| 摘要: | 研究背景：根據國民健康署2014年出生通報統計年報顯示，從2004年到2014年出生的新生兒數呈現下降的趨勢，但懷孕週數小於37週的新生兒百分比從2004年的8.92％到2014年卻上升到8.95％，這顯示早產兒的出生比例有上升的趨勢，而極低體重早產兒的出生比率也呈現上升的趨勢。由最近三年的出生通報資料顯示，早產兒約佔新生兒活產人數的8.95％-9.05％，而會造成較高死亡率與罹病率的極低體重早產兒（亦即出生體重小於1500公克），約佔新生兒活產人數的0.82％-0.86％。因此，為了提升新生兒的存活率，首要課題就是要預防早產的發生，再來就是要降低早產兒的死亡率，尤其是在高死亡率的極低體重新生兒。
研究目的：本研究的目為探討影響極低體重新生兒照護結果之因素，並以國家衛生研究院所發行之全民健康保險研究資料庫2010年承保抽樣百萬歸人檔(LHID2010)為資料來源，分析新生兒特質、醫療機構屬性與醫師特質對於極低體重新生兒照護結果之影響。
研究方法：本研究為回溯性研究，採用國家衛生研究院所發行之全民健康保險研究資料庫2010年承保抽樣百萬歸人檔(LHID2010)，再串聯2003年至2013年的住院醫療費用清單明細檔(DD)、住院醫療費用醫令清單明細檔(DO)、醫事機構基本資料檔(HOSB)、醫事人員基本資料檔(PER)、專科醫師證書主檔(DOC)及承保資料檔(ID)，以擷取極低體重新生兒出生後首次住院與第一年內住院資料。研究樣本選取方式係以2003年至2013年期間，出生後首次住院的極低體重新生兒為研究對象，亦即出生體重小於1500公克，追蹤其該次住院後的照護結果。
研究結果： 在350名極低體重新生兒中，男性新生兒佔187人(53.43%)，女性則佔163人(46.57%)，另外在追蹤研究一年期間，活存新生兒佔344人(98.29%)，死亡新生兒佔6人(1.71%)。在首次住院醫療費用方面，平均醫療費用為353,444元(標準差為432,968)，在第一年住院醫療費用方面，平均醫療費用為652,101元(標準差為498,960)。複迴歸分析的結果顯示，在極低體重新生兒特質方面，研究結果顯示首次住院醫療費用，新生兒出生體重等級愈重，醫療費用花費就愈低，達到統計上的顯著意義(P < 0.05)；在第一年住院醫療費用方面，新生兒出生體重等級愈重，醫療費用花費就愈低，達到統計上的顯著意義(P < 0.0001)；在使用呼吸器治療天數方面，首次住院的醫療費用，新生兒使用呼吸器治療天數愈多，醫療費用花費就愈高，達到統計上的顯著意義(P < 0.05)；在第一年住院醫療費用方面，新生兒使用呼吸器治療天數愈多，醫療費用花費亦愈高，達到統計上的顯著意義(P<0.0001)。在極低體重新生兒併發症方面，第一年住院的醫療費用，新生兒罹患常見併發症像是呼吸窘迫症候群、新生兒敗血症、早產兒視網膜病變、慢性肺疾病、腦室出血及壞死性腸炎等，其醫療費用花費亦越高，除了新生兒敗血症及壞死性腸炎未達到統計上的顯著意義，其它併發症均達到統計上的顯著意義(P < 0.05)。
在主要照護醫療機構屬性方面，研究結果顯示在第一年住院醫療費用，層級為醫學中心比地區醫院的醫療費用高(P<0.05)；在醫療機構權屬別方面，研究結果顯示在首次及第一年住院醫療費用，權屬別為私立醫療機構比公立醫療機構的醫療費用高(P<0.05)；在醫療機構分局別方面，研究結果顯示在第一年住院醫療費用，分局別為台北的醫療機構比北區、中區及南區的醫療機構其醫療費用較高(P<0.05)。
在主要照護醫師特質方面，研究結果顯示在首次住院醫療費用，醫師的年齡越大者，新生兒醫療費用花費就越低，達到統計上的顯著意義(P < 0.05)；醫師的小兒專科年資越高者，新生兒醫療費用花費就越高，達到統計上的顯著意義(P < 0.05)。
研究結論：本研究發現，極低體重新生兒特質中的出生體重、使用呼吸器治療天數及併發症與住院醫療費用均具有顯著的關聯性。主要照護醫療機構屬性中的層級、權屬別及分局別與住院醫療費用均具有顯著的關聯性。主要照護醫師特質中的年齡及小兒專科年資與首次住院醫療費有顯著的關聯性。根據研究結果，本研究建議衛生主管機關應制定相關政策，以提高產檢率及完善轉診制度，以期降低新生兒早產及後續併發症的發生率。
Backgrounds: According to Statistics of birth reporting system by Ministry of Health and Welfare, there is a downward trend in the annual number of live births from 2004 to 2014. The proportions of newborns born before 37 weeks has risen from 8.92% in 2004 to 8.95% in 2014, indicating a high proportion of preterm infants, and the birth rates of very low birth weight infants (VLBW) also increased with year.
Among newborns of live births from the recent three-year birth reporting data, the rates of premature infants were 8.95% -9.05%, and the rates of VLBW infants were 0.82% -0.86%. The VLBW infants are subject to have high mortality and morbidity rates. Therefore, in addition to prevent preterm births, it is essential to improve newborn survival rate by reducing high mortality rate of VLBW infants.
Objectives: The study aimed to identify factors influencing health outcomes of VLBW infants. We adopted information from Longitudinal Health Insurance Database 2010 of Taiwan (LHID2010) and examined the properties of neonatal factors, medical institutions and physicians’ characteristics that may influence health outcomes of VLBW infants.
Methods: In this retrospective study, we adopted the information from Longitudinal Health Insurance Database 2010 of Taiwan (LHID2010) and merged the following Registration files: Inpatient Expenditures by Admissions (DD), Details of inpatient orders(DO) , Registry for Contracted Medical Facilities (HOSB), Registry for Medical Personnel (PER) , Registry for Board-certified Specialists (DOC), and Registry for beneficiaries (ID) . The subjects of the study are VLBW infants (birth weight less than 1500 grams) and we tracked health care outcomes after its first hospitalization. We employed multiple regression analyses to detect significant factors.
Results: In 350 VLBW infants of the study, 187 were males (53.43%) and 163 were females (46.57%). 344 (98.29%) survived after the study period. The means of the first time and the first year hospital costs were NT 353,444 (SD = 432,968) and NT 652,101 (SD = 498,960), respectively. With respect to characteristics of VLBW infants, that expenses of the first time hospitalization were lower when birth weight were heavier (P <0.05). The expenses of the first year hospitalization were lower when birth weight were heavier (P <0.0001). The days on ventilator are positively associated with both the first time (P <0.05) and the first year (P <0.0001) hospitalization expenses. The occurrence of neonatal complications was also a significant variable. The first year hospitalization costs were higher as newborns suffering from complications such as respiratory distress syndrome, retinopathy of prematurity, chronic lung disease and intraventricular hemorrhage (P <0.05).
Regarding characteristics of medical care organizations, the expenses of hospitalization in the first year in medical centers were higher than that in regional hospitals (P <0.05). The hospitalization expenses in private medical care institutions were higher than that in public ones in the first time and first year hospitalization (P <0.05). In terms of characteristics of medical institutions branches, hospitalization expenses the first year in medical institutions in the Taipei branch tend to be high, compared with that in the North, Central and Southern District (P <0.05).
About primary care physicians’ characteristics, the age and the seniority in pediatric speciality are significantly correlated with hospitalization expenses. Older physicians are related to a low cost (P <0.05) and more senior specialist are related to a high cost (P <0.05).
Conclusions: The study had demonstrated that factors of VLBW infants such as birth weight, days of ventilator treatment and complications were significantly associated with hospitalization expenses. In addition, characteristics of medical care organizations and physicians were significantly associated with hospitalization expenses. Our study result suggested that the government should develop health policies to enhance the utilization of the prenatal services and improve medical referral system to reduce the incidence of premature birth and subsequent complications. |
