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研究生:許幼青
研究生(外文):Yu- Ching Shu
論文名稱:不同臨床路徑對醫療資源利用及品質之影響--以全人工髖關節置換術為例
論文名稱(外文):The effect of Clinical Pathways on the Resource Utilization and Quality of Care--Example of Total Hip Replacement
指導教授:邱亨嘉邱亨嘉引用關係
指導教授(外文):Herng-Chia Chiu
學位類別:碩士
校院名稱:高雄醫學大學
系所名稱:公共衛生學研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2001
畢業學年度:89
語文別:中文
論文頁數:155
中文關鍵詞:臨床路徑全人工髖關節置換術醫療資源利用醫療品質
外文關鍵詞:Clinical PathwayTotal Hip ReplacementUtilization of medical resourceQuality of care
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摘 要
中央健保局在有限的醫療資源考慮之下,將支付制度從論量計酬轉變成為前瞻性且多元化。導致許多醫院為了因應制度改變陸續採用不同的管理策略來降低成本,而臨床路徑(Clinical Pathways)即為策略之一。本研究的主要目的在評估臨床路徑介入前後,對於高屏地區三家醫學中心接受全人工髖關節置換術(THR)病患之醫療處置行為、醫療資源利用及醫療品質的影響,並比較臨床路徑後三家醫學中心於過程面及結果面的差異,找出各醫院之路徑特色,進而提供給相同層級的醫院參考。
本研究主要為回溯性的橫斷性調查研究,以病歷審查的方法收集三家醫院骨科實施「人工髖關節置換術」之病患基本和疾病特質、醫療處置行為及醫療品質等資料。醫療費用則取自於健保局。
統計有471位THR病患納入分析,路徑前為209位(非路徑組),路徑後為262位(路徑組)。研究結果發現,三家醫院實施路徑前後,兩組病患之疾病嚴重程度無差異。在醫療處置行為之項目及治療時間的時程呈現減少的趨勢,如檢查(驗)項目、抗生素的使用天數、第一次下床行走時間等項目。然而出院後的第一次正常複診時間及複診次數則有提早及增加的現象。雖然醫療資源利用方面,如總住院天數及總醫療費用於路徑後都顯著下降,但負向醫療品質則未呈現統計上顯著差異。三家醫院中,C醫院路徑後在醫療處置行為及醫療資源利用均較B及A醫院來得多。而醫療品質方面,除了因關節問題門急診比率C醫院升高外,其餘如併發症發生率、30天再入院率、48小時死亡率等三院間無統計上顯著差異。
整體來說,臨床路徑的實施不但可降低醫療機構之醫療處置行為、醫療資源利用,同時可維持醫療品質,故醫院或許可考慮採用臨床路徑作為管理策略之一,以降低成本變異及維持或改善醫療照護品質。
Abstract
In considering limited resources, the Bureau of National Health Insurance (BNHI) has gradually changed the fee for service payment system to prospective payment system and multiple cost containment methods. In order to meet the challenge, many hospitals have adopted various management strategies to cope with the cost pressure; which include the application of clinical pathway(CP) is one of them. The major purpose of this study is to evalute the effects of clinical pathway on treatment behavior, service utilization, and quality of care for these patients who had received total hip replacement(THR) at thee medical centers in Kao-Ping region. Furthermore, the study was to compare different pathways of treatment and care among three hospitals and to identify which clinical pathway was the best.
The study adopted a retrospective cross-sectional study design. The patient information (patient characteristics, treatment behavior, disease pattern, and quality of care) was derived from chart review, while health care expenditure were generated from claim data of the Kao-Ping branch, the Bureau of National Health Insurance,.
In total, there were THR 471 patients for the study. Among them, 209 patients were collected before the application of clinical pathway (called non-CP group), and 262 patients collected after clinical pathway (called CP group). The results indicated that there was no statistically difference in severity of illness between the two groups. A significant decreasing trend in treatment items and time were observerd, such as lab tests, the first day of walking, antibiotic days, and others. However, the CP group demonstrated a earlier first follow-up visit and more OPD visits, as compared with the non-CP group. Moreover, while the resources utilized (items of LOS and expenditures) were significantly decreased for the CP group, no difference in adverse outcomes were found in the two groups. For specific hospital, C hospital consumed more medical resources as compared with A and B hospitals. With respect to quality of care, no statistical difference was found among the three hospitals in terms of complication rate, 30-day re-admission, and 48 hours death after discharged, with an exception of ambulatory or emergency visits caused by joint problem.
In conclusion, clinical pathway not only reduced the variations of treatments and expenditures, but also maintained a equivalent quality of care for THR patients. Hospitals may consider adopting clinical pathways as one of management strategies to reduce variations of cost and maintain or increase quality of medical care.
目 錄
第一章 緒論
第一節 研究背景與動機1
第二節 研究目的3
第三節 預期研究結果及貢獻4
第四節 解釋名詞6
第二章 文獻探討
第一節臨床路徑之發展、效益及成敗因素8
第二節全人工髖關節置換術17
第三節 推行臨床路徑之效果--國外經驗21
第四節 臨床路徑之效果--國內經驗27
第五節 三家醫學中心骨科臨床路徑33
第三章 材料與方法
第一節 研究設計與研究架構40
第二節 研究假設42
第三節 研究對象與資料蒐集43
第四節 研究工具及信效度檢測46
第五節 研究變項與操作型定義48
第六節 資料處理和統計分析52
第四章 研究結果
第一節 樣本及樣本醫院基本特質描述54
第二節 臨床路徑實施前後醫療處置行為比較64
第三節 臨床路徑實施前後醫療資源利用及醫療品質比較76
第四節 不同醫學中心實施臨床路徑後其醫療行為、醫療資源利用及醫療品質之差異比較88
第五節 臨床路徑對住院天數及醫療費用之影響102
第五章 討論與建議
第一節 樣本代表性和臨床路徑前後病人差異性112
第二節 臨床路徑之效益與效果115
第三節 研究建議和限制127
參考文獻131
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