| 摘要: | 「呼吸器依賴患者整合性照護試辦計畫」(Integrated Delivery System；IDS)自西元2000年開始實施，為的是讓呼吸器依賴患者隨著住院天數逐步下轉，以解決加護病房床位無法有效運用的窘境。施行迄今健保署對各階段的醫療照護給付逐年下降，但是審查標準卻逐年提高，間接影響到下轉RCW的病患接受到的照護品質。依照目前健保署針對長期呼吸器依賴患者的政策，轉入RCW的病患除了需要訓練脫離呼吸器，或是下轉居家呼吸照護。根據近年來相關的研究報告及文獻發現幾個值得深入檢討的問題。首先在RCW階段的病患，僅有少部分可以脫離呼吸器，但病患脫離呼吸器後，是再住院或重新再使用呼吸器的高危險群。其次是轉居家呼吸照護病患常會因病回轉大醫院，讓家屬會陷入莫大心理及經濟壓力。於是將此動機轉化成本研究目的，試著找出呼吸器依賴患者在RCW階段最合適的治療處置，以評估各處置的成效。
本研究係以全民健保資料庫為資料來源，依研究目的將治療處置動向區分為脫離呼吸器組、轉居家呼吸照護組及繼續在RCW住院等三組，並將病患特質（性別及年齡）、臨床特質（合併症指數及有無氣切）及照護提供者特性（如醫院層級、醫院地區別、醫師服務量、專科醫師別及專科醫師年資）等因素列為控制變項，來分析前兩組病患的一年內再住院情形，與後兩組病患住院後6個月內存活情形是否有顯著性的差異。
本研究以2006年至2010年全民健康保險學術研究資料庫之住院醫療費用清單明細檔及住院醫療費用醫令清單明細檔為主資料來源，並串連醫事機構基本資料檔、專科醫師證書主檔及重大傷病證明明細檔，以取得RCW階段的病患作為研究對象，並採用Cox’s regression模式，分析脫離呼吸器組、轉居家呼吸照護組的再住院情形影響力，與轉居家呼吸照護組及繼續在RCW住院兩組病患，住院存活狀況的影響力與死亡風險。
本研究對象為2006-2010年18歲以上使用呼吸器大於63天，轉入RCW階段呼吸器依賴病患共4,432人。研究的結果發現，轉居家呼吸照護組再住院風險高於脫離呼吸器組，有顯著差異（57.7% vs 41.7%；HR:2.875, p<0.01）。轉居家呼吸照護組在追蹤期間住院死亡風險，較繼續在RCW住院組高，且有顯著差異（30.1% vs 24.8%；HR:3.121, p<0.001）。另外，從追蹤住院後6個月內的住院預後統計中發現，年齡與查爾森合併症指數是住院死亡風險的顯著相關因素。
病患到RCW階段，其脫離率約5%-8%，根據衛福部(2012）統計全台灣RCW約6,425床，但每日需要RCW床位的病患有七千多人，故有相當多數的人必須下轉居家呼吸照護，而這兩組處置的病患依據本研究發現有相當高的再住院率。因為使用呼吸器的關係，再住院後大部分病患必須在加護病房照顧，因此預估醫療花費將增加更多。加上轉居家呼吸照護組病患也有較高的再住院的死亡風險，所以這兩種處置動向應當加以檢討。
本研究的主要限制為次級資料運用時，有些與病況相關的資料無法取得（例如：生理機能、臨床檢驗值等），以及在經費許可下應該分析全民健保資料特殊疾病檔，來提升統計數字的精準性。最後，本研究依據結果分析提出以下的建議，供主管機關參考：（1）提供另一個介於RCW與居家呼吸照護間的階段，並給予合適的健保給付，以減少下轉病患再住院機會。（2）提高給付並給予獎勵配合重症安寧政策實施的RCW醫院，讓RCW不會面臨經營的困境。
Since National Health Insurance (NHI) started to come into force, for took care prolonged mechanical ventilation (PMV) patients, the department of health asked the specialists, Taiwan Society of Pulmonary and Critical Care Medicine, to develop management system, “ Integrated Delivery System ( IDS )”, and the plan started to perform since 2000. The PMV is defined as “use of a mechanic ventilator for at least 21 days.” But if patients can't wean from ventilator within 63 days, they would be transferred to Respiratory Care Ward (RCW) or be suggested to go home with home care ventilator. According to some studies or papers, there are some problems about the patients who were transferred to RCW or lived at home with home care ventilator.
First, the weaning rate was lower in the RCW, and some patients be weaning ventilator had high readmission rate. And the mortality of readmission patients were also higher than first time. Second, the patients lived at home with home care ventilator would have some problems that family couldn't handle, so they would be sent back to hospital again.
The purpose of the study is aimed to compare the patients are successful weaning from ventilator in RCW and lived at home with home care ventilator, about their one year readmission rate. And compared the patients' mortality rate among those home care patients readmitted and who continuous lived at RCW within 6 months hospital course. We conducted a retrospectively study using the National Health Insurance Research Database in Taiwan during the period from 2006 to 2010. Patients who used ventilator more than 63 days were classified as three different management groups, the weaned ventilator, transferred back to home with ventilator and kept living at RCW. And control variables were patient’s characteristics (such as age and gender), clinical characteristics (such as the comorbidity index and tracheostomy tube) and care provider characteristics (such as hospital level, hospital location, service volumes of hospital physicians, and clinical specialty etc..). Cox’s regression was used to estimate the hazard ratio(HR) for one year readmission rate and mortality rate within 6 months hospital course.
Total 4,432 patients were enrolled. The results showed patients who be tranferred back to home with ventilator group had higher readmission rate than the weaned ventilator group（57.7% vs 41.7%；HR:2.875, p<0.01）. And patients who be transferred back to home with ventilator group when they readmitted also had higher mortality rate than patients kept living at RCW group within 6 months hospital course（30.1% vs 24.8%；HR:3.121, p<0.001）. In our study, we also noted age and Charlson’s comorbidity index are significant influences on the mortality rate within 6 months hospitalization.
Patients with ventilator dependent in RCW peroids, had lower ventilator weaning rate. But some of them be required to wean ventilator or transfer back to home with ventilator, all had relative high risk of readmission. After readmitted, they also had higher mortality risk. So those two managements should be considered whether fit patients in RCW stage.
The limitation of the study is that secondary data source was used, and therefore many confounding variables (such as healthcare utilization) could not be taken into account. And in the future researchers should investigate the NHI special Research Database of ventilator dependent patients. Finally, we had two recommendations：(1) Provide another institutions between RCW and home care ventilator with suitable NHI coverage, it can reduce the readmission rate. (2) To reward RCW hospitals with hospices and palliative care in terminal ventilator dependent patients. That can encourage RCW hospitals keeping to take care them. |
