慢性病初級照護品質與疾病負擔相關性的OECD跨國比較研究

Abstract

研究背景與目的：慢性病為影響健康的主要原因，發生率高，且造成死亡、失能的比例高。各國需要制訂和實施適當的健康政策提升慢性病照護品質，以降低不斷上升的疾病負擔和照護費用。然而尚未有研究探討慢性病初級照護（primary care）品質的改變與疾病負擔改變之間是否存在相關。此外，過去研究發現醫療支出、醫療可近性、醫療資源和其他社會因素也可能影響疾病負擔。究竟照護品質的改善與疾病負擔之間有無顯著相關，和其他照護/非照護因素是否會影響前兩者的關係，是本研究欲釐清之問題。因此本研究欲以OECD Health statistics中的醫療照護品質指標，結合台灣的可避免住院率資料，以及IHME Global Burden of Disease中的疾病負擔和Disease risk factor資料，以國家為單位探討特定疾病的照護品質和疾病負擔之間有無關聯，且探討在OECD的醫療品質架構下，哪些構面因素對疾病負擔的影響更大。 材料與方法：本研究為回溯型跨國比較研究，採用OECD Health statistics中的醫療照護品質指標、台灣健保資料庫對應疾病可避免住院率，以及IHME Global Burden of Disease中的疾病負擔資料，研究疾病包括氣喘、慢性阻塞性肺病(COPD)、心臟衰竭、糖尿病、高血壓，先以描述性分析查看不同年份和不同疾病別照護品質和疾病負擔的變化趨勢、平均數、極端值，接下來以fixed-effects regression model進行分析，以驗證照護品質指標的改變是否與疾病負擔改變有關；最後分別控制照護可近性、醫療支出、醫療資源、醫療利用率和其他社會因素之後，探討醫療體系特質對照護品質和疾病負擔的影響。 研究結果：總體上，2009-2019年五種疾病住院率均呈下降的趨勢，即初級健康照護品質有改善的趨勢。疾病負擔中，氣喘、COPD、心臟衰竭的DALY(失能調整生命年)和YLL(生命損失年)都呈下降的趨勢，糖尿病和高血壓的DALY和YLL則沒有顯著變化趨勢。雙變量分析中，氣喘、COPD、糖尿病住院率和YLL呈顯著正相關，心臟衰竭和高血壓則沒有顯著相關；COPD住院率和DALY也呈顯著正相關，但糖尿病住院率與DALY呈負相關。氣喘、COPD住院率和YLL之間的正相關在加入控制變項後仍顯著，但氣喘住院率與DALY的相關性不顯著，心臟衰竭和高血壓住院率與疾病負擔相關性皆不顯著，糖尿病住院率與DALY顯著負相關，但在YLL中相關性不顯著。不同構面的控制變項均會對不同疾病照護品質和疾病負擔產生影響，健康支出與疾病負擔的相關性在五種疾病均顯著，醫療資源在五種疾病均與疾病負擔呈負相關，醫療利用率、貧窮率與部分疾病負擔呈負相關，IHME disease risk factors與疾病負擔正相關，其餘變項則未達統計顯著（P>0.05 in fixed-effects regression analyses）。 結論：在OECD primary care quality index測量的五種慢性病中，氣喘、COPD住院率與疾病負擔之間有顯著正相關，且相關性在控制其他變項之後依然保持顯著。初級醫療照護品質改善與特定疾病負擔改變相關，醫療支出、醫療資源、醫療利用率和IHME disease risk factors對照護品質和疾病負擔之間的關係均有影響。

Background: Organization for Economic Cooperation and Development (OECD) countries introduced and dedicated to perfecting their Health indicators in order to measure health care quality and improve health system performance during the past decades. Few studies have tried to assess the contributions of health care quality improvement to reducing specific disease burden for OECD countries. This study seeks to examine the significance of primary care quality and various health system factors influencing to the burden of chronic diseases for the 2009-2019 period. More specifically, the associations between disease burden and independent factors attributable to health system performance are measured and evaluated. Methods: This was a pooled cross-sectional, secondary panel data analysis. Data were derived from OECD health statistics, a public-use database. Primary care quality was one of the sets of OECD health care quality indicators, including hospital admission (age-sex standardized rate per 100 000 population) for Asthma, COPD, Congestive heart failure, Diabetes and Hypertension. Additional explanatory variables were introduced in different model specifications to test the robustness of the results. There were health expenditure, health care access, health care resource, health care utilization and social factors in each disease-model to study the potential role of health care quality to burden of diseases in OECD countries. A fixed-effects regression model was used to assess the influence of primary care quality to disease burden. Principle Findings: Hospital admission rates of all diseases were reduced during 2009-2019 period in most of the study countries. Burden of diseases were reduced in Asthma, COPD, and Congestive heart failure, while remaining stable in Diabetes and Hypertension. COPD hospital admission rate was significantly associated with higher COPD DALY and YLL. This relationship was significant, even while controlling for all of the adjustments. Asthma hospital admission rate was significantly associated with higher asthma YLL, whereas it is not significant between asthma hospital admission rate and DALY. The hospital admission rate was negatively associated with Diabetes DALY, even though it turned insignificant in YLL. Congestive heart failure and Hypertension hospital admission rate were not significantly associated with their burden of diseases. Health expenditure, health care resource, and sometimes, health care utilization and poverty rate were negatively associated with disease burden in specific diseases. Conclusions: Better primary care quality and health system performance such as health expenditure, health care resource, and health care utilization were associated with reduced disease burden. Despite all the adjustment factors, few kinds of disease burden can be attributed to their primary care quality in OECD health statistics as assessed by this study.