急性心肌梗塞病患照護連續性與照護結果及醫療費用之關係

Association of continuity of care with healthcare outcomes and expenses among acute myocardial infarction patients

目標：過去研究發現，急性心肌梗塞（acute myocardial infarction, AMI）出院病人住院前有較高照護連續性，會有較佳的出院後照護結果；然未有研究探討AMI出院病人出院後照護連續性，是否與出院後照護結果有關，再者，未有研究同時探討AMI出院病患住院前與出院後的照護連續性，對出院後照護結果及費用之相對影響強度。方法：本研究利用全民健康保險研究資料庫全國代表性樣本，分析2007年至2011年AMI出院病人，共1,884位。本研究採用廣義估計方程式（generalized estimating equation, GEE）及Cox比例風險穩健夾擠估計模式（Cox proportional hazards model with robust sandwich variance estimates），探討住院前、出院後照護連續性對出院後1年再住院次數、死亡以及醫療費用之影響。結果：住院前照護連續性與出院後照護結果及醫療費用無顯著相關；出院後照護連續性高之病患，有較低的出院後1年死亡風險、再住院次數與醫療費用。結論：AMI病人出院後而非住院前照護連續性，與出院後照護結果及醫療費用有關，因此為改善出院後照護結果及醫療費用，健康政策制定者及醫療服務提供者可著重提升AMI病人出院後照護連續性。

Objectives: Previous research has shown that discharged patients following acute myocardial infarction (AMI) who had higher continuity of pre-admission care had better post-discharge care outcomes; however, no study has determined whether or not discharged patients following AMI who had higher continuity of post-discharge care had better post-discharge care outcomes. Moreover, no study has determined the relative strength of influence of pre-admission and post-discharge care continuity on post-discharge outcomes and expenses. Methods: This study utilized data from the nationwide representative sample through the National Health Insurance Research Database, and analyzed 1,884 AMI patients discharged from the hospital between 2007 and 2011. Generalized estimating equation and Cox proportional hazard models with robust sandwich variance estimates were performed to examine the effects of pre-admission and post-discharge care continuity on 1-year post-discharge mortality, readmissions, and medical expenses. Results: There was no significant relationship of continuity of pre-admission care to post-discharge care outcomes and medical expenses. Patients with a high continuity of post-discharge care had lower 1-year post-discharge mortality, readmissions, and medical expenses. Conclusions: Among AMI patients, post-discharge care continuity, rather than pre-admission care continuity, is associated with post-discharge care outcomes and medical expenses. Therefore, to improve post-discharge care outcomes and medical expenses, health policy makers and providers might focus on enhancing continuity of post-discharge care for patients with AMI.