臺灣博碩士論文加值系統

研究背景與目的：台灣心臟疾病逐漸躍升為國人十大死因的第三位之時，形成台灣施行經
皮冠狀動脈擴張術（Percutanueous Transluminal Coronary Angioplasty；PTCA）
病例數快速增加，可預見未來施行量將呈現遞增之趨勢，而如何提升醫療品質並控制
醫療利用，成為重要思考議題。國外有關PTCA醫療服務量與醫療療效關係（volume-
outcome）之研究發現高服務量醫院相較於低服務量醫院，其病人有較少的住院死亡率
與當次住院併行冠狀動脈繞道手術（Coronary Artery Bypass Surgery；CABG）率，
但對於再住院率幾乎無文獻探討。在醫療服務量與醫療利用間之相關性也以臨床較多
探討，在國外運用全國性資料庫之研究也多只以醫院服務量探討，本研究運用全國性
樣本探討醫院與醫師服務量多寡和醫療利用及品質之關係。
研究方法：利用1999~2003年國家衛生研究院「全民健康保險學術研究資料庫」之「特定
主題檔之住院醫療費用清單明細檔」，其中主手術（處置）碼為36.01、36.02、
36.05之PTCA手術患者，共79,111位，進一步合併「醫事機構基本資料檔」、「專科
醫師證書主檔」、「醫事人員基本資料檔」。控制病患特質（年齡、性別、合併症嚴
重度）、醫師特質（執業年數）、醫院特質（權屬別、層級別、地區別）後，以
Multivariate linear regression與Multivariate binary logistic regression按手
術量多寡對住院中與手術後醫療利用（住院天數、醫療費用）、品質（住院中死亡、
當次住院併行CABG、14天內因缺血性心臟病再住院）之影響。
研究結果：在控制病患特質、醫院特質與醫師特質後，在醫療利用方面，低服務量醫院之
住院天數（p＝0.00）與醫療費用（p＝0.00）高於高服務量醫院；低服務量醫師之住
院天數（p＝0.00）與醫療費用（p＝0.00）也高於高服務量醫師。在醫療品質方面，
低服務量醫院與高服務量醫院相比，高出1.92倍的住院中死亡（OR=1.92；95％CI=
1.48-2.50），高出3.42倍的當次住院併行CABG（OR=3.42；95％CI = 2.17-
5.40 ）， 高出1.77倍的14天內因缺血性心臟病再住院（OR=1.77；95％CI =1.32-
2.38）；以低服務量醫師與高服務量醫師相比，高出1.96倍的住院中死亡（OR=1.96；
95％CI=1.58–2.42），高出 86倍的當次住院併行CABG（OR=85.97；95％CI= 61.00- 121.16），而14天內因缺血性心臟病再住院在低服務量醫師方面則較不顯著（OR =
1.17；95％CI = 0.88- 1.55）。
結論：依據本研究結果得知，手術量高的醫院與醫師的確能減少醫療耗用與改善醫療品
質。因此建議，台灣心臟科學會評估訂定建議服務量最低標準，以當作減低照護病患
過程中不良結果之結構性指標，每所醫院應由高服務量醫師對於低服務量醫師定時
給予訓練與教學，並由高服務量醫師能從旁指導，提高執行次數，以服務量標準作為
醫院或醫師執行與訓練的目標。

Background ＆ Objective The Cardiovascular Disease (CVD) is No.3 cause of
death in Taiwan, leading the number of PTCA has grown dramatically. It is an important issue that how to enhance medical quality and to control medical utilization. Furthermore, many volume-outcome studies have suggested that hospitals with high volume of PTCA have lower in-hospital mortality and same-stay coronary artery bypass graft (CABG) surgery, but few studies discussed about re-hospitalization. While there is growing evidence in the literature to support hospital volume requirements, but there is little empirical support for physician volume standards. This study examined the relationship between PTCA volume and medical outcomes in Taiwan from 1999 to 2003.
Methods 79,111 PTCA cases (ICD-9-CM code 36.01, 36.02, 36.05) were conducted from National Health Insurance Research Database of the National Health Research Institutes in Taiwan during January 1, 1999 through December 31, 2003. The study employs Descriptive statistics, Multivariate linear regression and Multivariate binary logistic regression to assess the relationship between each of 2 provider volume (hospital volumes and physician volumes) for Percutaneous Transluminal Coronary Angioplasty (PTCA) and 5 medical outcomes (length of stay, hospital charges, in-hospital mortality, same-stay CABG surgery, Re-admission within 14 days).
Results After adjusted, when patients were treated with PTCA in low hospital– volume (<300 procedures) compared with high hospital-volume (≥1000 procedures ) had longer length of stay（p=0.00）and higher hospital charges （p=0.00）, higher in-hospital mortality （OR=1.92；95％CI=1.48-2.50）, higher same-stay CABG（OR=3.42；95％CI = 2.17-5.40）, higher re-admission for IHD within 14 days（OR=1.77；95％CI =1.32-2.38）. On the other hand, when patients were treated with PTCA in low physician-volume (＜40 procedures) compared with high physician- volume (≥150 procedures ) had longer length of stay （p=0.00）and higher hospital charges （p=0.00）, higher in-hospital mortality（OR=1.96；95％CI=1.58-2.42）, higher same-stay CABG（OR=85.97；95％CI=61.00-121.16）. But the re-admission within 14 days did not significantly different（OR=1.17；95％CI=0.88-1.55）.
Conclusions The results showed that high hospital-volume and high physician- volume had better medical outcomes following PTCA. The study suggested the Taiwan Society of Cardiology should establish the minimum volume requirement per year for hospitals and physicians offering PTCA. Further studies should concern about the recent and pending changes in PTCA technology and practice.

目 錄

論文授權書………………………………………………………………………….
論文合格通過證明………………………………………………………………….
誌謝………………………………………………………………………………….
中文摘要…………………………………………………………………………….
英文摘要……………………………………………………………………………. I
II
IV
目錄………………………………………………………………………………….
表目錄………………………………………………………………………………. VI
VII
圖目錄………………………………………………………………………………. VIII
附表目錄……………………………………………………………………………. IX
第一章 緒論
第一節 研究背景與動機…………………………………………………… 1
第二節�研究目的…………………………………………………………… 3
第三節�預期貢獻…………………………………………………………… 4
第四節�名詞解釋…………………………………………………………… 5
第二章 文獻探討
第一節 經皮冠狀動脈擴張術施行演進與概況…………………. ………. 9
第二節 學習曲線在服務量與醫療利用及品質的運用……………………. 11
第三節 醫院、醫師PTCA服務量與醫療利用及品質之相關性研究…….. 16
第四節 PTCA醫療利用與品質影響因子之實證性研究………………….. 20
第三章 研究方法
第一節 研究設計與架構…………………………………………………… 24
第二節 研究假設…………………………………………………………… 26
第三節 研究材料……………………………………………………………. 27
第四節 研究變項及操作型定義…………………………………………… 29
第五節 研究資料處理與統計分析方法…………………………………… 33
第四章 研究結果
第一節 1999~2003年研究樣本基本資料描述…………………………….. 35
第二節 1999~2003年施行PTCA醫療利用及品質分佈概況…………….. 39
第三節�各手術量醫院及醫師其病患特質、醫院特質、醫師特質描述…… 51
第四節�醫院與醫師手術量對醫療利用及品質的影響……………………. 57
第五章 討論與建議
第一節 基本特質資料討論…………………………………………………. 68
第二節 研究目的、假說與結果之討論…………………………………… 71
第三節 研究限制與未來研究方向…………………………………………. 78
第四節 結論與建議…………………………………………………………. 81
參考文獻
中文部分………………………………………………………………………. 82
英文部分………………………………………………………………………. 83
表目錄

表2-1 OECD國家冠狀動脈成形術手術率………………………………………… 10
表2-2 美國健康照護機構醫療處置與醫院服務量建議表………………………... 13
表2-3 國外疾病與手術方面之服務量與醫療結果相關文獻……………………... 14
表2-4 國內學者關於服務量與醫療結果間之相關研究…………………………... 15
表2-5 PTCA之服務量與醫療品質、醫療耗用相關文獻結果……………………... 18
表2-6 影響PTCA醫療利用與術後醫療品質因子之相關文獻統整……………… 23
表3-1 Charlson合併症權重與Romano等（1993）診斷碼定義表………………….. 32
表4-1 1999~2003年台灣地區執行PTCA之病人特性……. ……………………… 36
表4-2 1999~2003年台灣地區執行PTCA之醫院與醫師特性…………………….. 37
表4-3 1999~2003年台灣地區執行PTCA病患醫療利用與品質分佈……………. 38
表4-4 1999~2003年台灣地區執行PTCA之病患住院天數情形……. …………… 40
表4-5 1999~2003年台灣地區執行PTCA之病患醫療費用情形……. …………… 41
表4-6 1999~2003年台灣地區執行PTCA之病患住院中死亡率情形……. ……… 42
表4-7 1999~2003年台灣地區執行PTCA之病患當次住院併行CABG率情形…. 43
表4-8 1999~2003年台灣地區執行PTCA之病患14天內因IHD再住院率情形… 44
表4-9 1999~2003年台灣地區執行PTCA之病患手術醫院與醫師住院天數情形 47
表4-10 1999~2003年台灣地區執行PTCA之病患手術醫院與醫師醫療費用情形 48
表4-11 1999~2003年台灣地區執行PTCA之病患手術醫院與醫師住院中死亡率情形…………………………………………………………………………...
49
表4-12 1999~2003年台灣地區執行PTCA之病患手術醫院與醫師當次住院併行CABG率情形…………………………………………………………………
49
表4-13 1999~2003年台灣地區執行PTCA之病患手術醫院與醫師14天內因IHD再住院率情形………………………………………………………………...
50
表4-14 1999~2003年醫院與醫師執行PTCA手術量之分佈……………………….. 51
表4-15 各執行PTCA手術量醫院與醫師之病患基本特質………………………… 53
表4-16 各執行PTCA手術量醫院與醫師之特質…………………………………… 54
表4-17 各執行PTCA手術量醫院與醫師之醫療利用與醫療品質狀況…………… 55
表4-18 本研究之自變項間相關性…………………………………………………... 57
表4-19 本研究住院天數與依變項間之相關性……………………………………... 57
表4-20 醫院與醫師手術量對住院天數之影響分析………………………………... 59
表4-21 醫院與醫師手術量對醫療費用之影響分析………………………………... 61
表4-22 醫院與醫師手術量對住院中死亡之影響分析……………………………... 63
表4-23 醫院與醫師手術量對當次住院併行CABG之影響分析…………………... 65
表4-24 醫院與醫師手術量對14天內因IHD再住院之影響分析………………….. 67
表5-1 研究目的、假說與研究結果對照表………………………………………... 71
表5-2 施行PTCA病患醫療利用之顯著影響因子………………………………... 76
表5-3 施行PTCA病患醫療品質之顯著影響因子………………………………... 77
圖目錄

圖2-1 醫療產業學習流程圖……………………………………………………… 12
圖3-1 本研究架構………………………………………………………………… 25
圖3-2 研究對象選取與刪除步驟流程圖………………………………………… 28
圖3-3 串取檔案變項圖…………………………………………………………… 33
圖4-1 1999~2003年台灣施行PTCA手術量之成長變化……………………… 35
圖4-2 醫院與醫師執行PTCA手術量分佈圖…………………………………… 52
圖 4-3 醫師服務量於醫院服務量所佔百分比…………………………………… 52
圖4-4 1999~2003年台灣PTCA醫院手術量其醫費利用之變化………………. 55
圖4-5 1999~2003年台灣PTCA醫院手術量其醫費利用之變化………………. 56
圖4-6 1999~2003年台灣PTCA醫院手術量其醫療品質之變化………………. 56
圖4-7 1999~2003年台灣PTCA醫師手術量其醫療品質之變化………………. 56











附表目錄

附表1 醫院與醫師手術量對住院天數（未取對數校正）之影響分析…………… 89
附表2 醫院與醫師手術量對醫療費用（未取對數校正）之影響分析…………… 90
附表3 PTCA論病例計酬其「得核實申報上限金額」、「得核實申報個案數比率」 91
附表4 PTCA診療項目與支付醫院層級點數……………………………………… 92
附表5 PTCA項目之國際疾病臨床分類修正代碼………………………………… 93
附表6 PTCA（未裝血管支架），無主要合併症或併發症(住院）診療項目要求表 94

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