33% after intervention. On the contrary, BP in control group with well control, changed from 63.63% to 65.15%. By comparing the results before and after intervention, the control group had more cardiac events than that the intervention group had (CHF: 6.06 % V.S. 1.30%, Hypertension crisis: 6.06% V.S. 1.30%, Hemorrhage stroke: 1.52% V.S. 0%). Comparing the outpatient costs of these two groups, although the intervention group expense was less than that of the control group in average, it was not significant statistically. Conclusion: Disease management for hypertension outpatient clinic in a community hospital showed an improvement of blood pressure control and reduction of the cardiac events, although the expense of the patients were not different statistically in the short term follow-up. Based on these findings, this research offered some suggestions on the future researches and policy making.