探討低價值服務利用趨勢及影響因素 －以下背痛患者使用診斷性造影為例

Abstract

背景：醫療服務普及化之下，同時也衍生不適當、非必要的照護服務進而導致醫療浪費，此議題長久以來受到重視與討論。自2012年Choosing Wisely是由美國內科醫學會聯合其他專科醫學會，審視現有醫療服務項目並歸類為低價值服務，其定義為無效的、不適當的或是不符合成本效益之醫療服務，近年國外開始引進低價值服務之概念，反觀我國醫療服務體系對於低價值服務之態度、以及臨床中是否有出現符合低價值服務概念服務之相關研究仍缺少，因此無法進一步了解目前國內低價值服務其醫療利用之影響程度。 目的：國外部分醫療體系也開始將Choosing Wisely所公布臨床診斷指引，使用於臨床診斷治療之中，因此，本研究挑選門診下背痛患者使用診斷性造影作為低價值清單中的研究項目，欲了解下背痛患者使用診斷性造影之趨勢現況，以及影響下背痛患者使用診斷性造影之重要因素。 方法：本研究使用2009年至2015年全人口資料檔隨機抽樣20%後下背痛患者於門急診之就醫資料，研究對象為主診斷下背痛且就醫年齡為20歲以上(含)，首先探討下背痛患者於各年度使用診斷性造影之趨勢，依據Choosing Wisely Campaign提供低價值服務清單中之診斷指引建議，採用Joinpoint regression分析國內下背痛患者使用診斷性造影之現況，後續則合併七年橫斷性資料，並以二元邏輯斯迴歸模型與廣義估計方程式進行統計分析，探討下背痛患者使用低價值診斷性造影之影響因子。 結果：第一部份趨勢分析結果顯示，新發下背痛病患中有345,621位(64.02%)於42日曾使用過至少一次診斷性造影，其中約11%皆屬低價值服務，且低價值診斷性造影使用率則呈現持續增加之利用趨勢，且達統計上顯著(P<0.001)，第二部份則使用二元邏輯斯迴歸與廣義估計方程式分別進行影響因素分析，將病人層級特質作為控制變項後，發現醫師年資、專科別、服務量與執業院所層級別、地區別皆與使用低價值造影具有高度顯著相關(P<.0001)。 結論及建議：2009年至2015年期間顯示下背痛患者使用低價值造影存在持續增加之趨勢，且達統計上顯著差異，而影響醫師提供低價值造影之因素分析結果發現，年資較少、神經外科、服務量高以及執業院所為醫學中心、臺北區之醫師，有較高傾向為下背痛患者開立低價值造影服務。建議政府未來應考量醫師臨床診斷行為與病患就醫習慣，以建置屬於我國合適的低價值清單，並以減少使用低價值服務為目標，以提供民眾能為健康帶來實值效益之服務；也建議未來研究者能夠挑選其他低價值清單項目進行探究，透過質性研究初步探討低價值服務概念與Choosing Wisely Campaign對於醫界之影響。

Background: Beginning in 2012, Choosing Wisely is an effort of the American Board of Internal Medicine (ABIM) Foundation to create based on the specialty societies’ lists of recommendations of tests and treatments that may be unnecessary. Low-value care, which occurs when the benefit of an intervention is deemed too low given its cost and inherent risk. However, little is known regarding untilization of low-value services and physician behavior towards low-value care in Taiwan.

Objective: Since Choosing Wisely recommendations have also been incorporated into clinical ordering processes at some health systems. Our goal was to evaluate changes in low-value services associated with potential factors of physicians in Taiwan, and we narrowed our focus to one of the target recommendations: “Do not order imaging (x-ray, computed tomography, and magnetic resonance imaging) for low back pain within the first six weeks, unless red flags are present.” Methods: Secondary data on all acute low back pain visits was used from the National Health Insurance Database during the study period from 2009 to 2015. Adults who were ages 20 above at the time of visits were included. Our study first access changes in ordering lumbar imaging for low back pain. We also examined differences in response by key physician characteristics. The joinpoint regression was applied to analyze trend by adopting joinpoint models. Binary logistic regression and generalized estimating equations (GEE) model were used to evaluate characteristics of low-value imaging for low back pain. Results: Of the 345,621 imaging occurred within 42 days after the visit, and nearly 10 percent were classified as low-value service. We found there was no decline but steady increase in the trend of low-value imaging rate from 2009 to 2015. We also found scans ordered in the neurosurgery (OR=4.017, P<.0001) were most likely to be classified as low-value imaging compared to orthopedics. Physicians with less clinical experience (P<.0001) and higher surgeon volume (P<.0001) were prone to ordering low-value imaging. The level of teaching hospital (P<.0001) and Taipei branch of NHIA were most likely to provide low-value imaging as well. Conclusions: Our findings highlight the rate of low-value imaging showed constant increase during study period. And the hypothesized physician characteristics were significantly associated with ordering lumbar imaging for low back pain. We suggest particular attention ought to be paid to the importance of low-value services in the future research. Perhaps by increasing awareness of low-value services and Choosing Wisely Campaign may translate into improving physician’s behavior at clinical settings.