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研究生:林雍凱
研究生(外文):Yung-Kai Lin
論文名稱:冠狀動脈繞道手術臨床路徑實施之成本效果分析–以台灣某醫學中心心臟血管科經驗為例
論文名稱(外文):The Cost-Effectiveness of Clinical Pathway in Coronary Artery Bypass – Experience of Cardiovascular Department in One Medical Center in Taiwan
指導教授:陳家彬陳家彬引用關係
學位類別:碩士
校院名稱:國立中興大學
系所名稱:高階經理人碩士在職專班
學門:商業及管理學門
學類:其他商業及管理學類
論文種類:學術論文
論文出版年:2008
畢業學年度:96
語文別:英文
論文頁數:44
中文關鍵詞:臨床路徑成本效果冠狀動脈繞道手術照護成本照護品質
外文關鍵詞:clinical pathwaycost-effectivenesscoronary artery bypass surgerycare costscare quality
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研究背景:臨床路徑 (Clinical Pathway, CP) 是一種包含不同領域的綜合計畫,其目的是在計畫性的時間內讓病患能得到良好醫療品質的有效治療。臨床路徑的成效深受路徑的發展與執行過程影響,在過去的許多文獻報告中指出,臨床路徑可以使治療在住院天數、住院費用、醫療資源利用與醫療品質達到效益;然而,這些報告僅有少數是關於冠狀動脈繞道手術的研究,因此,本研究以台灣地區某一醫學中心之冠狀動脈繞道手術病患為樣本,探討臨床路徑對於該疾病治療之影響,以期找出最佳的疾病治療方針,同時兼顧經濟效益。
研究方法:這是一份針對 212 位在台灣中部某醫學中心接受冠狀動脈繞道手術病患的回溯性研究報告,研究中收集病患的年紀、性別、EuroScore 疾病嚴重度及手術方式等控制因素資料,以及臨床路徑實施有無下,病患之醫療費用,包括病房費用、治療費、手術費、麻醉費、檢查費、輸血費用等,以及手術後併發症發生率之資料。並以描述性統計、單變量(包括Wilcoxon W, ANOVA),以及多變量複回歸進行統計分析。
研究結果:本研究在成本費用分析方面發現,臨床路徑實施在傳統人工心肺機使用的冠狀動脈繞道手術病患上,其所有細項成本與總成本支出方面,與未進入臨床路徑的病患,並未有統計上的差異存在。臨床路徑實施在心臟不停跳手術的冠狀動脈繞道手術病患方面,其檢查費用、手術相關費用,以及藥物相關費用等,均較未進入臨床路徑治療的病患為高;然放射線檢查與手術特殊材料花費,則較未進入臨床路徑治療的病患費用為低。臨床路徑實施在合併機器人手臂輔助的心臟不停跳手術病患方面,其手術及麻醉費用,比未進入臨床路徑治療的病患費用為高;但血液血漿費用支出,則較未進入臨床路徑治療的病患為低。整體成本費用而言,臨床路徑實施在心臟不停跳手術的冠狀動脈繞道手術病患,與未進入臨床路徑治療的病患,其總成本費用並無統計上顯著的差異。本研究亦發現,心臟不停跳手術的冠狀動脈繞道手術病患的手術後一般病房住院天數,與其診察費用、病房費用、檢查費用、治療費用、復健費用,以及藥物相關費用方面,均呈現統計的正相關。而病患進入冠狀動脈繞道手術臨床路徑與否,與其手術後併發症發生率,並無統計上顯著的相關性。
研究結論:本研究顯示進入冠狀動脈繞道手術的病患,在醫療費用細項及總成本方面,與未進入臨床路徑病患相較下,並無統一的正向或負向相關性;而術後併發症,病患有無進入臨床路徑,亦無明顯差異。另外,本研究發現住院費用與術後病房住院天數有強烈正相關,是對於成本控制的一個重要訊息。雖然本研究發現個案醫院實施冠狀動脈繞道手術的臨床路徑,並無太大的成本效果呈現,然本研究過程及結果,可以提供個案機構在未來修正及實施臨床路徑內容方面的改善依據。
Background. Clinical pathway (CP) contains multidisciplinary plans that outline the sequence and timing of actions necessary to achieve expected patient outcomes with optimal efficiency. The impact of clinical pathways is greatly influenced by the pathway development and implementation process. Previous studies have raised various effectiveness of the implementation of clinical pathways, including hospital length of stay, care costs, resource utilization, and quality of care. However, few studies have been devoted to the exploration of the effect of clinical pathways on coronary artery diseases treated with coronary artery bypass surgery.
Study Purposes. This study was aimed to investigate the cost-effectiveness of the implementation of the clinical pathway on coronary artery bypass surgery in one medical center of the central Taiwan. It was expected to stimulate researches to establish best practice and advance the care of patients with coronary artery disease under coronary artery bypass surgery.
Study Methods. This is a retrospective study with secondary datasets as data sources. Two hundred and twelve CAB surgery patients were included in this study. The cost measurements for CAB surgery patients included costs of visiting, wards, examinations, radiology, operation, anesthesia, specific medical materials of operations, blood transfusion, medication, and so on. The post-operative complication occurrence, the number of graft bypass, and length of postoperative stays, were traced. Patient demographics such as age and gender, and patient surgical risk indicator, EuroSCORE, were also collected. Descriptive, Wilcoxon W, ANOVA, and multiple regression analyses were performed.
Study Results. Cost analyses revealed that there was no statistically differences of costs in heart arrest CAB surgery patients with vs. without enrolled clinical pathways. And non-robotic beating heart CAG surgery patients with enrolled clinical pathways had higher costs of examination, surgery operation, and medication-related costs; and had lower costs of radiology and special medical materials than did beating heart CAG surgery patients without enrolled clinical pathways. And robotic beating heart CAG surgery patients with enrolled clinical pathways had higher costs of surgery operation and anesthesia; and had lower blood transfusion costs than did beating heart CAG surgery patients without enrolled clinical pathways. However, there was no statistical difference in total costs of beating heart CAG surgery patients with and without enrolled into clinical pathways. In addition, it was found that length of ordinary ward stays were positively related to the costs of heart beating CAB surgery patients in the cost items of visiting, wards, examination, treatment, rehabilitation, and medication. However, it was found that there was no significant difference of complication occurrence in CAB surgery patients with and without enrolled into clinical pathways.
Study conclusions. In this study, it was found that there was not much cost differentiation and no postoperative complication difference existing in CAG surgery patients enrolled into clinical pathways. The length of ordinary ward stay was identified in this study as a positive indicator in predicating the cost of the CAB surgery. The implemented clinical pathways in the studied medical center seem not to be shown cost-effectiveness in CAB surgeries and it provides an opportunity to re-evaluate the existing clinical pathways.
Contents

Introduction 1
Previous Studies in Effectiveness of Clinical Pathways for Surgeries 3
Background of Implementation of the Clinical Pathway of Coronary Artery Bypass Surgery in the Studied Medical Center 5
Methods
Study patient subjects 9
Measurements 10
Data collection 10
Statistical techniques 10
Results 12
Cost analysis for heart arrest CAG surgery patients 12
Cost analysis for beating heart CAG surgery patients 13
Postoperative complication analysis for CAG surgery patients 13
Discussion 16
Conclusion 20
Tables 21
Appendix 29
Reference 33
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