影響台灣尿路結石治療品質與醫療支出相關因素之探討

Abstract

全民健保實施後，醫療支出年年增加，而高科技醫療的使用成為醫療費用上漲的主要原因。尿路結石在台灣，是高盛行率的疾病，但其疾病的就醫情況與醫療支出，卻少有研究。而體外震波碎石術是結石治療中，醫療支付點值最高的，健保署也在1999年針對體外震波碎石術加以專案審查及設限，希望能減少體外震波碎石術的浮濫使用，但其對於能否控制醫療支出的成效仍有待評估。此外，經皮腎造廔碎石術常用以治療大型或困難的腎結石，是一需麻醉及住院的侵入性治療，會有出血及感染等併發症，甚至死亡的風險。在考慮結石治療的成本時，除了醫療上的支出及花費，也會有因休養及無法工作造成的損失等無形的成本。此類侵入性治療的醫療照護品質特別需要減少併發症，減短住院天數，以降低醫療支出。 本研究利用全民健康保險醫療統計及全民健康保險資料庫2005年百萬抽樣歸人檔，探討泌尿道結石就醫情形與醫療花費。並研究體外震波碎石術1997 至 2004的醫療利用情況，探討體外震波碎石術專案審查政策實施，對體外震波碎石術合理利用及降低其使用次數與花費的成效。本研究也探討採用經皮腎造廔取石術的病患，在出院後3日內到急診或14天內再次入院的相關因子。 研究結果有三項發現： 第一部分：1997-2010年台灣尿路結石每10萬人口就醫率及醫療支出趨勢。 每10萬人的尿路結石醫療就診率從1998年的1,532人增加到2010年的1,627人，增長了6.2％。同樣，尿路結石的醫療費用從1998年的29億5千7百萬元增加到2010年的42億4千8百萬元，增長了43.7％，兩者均呈逐年增加的結果。 第二部分：健保對於體外震波碎石術的管控措施，是否能降低結石治療 的醫療費？ 在1997 年至 2004 年間，體外震波碎石術醫療利用 除了在 1998 年至 2000 年間，體外震波碎石的使用次數從1998的 77847下降到2000 年55381次，有下降之外，自2000年起，從55381上升至 2004 年71415次，使用次數有逐年上升的趨勢。 第三部分：研究接受經皮腎造廔取石術的病患，分析影響其術後3天內到急診，14天內再入院的相關因素。 1997年至2010年期間，有995例腎結石患者接受了經皮造廔取石術。在38例（3.8％）受試者中觀察到經皮腎造廔取石術後3天內急診就診，68例（6.8％）受試者14天內再次入院率。出院後3 天內到急診與住院中血尿需進一步醫療處置，共病疾病嚴重度及醫師年平均手術量顯著相關。而出院後14天內再入院與病人年齡住院中敗血症、泌尿道感染、手術部位感染、血尿需進一步醫療處置及出院內三天內到急診及地區醫院接受手術顯著相關。 台灣的健保署須考慮醫療資源的合理分配、政策的成本與效果，及改善醫療品質以降低醫療費用。本研究的結果對此提供了重要的資訊，我們期望經由本土的研究以提供健康保險主管機關、醫院管理者及病患能據此做出最好的醫療決策的參考。

Following the implementation of National Health Insurance (NHI), the medical expenditure rose rapidly, Urolithiasis is a prevalent disease in Taiwan. However, studies on the prevalence and medical expenditure of urolithiasis in Taiwan is scarce. Additionally, high-tech medical devices have become one of the main factors causing an increase in health care expenditure. Extracorporeal shock wave lithotripsy (ESWL) served as the most commonly adopted and the highest payment unit in medical equipment usage for treatment of urolithiasis. The utilities of ESWL in Taiwan increased rapidly after the implementation of Taiwan’s NHI. The authorities issued NHI payment guideline and utilization review policy on ESWL in 1999. The effectiveness of the regulation policy on the reasonable usage of ESWL should be evaluated. Moreover, percutaneous nephrolithotomy (PCNL) has been commonly used for treatment of complicated and large renal stone. PCNL is an invasive procedure with potential risks of complications and mortalities Weeks of convalescence period and loss of work absence in inevitable for patients receiving PCNL. To identify factors associated with medical care quality to improve patient safety and lower medical cost is an important issue. This study used a subset of the Taiwan National Health Insurance Research Database (NHIRD) known as Longitudinal Health Insurance Database 2005 (LHID2005), which contains the data of all medical benefit claims 1998-2010 for a subset of 1,000,000 enrollees randomly drawn from the population of 22.72 million individuals who were enrolled in 2005. The results of the study are divided into three parts as follows: Part I. We analyzed medical utilities and costs for management of urolithiasis in Taiwan, 1998-2010. Our results showed tract there were significantly rising trends in the annual medical visits and costs for stone disease. The rate of medical care visits increased by 6.2%, from 1,532 in 1998 to 1,627 in 2010 per 100,000 subjects (r2=0.25; p=0.050). Similarly, the medical cost increased by 43.7%, from $101.9 million dollars in 2000 to $133.8 million dollars in 2010 (r2=0.63; p=0.001). There were rising trends in both medical utilization and costs for stone disease during the period. Part II. We investigated the efficacy of the regulation policy on the reasonable usage of ESWL. The growing rate of average utilization of ESWL per thousand people from 1997 to 2004 is 6.588%. The average utilization of ESWL is 1.466 times per person. The regulation and utilization review policy elicited short-term and transient effect on decreasing ESWL utilization. Part III. We examined factors associated with two quality indices of medical care and medical expense, including emergency room visit within 3 days after discharge and rehospitalization within 14 days after discharge. A total of 995 cases receiving PCNL. Among them, 38（3.8％）experienced emergency room visit within three days after discharge and 68（6.8％）needed re-hospitalization within 14 days after discharge. Factors associated with emergency room visit included hematuria needed additional therapeutic procedures and higher Charlson comorbidity index and surgeon caseload volume. Factors associated with rehospitalization included sepsis, urinary tract infection, surgical site infection, hematuria needed other therapeutic procedures and emergency room visit within three days and treatment at district hospital. In conclusion, our study indicated the increasing trends in medical utilization and costs of urolithiasis in Taiwan. The utilization review policy provided short-term and transient effect on decreasing the utilization of ESWL. To decrease emergency room visit or rehospitalization after discharge, care-provider should consider to transfer high-risk patients with severe comorbidities to high-volume surgeon and hospital of higher level. Our study provides important information for policy making and clinical practice to reduce medical expenses and improve quality of care.