慢性阻塞性肺病患者之直接與間接醫療成本

Abstract

背景：慢性阻塞性肺病(Chronic Obstructive Pulmonary Disease, COPD)是一個常見的肺部疾病，在全球造成許多死亡和失能。根據WHO的估計，2004年全球約有6,400萬人患有COPD，預測2030年將會成為全球第三大死因。許多研究皆指出COPD為重要的致病及致死原因之一，造成社會極大的經濟負擔，各國也逐漸開始重視COPD對醫療體系的影響。相較於歐美地區，目前針對台灣COPD之經濟負擔的研究相當缺乏。 研究方法：本篇研究藉由分析2011年全民健康保險研究資料庫百萬歸人檔與對醫院門診病患進行結構式問卷調查的方式，試著瞭解慢性阻塞性肺病相關醫療利用，以及其直接醫療成本與間接成本等疾病負擔。研究樣本的篩選條件為：(1)健保資料庫中疾病診斷碼(ICD-9-CM)之主次診斷碼為慢性阻塞性肺病(491.XX、492.XX、496)者。(2)年齡40歲以上。(3)過去一年至少有2次COPD的門急診紀錄，或是1次住院紀錄。(4)排除年齡、性別有誤或其他欄位邏輯矛盾者。納入研究的門急診和住院資料共有76,535人次，歸人後為11,714人。結構式問卷的收案對象為中部某醫學中心胸腔科門診病患，並且(1)經醫師診斷為COPD之患者；(2)年齡40歲以上；(3)意識清楚且能正常交談者，調查時間為2014年7月至8月，回收有效問卷共39份。 研究結果：COPD患者每人每年的直接醫療成本，平均門急診總費用為9,750點，平均住院總費用為19,744點，就醫時健保以外的自付費用為5,472元，其他照護費用為32,269元，生產力損失為1,782元，醫療利用為平均門診次數為6.17次，急診次數為1.22次，住院次數為0.31次且住院天數為3.99天。而假如僅考慮有該醫療利用者的平均，平均門急診總費用上升為10,551點，平均住院總費用上升為95,258點。經差異性分析與迴歸分析後發現，在門急診和住院的總費用部分，男性的費用高於女性，年齡組越高費用也越高、非榮民身分的費用大於榮民身分、主要就醫場所的特約層級越高費用也越高、共病症數目越多費用越高、有使用吸入性類固醇的患者費用遠大於無使用吸入性類固醇者。主要就醫場所為醫學中心和非公立醫院者的人數大於區域醫院、地區醫院與公立醫院。並且瞭解性別、年齡、主要就醫場所特質、共病症多寡和有無使用吸入性類固醇會對醫療成本和利用產生影響，特約層級高低也會影響到醫療成本。 結論： COPD患者中，70歲以上男性，且有共病症和使用吸入性類固醇者，耗費較多的醫療資源和成本。建議醫療院所強化患者對COPD的疾病認知和接受治療的效率，尤其是要教導病患如何正確使用吸入式的治療藥物。透過相關衛生教育活動讓病患能確實控制病情，避免COPD症狀的惡化，以減少COPD的疾病成本與經濟負擔。

Introduction: Chronic obstructive pulmonary disease (COPD) is a common chronic lung disease which causes numerous deaths and disabilities. In accordance with the estimation of World Health Organization (WHO), 64 million people are diagnosed with COPD around the globe in 2004, and it is predicted to be the third leading cause of death in 2030. Moreover, the great mortality and morbidity resulted from COPD also incur enormous social economic burden. Many countries are aware of the importance of impact of COPD to the health care system gradually. Comparing to a plenty of economic burden research focused on COPD, there is a lack of studies in the field of discussing the cost of COPD in Taiwan. Materials and methods: In this study, the economic burden and health care utilization of COPD patients are calculated through the data of one million people’s 2011 Longitudinal Health Insurance Database of National Health Insurance Research Database (NHIRD), and a self-developed structured questionnaire. The sampling criteria for patient selection are: (1) with principal or secondary diagnosis of ICD-9-CM code in 491.xx, 492.xx or 496; (2) aged more than 40 years old; (3) at least two outpatient visits or one inpatient admission in a year; (4) exclude patients with illogical information in administrative claims. Second, the sampling criteria of structured questionnaire are: (1) identified with COPD by physicians; (2) aged more than 40 years old; (3) able to communicate and being conscious. In the part of secondary analysis based on NHIRD, 76,535 OPD or IPD visits and 11,714 COPD patients are included in this study. For the part of structured questionnaire, 39 COPD patients are recruited from a Chest Medicine Outpatient Department in a tertiary hospital in central Taiwan from July 2014 to August 2014. Result: In terms of direct medical costs, COPD patients have an average medical cost of 9,750 points in outpatient and emergency room visit, and 19,744 points in hospitalization per person per year. Patients’ mean annual extra costs beyond NHI coverage are NT$ 5,472, and other care giving costs are NT$ 32,269, and the costs of productivity loss are NT$ 1,782. Average numbers of outpatient visits, emergency room visits, hospitalization and length of stays are 6.17 times, 1.22 times, 0.31 times and 3.99 days, respectively. If the cases who didn’t use OPD or IPD services are excluded in calculating the mean of medical cost, the average OPD medical cost increases to 10,551 points, and the average IPD medical cost increases to 95,258 points. In terms of results of regression analysis, total direct medical cost was significantly correlated with gender, age, number of co-morbidity, and the use of inhaled corticosteroid (ICS). Being male,older, had more co-morbidity, and used ICS had higher medical cost.The out-of-pocket cost increases with higher hospital levels, and the number of patients who choose medical centers and private hospitals as their common place to seek medical advice is more than those who choose local, regional and public hospitals. Conclusion: Male COPD patients with age more than 70 years old are tend to have higher total medical cost as well as health utilizations, especially for patients with co-morbidity and using inhaled corticosteroid. In order to reduce the medical costs and disease burden of COPD, medical care providers are recommended to strengthen patients’ knowledge about the COPD and the proper way to inhale COPD medicines, which in turn may enhance the efficiency of intervention and delay the progression of COPD.