遵循抗生素臨床指引與治療結果關係之研究-以肺炎治療性抗生素與手術預防性抗生素之使用為例

Abstract

背景：抗生素的使用持續成長與抗藥性細菌的問題日益顯著，已經是全球性的重要衛生議題，而國內抗生素使用的問題同樣嚴重，如何規範合理使用抗生素，成為現階段臨床照護與醫療品質的重要課題。透過實證臨床指引的介入，是建議採取的有效策略，但臨床指引的實際遵循程度與臨床指引對治療結果的關係，缺乏足夠的研究與評估，因此有進一步探討的必要性。 目的：一、瞭解我國抗生素使用的現況與臨床指引遵循程度的趨勢。二、分析遵循抗生素臨床指引的相關影響因素。三、研究遵循抗生素臨床指引與治療結果的關係。四、研究遵循抗生素臨床指引與醫療費用的關係。 方法：選取「肺炎治療抗生素臨床指引」(1999 & 2006) 與「外科手術預防性抗生素臨床指引」(2004) 為研究標的，資料來源為全民健康保險學術研究資料庫之「2005年百萬抽樣歸人檔」與「健保資料庫特殊申請檔」，研究期間為1998年至2009年。以「點連結迴歸」來定義出1998-2009年間臨床指引遵循程度的變化趨勢是否具有統計上的意義，並採用廣義估計方程式做多變項迴歸分析，以分析是否遵循臨床指引的相關影響因素，以及遵循臨床指引與治療結果與醫療費用的關係。 結果：一、國內抗生素指引遵循程度在研究期間呈現逐漸上升的趨勢，但不同疾病與手術類型的抗生素指引遵循趨勢有明顯的差異。二、在控制病人特性的情形下，遵循抗生素臨床指引與不同的醫師特性與醫院特性相關。三、門急診社區型肺炎抗生素治療遵循指引可以減少看診後七天內住院的機會；而外科手術預防性抗生素使用遵循指引可以降低出院後三十天內再住院的機會，也與減少手術當次住院日數相關。四、遵循抗生素臨床指引與醫療花費呈負相關，亦即遵循臨床指引則醫療花費較少。 結論：遵循抗生素臨床指引是有用的醫療品質過程面指標，不僅容易測量，利用行政申報資料即可操作，而且與醫療結果呈現高度相關性。

Background: The overgrowing usage of antibiotics with the problem of increasing drug-resistant bacteria has been a significant global health issue, while the same serious condition exists in our society. How to regulate the rational use of antibiotics has become an important theme in the aspects of clinical care and quality of healthcare. Through the intervention of evidence-based clinical practice guidelines has been recommended as an effective strategy; however, it is in lack of adequate research and evaluation about the actual adherences to clinical guidelines and the associations between clinical guidelines and treatment outcomes, so there is a need for further exploration. Purposes: First, understand the current status of antibiotic usage and the trend of guideline adherences in our society. Second, analyze the explanatory factors of adhering antibiotic clinical guidelines. Third, study the associations of antibiotic guideline adherences and treatment outcomes. Fourth, evaluate the relationship between antibiotic guideline adherences and medical expenses. Methods: Choose the ‘guidelines on antimicrobial therapy of pneumonia in Taiwan’ (1999 & 2006) and the ‘guidelines for the use of prophylactic antibiotic in surgery in Taiwan’ (2004) as targets. Use 12-year (1998 to 2009) claim data from the ‘Longitudinal Health Insurance Database 2005’ and special application data of National Health Insurance. Joinpoint regression was used to define whether it is statistically significant in the degree of trend of guideline adherences during 1998 to 2009, and generalized estimating equations for multivariate logistic regression analysis to examine the explanatory factors of adhering clinical guidelines, as well as the relationship between clinical guidelines and treatment outcomes and medical expenses. Results: First, the antibiotic guideline adherences during the study period showed a gradually upward trend, but there were significantly different degrees of trend among different diseases and types of surgery. Second, in the case of controlling patients' characteristics, antibiotic guideline adherences were associated with different physicians’ characteristics and hospitals’ characteristics. Third, antibiotic guideline adherences for community-acquired pneumonia in ambulatory departments could decrease the possibility of hospitalization by the pneumonia-related diagnosis within 7 days after the visit, and adherence to prophylactic antibiotic guidelines in surgery could reduce the readmission rate within thirty days after discharge and lessened the length of hospitalization. Fourth, antibiotic guideline adherences were negatively correlated with medical expenses, i.e. the higher the guideline adherences the less the healthcare costs. Conclusion: Antibiotic guideline adherence is a useful quality indicator in the aspect of process. It is not only easy to measure and can be operated by using administrative claims data, but it shows a high degree of correlation with the medical outcomes.