老年失智症患者診治時間間隔之相關因素及其對醫療和居家照護利用及照護結果之影響

Abstract

較少研究針對失智症患者診治時間長短對確診前、後的醫療和居家照護利用及照護結果進行調查，且欠缺完整的相關因素考量。本研究以失智症患者診治時間間隔為核心，並依患者使用藥品類型(包括失智症治療藥品和改善腦部功能藥品)分別探討之主要目的：1)老年失智症患者診治時間間隔與患者、機構及醫師因素之關係；2)老年失智症患者診治時間間隔對其開始治療前、後醫療利用變化；3)老年失智症患者診治時間間隔對其開始治療後的健保給付居家照護利用和照護結果之影響。 本研究採回溯性世代研究設計，資料取自全民健康保險研究資料庫2010年承保抽樣百萬歸人檔中2004‒2013年檔案，包括門診醫療費用清單明細檔(CD)、住院醫療費用清單明細檔(DD)、門診處方及治療明細檔(OO)、住院醫療費用醫令清單明細檔(DO)、承保資料檔(ID)、重大傷病證明明細檔(HV)、醫事機構基本資料檔(HOSB)、醫事人員基本資料檔(PER)，以及專科醫師證書主檔(DOC)等，而針對研究議題採用廣義估計方程式、差異中差異法和Cox proportional hazard迴歸模式進行統計分析。 研究結果發現：1)首次診斷年齡較輕、機構住民的患者(包括使用失智症治療藥品和改善腦部功能藥品患者)診治時間間隔顯著較長。此外，患者經由非神經科醫師首次診斷時，其診治時間間隔亦顯著較長的情形。2)診治時間間隔較長的患者(包括使用失智症治療藥品和改善腦部功能藥品患者)於開始藥品治療介入後1年內失智症相關總醫療和門診醫療費用相較於較短的患者有明顯增加，但僅使用改善腦部功能藥品患者在介入後1年(含)以上至2年內失智症相關總醫療和門診利用次數及醫療費用則明顯減少。3)診治時間間隔較長的患者(包括使用失智症治療藥品和改善腦部功能藥品患者)於開始藥品治療後使用健保給付居家照護的可能性增加。 本研究提出相關建議：1)醫療機構應引導有疑似失智症長者盡早就醫檢查。2)未來研究者需瞭解診治時間間隔較長的患者開始藥品治療後醫療費用較高的原因。3)衛生福利部或健康保險署應設法避免因為診治時間間隔較長所增加對居家照護之利用。

There are scarce studies investigating the delayed time of diagnosis and treatment for dementia patients influence pre- and post-diagnosis use of medical care and home care, and care outcomes. Moreover, related factors were seldomly considered. Thus, we centered on the delayed time interval between diagnosis and treatment for dementia patients based on medication type (including anti-dementia drugs and brain function enhancing drugs). This study aimed to explore: 1) factors associated with time interval between diagnosis and treatment for elderly dementia patients; 2) effect of first drug treatment on use of medical care for time interval between diagnosis and treatment elderly dementia patients; 3) effect of time interval betweem diagnosis and treatment elderly dementia patients on the use of home care reimbursed by the National Health Insurance (NHI) and its care outcomes after first drug treatment. This study cohort was obtained from the Longitudinal Health Insurance Database 2010 (LHID 2010) between 2004 and 2013, which contained the claims of 1 million beneficiaries who were randomly sampled from the Registry for Beneficiaries of the National Health Insurance Research Database (NHIRD). We used the unique encrypted identification number to link different data files, including ambulatory care expenditures by visits (CD), and details of ambulatory care orders (OO), inpatient expenditures by admissions (DD), details of inpatient orders (DO), registry for catastrophic illness patients (HV), registry for beneficiaries (ID), registry for contracted medical facilities (HOSB), registry for medical personnel (PER), and registry for board-certified specialists (DOC). In addition, statistical analyses were performed using generalized estimating equations (GEE), the difference-in-difference design in GEE, and Cox proportional hazards regression models. The results showed that 1) Dementia patients (including receiving anti-dementia drugs and brain function enhancing drugs) who aged ≤69 years and those who lived in long-term care facilities had a significantly longer time interval between diagnosis and first treatment. In addition, those who were diagnosed by non-neurologists also had a significantly longer time interval between diagnosis and treatment. 2) Patients who had longer time interval (including receiving anti-dementia drugs and brain function enhancing drugs) had significantly higher total and outpatient dementia related medical expenses after first year of drug treatment than those with shorter time interval between diagnosis and treatment. However, patients receiving brain function enhancing drugs had significantly lower total and outpatient dementia related medical use and expenses after drug treatment from first year to second year. 3) Patients who had longer time interval (including receiving anti-dementia drugs and brain function enhancing drugs) had higher likelihood of using home care reimbursed by the NHI after drug treatment. This study suggested that 1) Elderly patients who may have dementia should be guided to be diagnosed as early as possible. 2) The reasons of higher medical expenses after drug treatment for patients with longer time interval between diagnosis and treatment should be studied. 3) The MoHW or NHIA should take actions to prevent the increased use of NHI reimbursement for home care due to longer time interval between diagnosis and treatment.