臺灣博碩士論文加值系統

臨床路徑實施可提昇醫療品質及減低成本，已廣泛應用於醫療。本研究目的在探討精神分裂症住院過程中成果目標及臨床措施，並發展臨床路徑。
將精神分裂症分高功能、中功能、低功能，依不同功能層次設立成果目標，並草擬臨床路徑，根據其內容制定結構式問卷。研究採立意取樣，以榮民系統，三家甲級教學醫學中心之急性精神科病房醫療人員為對象，發出164份問卷，回收有效問卷130份，以SPSS 9.0套裝軟體進行資料分析，初步結果再經由精神醫療專家鑑定。
研究結果顯示：（一）精神分裂症臨床路徑醫療措施，經Boxplot 75﹪相對應值、Kruskal Wallis test、Bonferroni test做篩檢及因素分析後，原100項措施簡化為65項醫療照護措施因素。（二）成果目標經Boxplot 75﹪相對應值、Kruskal Wallis test及因素分析後，原53項精簡為37項成果目標因素。（三）上述初步精神分裂症臨床路徑結果，經十位精神醫療專鑑定後，彙整意見，完成「醫學中心精神分裂症臨床路徑因素表」及其使用說明之制定，此路徑住院日數為28天，入院期為第1~3天，穩定期為第4~23天，出院期為第24~28天。（四）職責方面：護理師與醫師的職責最多，且半數皆為第一優先考量，因此兩者角色地位十分重要。（五）本研究制定之臨床路徑，醫療所應支付基本點數為49705點。
本研究之臨床路徑，所列舉的醫療照護措施項目，為各種專業畢業生進入職場前，應具之專業知識，學生可參考使用說明，瞭解醫療照護內容。此外該路徑可為其他精神醫療機構實施臨床路徑之參考，醫療保險相關機構，亦可參考本路徑，建立論病計酬的給付標準。建議將來可進一步將此路徑應用於臨床實務，並加以確認干擾因素，來印證或修正該路徑及分類標準。

Clinical pathways have been broadly used as standard of care for patients by hospitals in other countries for a long time. It has been shown that this approach in patient care improves quality of care and reduces costs. The goals of this study were to evaluate our psychiatric clinical interventions, excepted patient outcomes, and to develop a clinical pathway for schizophrenic inpatients in our culture.
Methods:
Patients were divided into three groups based on their level of psychiatric function. The outcome and a clinical pathway were first designed based on patients'' functional level. A structural questionnaire was then formulated to ensure the clinical validity of the pathway. Multidisciplinary provider team members in three veteran general hospitals psychiatric inpatient units were given the questionnaire and rated the pathway on a five point scale. Of all the questionnaires that were returned, one hundred and thirty were included in the study. Data was screened and analyzed by SPSS 9.0, "boxplot 75% of the measures", Kruskal Wallis test, and Bonferroni test. The final product was reviewed and determined valid by Psychiatric experts.
Results:
1. Of 100 interventions of the clinical pathway 65 were validated.
2. The 53 patient outcomes were modified to have 37 items.
3. The revised clinical pathway was then implemented on schizophrenic inpatients in a medical center. The projected length of stay was 28 days. Admission phase was from day 1 to day 3. Stabilization phase was from day 4 to day 23. Discharge phase was from day 24 to day 28.
4. The data showed psychiatrists and nurses played most important roles in the treatment team.
5. The study suggested the medical basic cost was 49705 points.
This study provided professional knowledge for students and new graduates. In addition, this study could be a reference for psychiatric facilities as they plan to develop their clinical pathways. The study provided important data for Health insurance companies to establish their diagnosis related group payment standard. Future studies are needed to apply the pathway to patient care and make modifications as necessary; and to identify variance that might interfere with the study results.

第壹章 緒論……………………………………………………………………1
第一節 研究動機背景……………………………………………………………2
第二節 研究問題…………………………………………………………………4
第三節 研究目的…………………………………………………………………4
第四節 研究重要…………………………………………………………………4
第貳章 文獻查證………………………………………………………………6
第一節 精神分裂症………………………………………………………………6
第二節 臨床路徑…………………………………………………………………7
第三節 臨床路徑應用於醫療資源之現況………………………………………9
第四節 精神分裂症臨床路徑之制定……………………………………………11
第五節 國內外相關研究…………………………………………………………25
第參章 研究方法………………………………………………………………28
第一節 研究架構…………………………………………………………………28
第二節 名詞界定…………………………………………………………………32
第三節 研究對象…………………………………………………………………33
第四節 研究工具及其檢定………………………………………………………35
第五節 資料收集過程……………………………………………………………38
第六節 資料處理及統計分析……………………………………………………38
第肆章 結果……………………………………………………………………41
第一節 樣本之基本屬性…………………………………………………………41
第二節 臨床路徑應涵蓋之醫療照護措施與成果目標…………………………43
第三節 臨床路徑因素分析之結果………………………………………………46
第四節 醫療照護措施職責排序 ……………………………………… ………54
第五節 臨床路徑表格……………………………………………………………55
第六節 臨床路徑意見及建議……………………………………………………61
第七節 臨床路徑之收費…………………………………………………………71
第伍章 討論……………………………………………………………………75
第一節 變因的整合………………………………………………………………75
第二節 臨床路徑設計的策略……………………………………………………76
第三節 內容信效度………………………………………………………………78
第四節 臨床路徑呈現之方式……………………………………………………78
第五節 專業領域的指引…………………………………………………………79
第六節 給付的考量………………………………………………………………80
第陸章 結論及建議……………………………………………………………82
第一節 結論………………………………………………………………………82
第二節 建議………………………………………………………………………83
第三節 研究限制…………………………………………………………………84
第柒章 參考文獻………………………………………………………………86
附錄一：問卷同意書………………………………………………………………92
附錄二：精神分裂症臨床路徑醫療照護措施與成果目標問卷…………………93
附錄三之1：精神分裂症臨床路徑表……………………………………………101
附錄三之2：精神分裂症病人分類及成果目標…………………………………104
附錄四：問卷內容效度專家名單…………………………………………………106
附錄五之1：量表各向度專家內容效度…………………………………………107
附錄五之2：問卷修訂前後題數比較……………………………………………109
附錄六：變項之性質及描述性統計………………………………………………110
附錄七：各變項所應用之推論統計方法…………………………………………111
附錄八：醫療照護措施給分較低之職業別加權平均……………………………112
附錄十：醫療照護措施職責排序…………………………………………………114
附錄十一：專家結果鑑定專家名單………………………………………………118
附錄十二：專家結果鑑定內容………………………………………………… 119
附錄十三醫學中心精神分裂症臨床路徑因素表使用說明………… …………135
圖1 精神分裂症臨床路徑內容……………………………………………………30
圖2 精神分裂症臨床路徑標準作業建構流程……………………………………31
圖3 資料分析步驟…………………………………………………………………40
表1 國內外臨床路經相關文獻……………………………………………………25
表2 母群體與研究樣本人員配置…………………………………………………34
表3 量表各向度Cronbach''s α值………………………………………………37
表4 基本屬性………………………………………………………………………42
表5 統計分析篩選出的醫療照護措施之職責得分………………………………45
表6 臨床路徑各向度題數及萃取之因素…………………………………………47
表7 臨床路徑醫療照護措施所屬因素及重新命名………………………………48
表8 臨床路徑成果目標所屬因素及重新命名……………………………………51
表9 跨兩因素之醫療措施項目因素負荷量………………… ……… …………53
表10-1 精神分裂症臨床路徑因素表…………………………… ………………56
表10-2 精神分裂症病人分類及成果目標因素表………………… ……………58
表11-1 醫學中心精神分裂症臨床路徑因素表…………………… ……………66
表11-2 醫學中心精神分裂症病人分類及成果目標因素表……… ……………68
表12 臨床路徑醫療措施項目相對應之健保給付………………… ……………74
表13 臨床路徑醫療措施不給付之項目及其職責………… ……………………76
表14 臨床路徑未包含之健保收費項目………………………………… ………76

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