臺灣博碩士論文加值系統

本研究係以國家衛生研究院之全民健康保險研究資料庫所收錄的行政性資料為樣本來源,做一縱貫性且全國性的研究.目的係在探討中央健保局自1999年七月開始針對部分心臟冠狀動脈繞道手術實施按病例計酬之後,國內各醫院對於這一單項手術的費用效益以及利潤關係,並藉以分析其與醫院結構面與手術結果面的關聯.
本研究對象為民國88 年7 月至96 年6 月共8 年間,全台灣地區醫院向健保局申報冠狀動脈繞道手術按病例計酬之案件共15,449件,經資料收集後以SPSS 16.0 for windows 套裝軟體進行描述性及推論性分析比較.我們採用一般線性模式探討和分析每位醫師的平均手術利潤比和醫師個人手術量,醫師執行手術時之年齡,病患年齡,病患性別,病患住院日數, 病患出院後七日內再住院以及醫院權屬,醫院評鑑等級和醫院所屬健保局分局等變項之關聯;並以二元羅吉斯迴歸預測病患出院後七日內再住院與上述變項之機率.
研究結果發現手數量介於150到300例的醫師和年齡長於60歲的醫師具有最低的平均手術利潤比（即其病患住院費用總和平均最低）,位於健保局北區分局轄區的醫院和公立醫院在所有醫院間有最低的平均手術利潤比.較常住院日以及出院後七日內再住院都提升平均手術利潤比.私立醫院醫學中心及低病患年齡均預測較低的七日內再住院機率.
本文是第一次以國內心臟冠狀動脈繞道手術實施按病例計酬的病例為研究對象探討費用效益的研究,在按病例計酬制即將完成階段性使命並代以全面性實施台灣版的診斷關聯群支付制度之際, 期望能透過本研究的結果提供執行診斷關聯群支付制度的實證參考.

This longitudinal, population-based, nation-wide study collected 15,449 patients who had received coronary artery bypass grafting (CABG) surgery during an eight-year and half period by 281 surgeons in Taiwan. The samples are drawn from the National Health Insurance Research Database (NHIRD). All cases share the same character of being reimbursed by National Health Insurance Bureau (NHIB) under the case-payment category implemented ever since July of 1999.
Using this administrative data, we investigated the cost-efficiency of all hospitals and surgeons undergoing CABG of this category and analyzed the associations between it and cumulative surgeon volume in addition to other parameters of hospitals and patients. “Cost” in this study specifically indicates “charge” of hospitalization. We take mean profit ratio as indicator of cost-efficiency; a lower ratio implies a higher efficiency.
General linear model (GLM) was used to explore associations between profit ratio per case and surgeon case volume (volume groups: One to 50, 51to 100, 101 to 150, 151 to 300 and >300), hospital ownership, accreditation status, geographic region; surgeon age, length of hospital stay and 7-day readmission. Data were statistically analyzed using SPSS 16.0 for Windows (SPSS Inc. Chicago, Illinois).
Results demonstrated surgeons performing cases between 151 to 300 and surgeons aged older than sixty have the lowest profit ratio among colleagues. Hospitals in northern area or public held performed best/better than their counterpart(s). Longer length of stay and readmission within a week after first discharge all brought profit ratio up. Private hospital, academic medical center and younger patient age predicted lower 7-day readmission possibility.
This is the first study focusing on cost-efficiency and associated surgical outcomes of CABG reimbursed by case-payment mechanism. This transitional payment system is to pass down the mission to a more continent Tw-DRGs in near future. Our study might act as a pilot for more precisely defining the implementation of Tw-DRGs.

Table of Contents

Research purpose and background ------------------------------------------------------ 1
Review of literatures
Improvement of medical and surgical quality -------------------------------------------- 2
Diagnosis-Related Group (DRG) and Case-Payment systems ------------------------- 6
Case-payment in Taiwan and quality improvement ----------------------------------- 8
Methods
Material -------------------------------------------------------------------------------------- 11
Variables ------------------------------------------------------------------------------------- 12
Statistics -------------------------------------------------------------------------------------- 19
Results
Descriptive statistics -------------------------------------------------------------------------21
One-way ANOVA --------------------------------------------------------------------------- 34
General linear model ------------------------------------------------------------------------ 38
Binary logistic regression of 7-day readmission -----------------------------------------40
Discussion --------------------------------------------------------------------------------------- 42
Study limitation -------------------------------------------------------------------------------- 61
Conclusion --------------------------------------------------------------------------------------- 63
Reference ----------------------------------------------------------------------------------------- 65
List of Figures
Figure 1. Frequency of surgical volume of all surgeons --------------------------------------23
Figure 2. Length of hospital stay and patient age/sex ---------------------------------------- 27
Figure 3. Association between length of hospital stay (LOS) and surgeon volume ------ 28
Figure 4. Length of stay and surgeon age ------------------------------------------------------ 29
Figure 5. Patient age/sex in relation to mean profit ratio -------------------------------------31
Figure 6. The Association between Profit Ratio and Surgeon Volume ---------------------32
Figure 7. The association between mean profit ratio and surgeon volume ---------------- 32
Figure 8. Association between surgeon age and their mean profit ratio ------------------- 33
Figure 9. Association between profit ratio and hospital accreditation level --------------- 33
Figure 10. Mean profit ratio by different NHIB branches ------------------------------------ 34
Figure 11. Average daily ward fee of our patients --------------------------------------------- 47
Figure 12. Statistics of average percentage of ward fee to the total hospital cost --------- 47
Figure 13. Distribution of surgeons with volume >300 by hospital accreditation level--- 54
Figure 14. Distribution of surgeons with volume between 151-300 by hospital
accreditation level ------------------------------------------------------------------- 54
Figure 15. Radar chart showing younger surgeons predominance in hospitals
managed by northern and southern branches of NHIB -----------------------------60












List of Tables
Table 1. Public hospitals in Taiwan, yearly numbers ----------------------------------------- 14
Table 2. Private hospitals in Taiwan, yearly numbers ---------------------------------------- 15
Table 3. Number of hospitals by accreditation level and NHIB branches in Taiwan ----- 16
Table 4. History of RVUs adjustment for CABG reimbursed by case-payment ---------- 17
Table 5.History of RVUs adjustment for CABG operation and ECC fee based on FFS - 18
Table 6. Sex, age distribution and yearly number of patients -------------------------------- 21
Table 7. Patient number by hospital accreditation level, ownership and NHIB branch -- 22
Table 8. Number of surgeons by different surgical volume groups ------------------------- 24
Table 9. Detailed case numbers for surgeons performed for less than 51 cases ----------- 24
Table 10. Number and percentage of patients associated with hospitals accreditation
level and each surgeon volume ------------------------------------------------------- 25
Table 11. Number and percentage of patients of each surgeon volume group
in different hospital accreditation level ---------------------------------------------- 25
Table 12. Patient number versus surgeon volume and age ------------------------------------ 26
Table 13. Length of hospital stay ----------------------------------------------------------------- 26
Table 14. Distribution of various LOS of different hospital accreditation level ------------ 28
Table 15 Seven-day readmission rate among different surgeon volume groups ------------ 30
Table 16. Statistics of profit ratio of our samples ----------------------------------------------- 30
Table 17. One-way ANOVA of surgeon volume and mean profit ratio --------------------- 35
Table 18. One-way ANOVA of surgeon age and mean profit ratio -------------------------- 35
Table 19. One-way ANOVA of patient sex/age and profit ratio ------------------------------ 35
Table 20. Mean profit ratio of patients operated in different hospitals ----------------------- 36
Table 21. Mean profit ratio of patients operated in hospitals governed
under different NHIB branches -------------------------------------------------------- 36
Table 22. Mean profit ratio associated with various length of hospital stay ----------------- 37
Table 23. LOS and surgeon volume --------------------------------------------------------------- 37
Table 24. LOS and hospital accreditation level -------------------------------------------------- 38
Table 25. ANOVA and logistic regression for 7-day readmission and mean profit ratio -- 38
Table 26. General linear modeling results of mean profit ratio for different
surgeon volume --------------------------------------------------------------------------- 40
Table 27. Binary logistic regression of seven-day readmission -------------------------------- 41
Table 28. The payment standards for patients stay at ICU and general ward ---------------- 46
Table 29. Average fees charged during admission for each different duration
of hospital stay ------------------------------------------------------------------------------ 49
Table 30. Cross-tabulation between surgeon volume and hospital accreditation level ------ 53
Table 31. Accreditation levels of major public and private (for- and not-for profit)
hospitals inTaiwan ------------------------------------------------------------------------ 58
Table 32. Number and percentage of patients operated by surgeons of different age
in each NHIB branch----------------------------------------------------------------------- 59

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