實施最新的臨床路徑對非靜脈瘤型急性上消化道出血治療的成本效益探討

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题名:	實施最新的臨床路徑對非靜脈瘤型急性上消化道出血治療的成本效益探討
其它题名:	Cost Effectiveness of an Updated Clinical Pathway for Acute Nonvariceal Upper Gastrointestinal Bleeding
作者:	李騰裕 Lee, Teng-Yu
贡献者:	陳潭 Chan, Tam 東海大學工業工程與經營資訊學系
关键词:	臨床路徑;要徑;胃腸出血 clinical care pathway;critical pathway;gastrointestinal hemorrhage
日期:	2007
上传时间:	2011-03-23T09:13:01Z (UTC)
摘要:	非靜脈瘤型急性上消化道出血是臨床醫師所經常遭遇的一種醫療急症，而這種疾病也高度地消耗了許多的醫療資源與金錢；然而，至目前為止，仍然只有極少數的證據可以證實將臨床路徑的方法運用於非靜脈瘤型急性上消化道出血時，具有經濟有效的成效。本研究乃是以最新的實証醫學(evidence-based medicine)為基礎來設計一套處理非靜脈瘤型急性上消化道出血的臨床路徑，並導入醫師提示系統(physician reminder system)，以增進醫師對於臨床路徑的遵從性，希望可以藉此研究證實運用臨床路徑的方法可以在節省成本及醫療品質的各項指標上有明顯的助益。本研究除了設計以最新實証醫學為基礎的臨床路徑，並建立由主要的提示者(總住院醫師)、核對清單(checklist)、及案例回顧會議所建構的醫師提示系統後，將本臨床路徑導入實施於一般內科病房之中。藉由比較導入臨床路徑前後的各項花費指標：昂貴靜脈注射劑型制酸藥物的使用、住院天數、以及各項費用(包括藥費、檢查費用)，來比較臨床路徑是否具有節省成本的效果。此外，藉由比較導入臨床路徑前後的各項醫療品質指標：住院期間再出血率、住院期間重複做胃鏡率、以及三十天內因出血而再住院率，來比較臨床路徑是否會影響醫療品質。比較結果顯示，實施本臨床路徑後，明顯地減少昂貴靜脈注射型制酸藥物的使用由88%至34%、減少每位病患的平均住院天數由6.7天至3.6天、減少每位病患的平均藥費由新台幣8768元至3940元(費用節省55.1%)、減少每位病患的平均檢查費用由新台幣12560元至9493元(費用節省24.4%)、以及減少每位病患的平均總住院費用由新台幣33142元至19519元(費用節省41.1%)。此外，醫療品質的各項指標在實施本臨床路徑之後，並未有明顯的改變。本研究的結論為：以臨床路徑的方法來處理非靜脈瘤型急性上消化道出血，具有經濟有效的優點；而透過醫師提示系統來增進醫師在臨床實務時對於臨床路徑的遵從性，可能促進了本臨床路徑的成功。 Acute nonvariceal upper gastrointestinal (UGI) bleeding is a common medical emergency encountered by primary physicians that causes high costs, but there still is little evidence to prove the cost effectiveness of a clinical care pathway. We introduce the physician reminder system into an updated clinical pathway to improve physicians' adherence and hope there is significant impact on outcomes. The updated evidence-based clinical care pathway was designed and implemented in the general internal medicine wards, and used the physician reminder system that included chief residents as major reminders, checklists, and case review meetings. Use of medicine for acid suppression, length of stay (LOS), and variable costs including medicine, diagnostic tests were compared between patients before and after implementation of the clinical pathway. Quality of care was monitored by the rate of recurrent bleeding during hospitalization, rate of repeated UGI endoscopy, and rate of readmission due to recurrent bleeding within 30 days after discharge. This clinical pathway significantly reduced the use of intravenous medicine for acid suppression from 88% to 34%, with mean LOS per patient down from 6.7 to 3.6 days, mean cost of medicine per patient down from NTD 8768 to NTD 3940 (cost down 55.1%), mean cost of diagnostic tests per patient down from NTD 12560 to NTD 9493 (cost down 24.4%), and mean total hospital cost per patient down from NTD 33142 to NTD 19519 (cost down 41.1%). The indicators for quality of care were not significantly different. In conclusion, the clinical care pathway is a cost-effective method in management of acute nonvariceal UGI bleeding, and the physician reminder system may improve the compliance of primary physicians throughout clinical practice making the clinical pathway successful.
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