目的：本研究主要在於了解CT/MRI影像檢查之適當性，並探討影響CT/MRI利用適當性的因素。方法：本研究為回溯性研究，隨機抽取健保局南區分局94年4月至6月間重覆執行CT及MRI二次（含）以上的腦阻塞或顱內傷案件共359件，由專業審查醫師評估執行CT/MRI的臨床適當性。以SPSS12.0套裝軟體進行卡方、獨立樣本t檢定及羅吉斯迴歸分析，預測變項包括醫院特性、病人人口學特性、臨床特性、專業審查特性及跨院等。結果：首次執行適當佔了97%（348/359），其中主要不適當的原因為『病情不適合』。然而再次執行適當之案件下降為53%（189/359），其中『病情不適合』佔20.89%（75/359）為最多，依次為『檢查過於頻繁』15.88%（57/359）、『前次檢查已適當』8.64%（31/359）及『病歷記載不清』1.11%（4/359），其中腦阻塞再次執行不適當的原因以『前次執行已適當』最多22.27%（43/193）；顱內傷則以『病情不適合』為最多28.31%（47/166）。CT/MRI執行不會因腦阻塞或顱內傷而有顯著差異，醫院特性分別於首次CT/MRI執行之適當性有關聯，權屬別（p<0.0001）、層級別（p<0.05）、病床數（p<0.0001）及市場佔有率（p<0.0001），再次執行之適當有關聯的有市場佔有率（p<0.05）與個案年齡（p<0.05）。在控制醫院權屬別、層級別、病床數、市場佔有率及個案年齡下，權屬別與首次執行適當性有關聯。再次執行再納入專業審查變數被控制下，跨院與再次執行CT/MRI影像檢查不適當性有統計上顯著關聯。結論：CT/MRI執行不適當之主要原因為不符合病情所需，其次為前次檢查已適當。本研究顯示醫院特性、病人年齡及跨院，具有影像檢查管理策略方向導引之弁遄C有助於釐清CT/MRI執行不適當個案之醫院特性、病人特性及跨院就醫之影響。提供健保局控制影像醫療費用支出之策略性思考方向，以提升影像資源效率。 Objectives: The aim of this study was to assess the appropriateness of computed tomography (CT) and magnetic resonance imaging (MRI) test and explain factors influential to the appropriateness of imaging tests.
Materials and methods: 359 repeated imaging patients with occlusion/stenosis of precerebral artery (193) and intracranial injury (166) encountering to contract hospitals in South BNHI from April 2005 and June 2005 were studied. The appropriateness of initial and subsequent imaging tests during the period of three-month was assessed by medical/surgical neurologists through a retrospective chart review. Clinical and hospital data were obtained from patient and hospital files respectively. Data were analyzed by the t test, the chi-square test and multiple logistic regression.
Results: The 97 percent (348/359) of 359 initial imaging tests performed with appropriate clinical indication, the main reason for inappropriate imaging at initial test was “no clinical indication.” However, per cent of appropriate imaging at subsequent test decreased to 53 (189/359). The most common reason for inappropriate imaging at subsequent test was also “no clinical indication” 20.89 percent (75/359); the additional reasons were “positive prior test” 15.88 percent (57/359); “heavy uses” 8.64 percent (31/359); and “incomplete medical records document” 1.11 percent (4/359). The most common reason for inappropriately repeated imaging for occlusion/stenosis of precerebral artery patients was “positive prior test” 22.27 percent (43/193), while it was “no clinical indication” 28.31 percent (47/166) with respect to intracranial injury patients. The rate of appropriateness for occlusion/stenosis of precerebral artery was not significantly different from that for intracranial injury. Hospital’s characteristics were significantly associated with the appropriateness of initial imaging: ownership (p<0.0001), accreditation (p<0.05), bed size (p<0.0001), market share (p<0.0001); but market share (p<0.05) and patient’s age (p<0.05) were significantly associated with the appropriateness of subsequent imaging. After controlling for the other covariates, multivariate logistic regression showed that hospital ownership was a factor affecting the appropriateness of initial imaging, private hospital attained higher appropriate rate (odds ratio= 7.217, p<0.05), but the variable ”across hospital” was significantly associated with subsequent appropriateness of imaging test. The imaging test performed across hospital attained less appropriate rate (odds ratio= 0.031, p <0.01).
Conclusions: In the occlusion/stenosis of precerebral artery and intracranial injury patients, physician’s requests for inappropriate repeated imaging were frequent. A higher inappropriate rate of patients across hospital and the reason for subsequent imaging “positive prior test” uncovered the inappropriateness for repeated imaging tests. This analysis provided data to help imaging resource planning to reduce unnecessary imaging tests.
