自主事前審查對醫療品質及醫療費用之影響 —以全膝關節置換術為例

自主事前審查對醫療品質及醫療費用之影響

—以全膝關節置換術為例

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，使用複迴歸分析來檢定影響全膝關節置換術相關因素。

研究結果顯示，實驗組在自主事前審查試辦作業實施後，其全膝關節置換術病患的平均 住院醫療費用顯著地減少。而 DID 分析結果則顯示，自主事前審查制度實施後，實驗 組與對照組醫院的全膝關節置換術病患之住院醫療費用均顯著地減少，但對照組醫院病 患的住院醫療費用比實驗組醫院病患顯著地減少。在醫療品質方面，實驗組醫院在試辦 作業實施後的病患出院後 30 天內再住院之機率較實施前為低。本研究發現，疾病嚴重 度、醫院評鑑等級、醫院年手術量、醫師手術量及專科年資等是病患住院醫療費用的預 測因素。依據本研究的研究發現，茲對健保局提出下列建議： 1. 健保局仍應持續監測 試辦醫院之全膝關節置換術病患的醫療品質； 2. 試辦醫院的病患住院費用比未參與試 辦醫院較高之原因應詳加探討，以做為未來醫療費用監控之參考； 3. 健保局應要求試 辦醫院訂定自主事前審查試辦作業後手術品質監控指標；及 4. 建置全國人工關節登錄 系統，以增進病患手術的安全性及置換成功率。

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The purpose of the study was to investigate the impacts of self-precertification review of total knee arthropla sty(TKA) on medical care quality and expenses. The quasi-experimental design was used. There are 1220 T KA cases from 11 hospitals participating the self-precertification program were enrolled as the experimental group, and 5,411 TKA cases from other hospitals which did not participate the self-precertification program were enrolled as the control group adopted from claim database of Taipei branch of National Health Bureau (NHIB) in year 2002 to 2003. Difference in Difference(DID) was carried out for analyzing the impact on me dical expenses of self-precertification program. Meanwhile, regression analyses were used to investigate the effect of independent variables of TKA.

We found that the average expenses of patients receiving TKA in the participating hospitals were significantl y lowered after participating the self-precertification program. With DID analyses, we also found that the exp enses both in the experimental group and the control group were decreased after the initiation of the self-prec ertification program. However, we found that the expenses in the experimental group were significantly high er than the control group after the program’s initiation. In addition to the expenses, the experimental group h ad a lower rate of re-admission within 30 days after the initiation of the program. We further demonstrated th at there were no significant differences in mortality, surgical complications, and re-admission within 90 days between both groups. The severity of illness, the level of hospital accreditation, the surgical volume of the ho spital, the surgical volume, and the practice seniority of the surgeon were noted to be important explanatory f actors for the medical expenses of TKA.

Base on the above findings, we proposed several suggestions for the NHIB. First, though there is no significa nt difference in the quality of TKA before and after the initiation of the self-precertification program for TK A, continuous monitoring of the surgical quality in the experimental group should be encouraged. Second, fu rther study is needed to determine the reasons why the TKA expenses of the experimental group are higher th an those of the control group, so as to monitor the expenses of the procedure in the future. Third, the indicato rs of the quality of post operation in the experimental group should be established under the supervision of N HIB. Finally, the national artificial knee registry system should be established to increase the safety for the p atients and successful operation results

Impacts of Self-Precertification Review on

Medical Care Quality and Expenses—Example

of Total Knee Arthroplasty