新論質計酬方案對於急性心肌梗塞接受介入性心導管治療之照護過程及照護結果影響

Abstract

研究背景：為加強急重症之醫療照護，衛生福利部中央健康保險署自2012年5月起實施全民健康保險急診品質提升方案，期透過財務誘因以提升急性心肌梗塞照護品質，該方案自2019年2月起調升急性心肌梗塞照護獎勵由2,000點至6,000點。台灣僅有一篇研究探討急診品質提升方案介入之成效，且結論發現對於急診急性心肌梗塞接受介入性心導管(percutaneous coronary intervention, PCI)治療病人醫療費用及照護結果於研究期間影響可能沒有影響。 研究目的：本研究評估提升急診品質提升方案照護獎勵調升後，對於急性心肌梗塞病人接受介入性心導管照護過程、醫療費用及照護結果影響。 研究方法：本研究使用全民健康保險研究資料庫，選取2016年至2023年資料，主診斷為急性心肌梗塞病人，控制人口特質、醫療機構特質及時間趨勢，利用分段廣義估計方程式(Segmented Generalized estimating equation, GEE)羅吉斯迴歸模式，探討新品質提升方案之照護獎勵調升，對於病人30天內全因死亡、住院死亡及到院90分鐘內接受PCI治療之影響，並以線性模式探討整體醫療費用之影響。 研究結果：全民健康保險急診品質提升方案之急性心肌梗塞照護獎勵提升，對於急診急性心肌梗塞且接受介入性心導管治療之病人住院期間醫療費用、到院90分鐘內接受PCI治療、30天全因死亡及住院死亡均無影響。 結論：提升全民健康保險急診品質提升方案之急性心肌梗塞照護獎勵誘因，對於急診急性心肌梗塞且接受介入性心導管治療病人之照護過程、醫療費用及照護結果可能沒有影響。

Background: To strengthen the quality of care for acute and critical illnesses, the National Health Insurance Administration (NHIA) of the Ministry of Health and Welfare in Taiwan launched the Emergency Department Pay-for-Performance Program (P4P) in May 2012. This initiative aimed to improve the quality of care for acute myocardial infarction (AMI) patients through financial incentives. In February 2019, the reward for AMI care was increased from 2,000 to 6,000 points. To date, only one study in Taiwan has evaluated the impact of the Emergency P4P, with findings suggesting that the program may not have significantly affected medical costs or care outcomes for AMI patients undergoing percutaneous coronary intervention (PCI) during the study period. Objective: This study aims to evaluate the impact of the Emergency P4P on the care processes, medical cost, and outcomes for AMI patients, with a specific focus on the effect of enhanced incentives on patients undergoing PCI. Methods: This study utilized data from the National Health Insurance Research Database (NHIRD), covering the period from 2016 to 2023 for patients primarily diagnosed with acute myocardial infarction. A segmented generalized estimating equation (GEE) model was employed, adjusting for patient demographics, hospital characteristics, and time trends, to evaluate the impact of P4P reward adjustments and subsequent trends on patient outcomes. Specifically, the analysis focused on 30-day all-cause mortality, in-hospital mortality, and the probability of receiving PCI within 90 minutes of arrival using logistic regression, while a linear model was applied to assess the impact on overall medical costs. Results: The enhancement of reward incentives under the Emergency Department P4P Program for acute myocardial infarction care was not significantly associated with differences in in-hospital medical costs, the likelihood of receiving PCI within 90 minutes of arrival, 30-day all-cause mortality, or in-hospital mortality among AMI patients undergoing PCI. Conclusion: Increasing the reward incentives under the Emergency P4P for AMI care may not significantly influence the care processes, outcomes, or medical costs for AMI patients undergoing PCI. The findings suggest that the impact of the P4P on the quality of care, outcomes, and medical costs for these patients may be limited.