推估高風險手術集中化政策對照護結果影響之成效探討－－以心血管處置為例

The implementation of centralization for high-risk surgery- estimating potentially avoidable outcomes of cardiac procedures

目標：探討若台灣針對經皮冠狀動脈氣球擴張術(PTCA)及冠狀動脈繞道手術(CABG)實施集中化政策，(1)對於病患處置後30日不良照護結果、(2)就醫可近性；以及(3)低服務量醫院之住院醫療收入之影響。方法：本研究對象為2010至2012年各年度第一次PTCA以及CABG之病患，以多階層羅吉斯迴歸以及G-Computation來估計可避免不良照護結果之事件發生人數，並且預測在集中化後病患需額外跨區就醫之人數。最後，瞭解醫院執行心臟處置之醫療收入占當年度住院醫療收入之比例來推測低服務量醫院在住院醫療收入的影響程度。結果：在2010年至2012年間，共有29,689人至低服務量醫院接受PTCA及4,150人接受CABG。集中化後，預估PTCA及CABG可避免死亡人數各有442人及127人，並且需額外跨區就醫的比例分別約為12%及18%。此外在低服務量醫院住院醫療收入影響上，平均各醫院每年可能將損失2%之CABG住院醫療收入；而PTCA則約損失6%。結論：集中化政策對於整體照護結果可以帶來正向影響，並對大部分病患就醫可近性及低服務量醫院財務的影響有限。

Objectives: The aim of this study was to estimate how many adverse outcomes could potentially be avoided in Taiwan if a centralization policy were implemented for Percutaneous Transluminal Coronary Angioplasty (PTCA) and/or Coronary Artery Bypass Grafting (CABG). We further examined how such a policy might affect accessibility to care as well as the potential for financial losses in low-volume hospitals. Methods: The study population included 9530 patients who underwent PTCA or CABG for the first time between 2010 and 2012. We used multilevel logistic regression and G-computation to estimate the number of potentially avoidable adverse outcomes, and we predicted how many patients would have to travel farther to access medical care as a result of a centralization policy. Finally, we predicted the impact that centralization of surgery would have on inpatient revenue in low-volume hospitals by calculating the ratio of revenue from inpatient cardiac procedures to total hospital inpatient revenue. Results: We found that 4,150 of the 9,530 patients who underwent CABG were admitted to low-volume hospitals. We estimated that centralization of PTCA and CABG could reduce the number of deaths by 442 and 127, respectively, and 12% of the patients who underwent PTCA and 18% of patients who underwent CABG would have to travel farther to access medical care. We determined that low-volume hospitals incurred financial losses of approximately 6% and 2%, respectively, by referring PTCA and CABG patients to higher-volume surgical centers. Conclusions: Centralization policies could have a positive impact on healthcare outcomes, only a minor impact on accessibility to care for patients, and minor financial consequences for low-volume hospitals.