目標：以全股（髖）關節置換術為例，探討醫院、醫師手術量與病患術後醫療品質的關聯性。方法：利用全國健保申報次級資料，以民國87年1月至89年12月進行單側全股（髖）關節置換住院者為研究對象，控制病患特質（年齡、性別、主診斷、疾病嚴重度）、醫院特質（地區別、公私立與層級別）與住院期間醫療利用及品質（住院日、復健治療次數與併發症發生情形）等，評估手術量與病患出院後90日及一年內死亡率與再住院率的相關。結果：總手術量≧50件的醫院之死亡率與再住院率較手術量≦7件的醫院低（90日內死亡率為0.66％與1.00％，adjusted OR=0.69；不分科再住院率為13.93％與48.31％，adjusted OR=0.69）。手術量≧２５件之醫師的死亡率與住院再住院率也較手術量≦５件之醫師為低（90日內死亡率為0.57％與2.55％，adjusted OR=0.23；不分科再住院率為13.67％與42.34％，adjusted OR=0.73），結論：手術量較低的醫院與醫師，其病患術後發生死亡與再住院的比率較高，建議健保局可利用手術量作為監控醫院與醫師醫療品質的替代指標，且應避免手術量過低的醫院與醫師執行全股（髖）關節置換術。

Objective: The goal of this study was to determine whether the volumes of total hip replacement (THR) of the quality of health care at hospitals and surgeons are associated with rate of mortality and complications. Methods: We analyzed claims data from the National Health Insurance (NHI) for patients who underwent elective primary THR procedures between Jan 1998 and Dec 2000. We assessed the relationship between surgeon and hospital procedure volume, as well as the rate of mortality, readmission, and dislocation within ninety days and one year postoperatively. Analyses were adjusted for age, gender, arthritis diagnosis, severity of disease the area, owner and size of hospital, LOS (length of stay), in-hospital rehabilitation and complication. Result: Ninety days after discharge, patients treated in hospitals in which there were more than 50 of these procedures had a lower risk of death and readmission than those treated in hospitals in which there were seven or few procedures (mortality rate, 0.66% compared with 1.00%; adjusted OR=0.69; readmission rate, 13.93% compared with 48.31%; adjusted OR=0.69). Ninety days after discharge, patients treated by surgeons who performed more than 25 of these procedures had a lower risk of death and readmission than those treated by surgeons who performed more than 25 of these procedures had a lower risk of death and readmission than those treated by surgeons who performed less than 10 procedures (mortality rate, 0.57% compared with 2.55%; adjusted OR=0.23; readmission rate, 13.67% compared with 42.34%; adjusted OR=0.73). Conclusion: Patients treated in hospitals and by surgeons with lower caseload of THR had higher rates of mortality and readmission. We suggest that NHI should concentrate THR in high-volume referral centers in order to reduce avoidable mortality and morbidity.

全股（髖）關節置換術；手術量；醫療品質；死亡率；再住院率

THR; volume; medical quality; mortality rate; readmission rate