智能醫療自我照護可降低氣喘急診就醫及醫療花費

Abstract

背景：研究顯示，智能手機應用程式（APPs）是一種方便的工具來啟動自我照顧之慢性疾病治療模型。網路陸續出現各種氣喘APP，不過，大多未能結合氣喘指引資訊與自我管理應用，並缺乏實證研究結果。 目標：我們想利用智能手機應用程式衛教，探討是否能改善氣喘控制功效及減少醫療花費。 方法：我們藉由台灣氣喘診療指引設計了一個人智能手機應用程式。我們預計收案210名氣喘控制不佳的兒童，其中70位使用這應用程式(APP組)，另外140位則無使用這應用程式(非APP組)，然後評估其使用此APP前後6個月的醫療成效及花費。病患透過手機APP記錄自己嚴重度、生活品質問卷及肺功能等生理變化。由手機APP，針對不同病患氣喘嚴重度及空氣污染狀況給予不同健康管理建議(如需就醫、少外出、提醒規則服藥)傳送至病患或其父母手機。用生活品質問卷 (MiniPAQLQ、PACQLQ、PASS)、肺尖峰流速(PEF)及類固醇劑量來評估病患使用此應用程式0、3、6個月之後的成效及其可能影響因素分析。我們也使用回顧性審查來評估類固醇的常規療程的變化和病患氣喘發作急診就醫次數，並評估就醫費用的差異。直接醫療費用包含急診就診和住院費用，間接醫療費用包含父母薪水和交通費的間接費用。 結果：在6個月時APP組的患者優於非APP組，有較高MiniPAQLQ及較低PASS分數。口服針劑類固醇的平均每日劑量由89.12（35.03）mg降至67.58（31.10）mg。與非APP組相比，APP組患者類固醇口服針劑劑量會降低，吸入類固醇劑量會增加，但未達到統計學顯著意義。由氣喘發作至急診的比例從17％降低到3％（p <0.001），而住院率從22％降到3％（p <0.001）。急診室就診總醫療費用，APP組從22,100元減到5,100元(新台幣)（p = 0.050）; 非APP組有下降，但無顯著差異。住院總醫療費用，從280,887元減到69,741元，（p = 0.050）；非APP組有下降，無顯著差異。直接醫療費用只有APP組有顯著差異，直接醫療費用之降幅以急診就診費的組間差異中之差異（DID）較顯著（p = 0.050）。在APP組中，影響父母平均薪水從7200元減少到779元，平均交通費從359元減少到58元（p =0.050）。非APP組中，影響父母平均薪水損失從6882元減少到778元，平均交通費從266元減少到54元（p =0.050）。間接醫療費用雖APP組及非APP組都有顯著差異，但父母平均薪水與交通費之降幅以APP組之組間差異中之差異（DID）較顯著（p = 0.001）。 結論：智能手機自我照護系統可提供氣喘自我監控和健康管理。減少紙本繁重衛教介入並提供個人化氣喘教學及治療輔助。 提升病患健康識能達到自我照護及氣喘控制，以改善氣喘病人生活品質，減少醫療費用，為健保論人計酬制度鋪路。

Background: Few studies have evaluated the medical outcome and cost after application of smart phone self-care system. Purpose: This study investigated whether a smart phone application self-care system may achieve better asthma, quality of life, and decrease asthma medical cost. Methods: We designed an intrusive smartphone app to provide timely support to asthma patients. Patients age between 3 and 18 years old with asthma were recruited to randomly receive APP (70 patients) and non-APP (140 patients) over a 6-month period. The Mini-Pediatric Asthma Quality of Life Questionnaire (PAQLQ), Pediatric Asthma Caregiver Quality of Life Questionnaire (PACQLQ), Pediatric Asthma Severity Scores (PASS), and peak expiratory flow (PEF) survey were used to assess non-APP before, during, and after the app use (0,3, and 6 months). A chart review was also performed to assess prescribed courses of systemic corticosteroids, inpatient admissions, and emergency room visits. The direct and indirect medical cost 6 months before and after the app was also evaluated. Result: Patients in the APP group had higher Mini-PAQLQ and lower PASS score than the non-APP group at 6 months. Patients in the APP group decreased their mean daily dose of systemic corticosteroids compared with the non-APP group, though failed to reach statistical significance. The rate of emergency visit because of asthma attack decreased from 17% to 3 % while the hospitalization rate decreased from 22% to 3% (p<0.001). Total medical cost of emergency room visits and admissions decreased. In the APP group, the mean cost per person of emergency room visits and hospitalizations cost decrease much more than the non-APP group (p=0.001). The difference in difference (DID) of medical cost of emergency room visits were statistically significance (242.86(665.41) versus 68.00(501.71), p = 0.050). The indirect cost of parents’ salary loss and transportation cost decreased. In the APP group, the DID of the mean cost per person of parents’ salary loss and transportation cost decreased much more than the non-APP group (p<0.001). Conclusion: The smartphone self-care system provided a practical self-monitoring and -management of asthma. It may achieve better asthma control and decrease asthma medical cost.