臺灣博碩士論文加值系統

為了舒解醫療財務沈重的壓力，我國全民健康保險於規劃時，部份住院病例的支付方式即改採用「論病例計酬制」，取代原有的「論量計酬制」。為了迎接支付制度改變所帶來的挑戰，許多醫院管理策略被提出討論，其中臨床路徑(clinical pathways)被認為是有效的管理工具。
本研究是以個案醫院推動腹腔鏡子宮切除術臨床路徑實施前的133位病患(90年1月至6月)，及實施臨床路徑後132位病患(91年1月至6月) 為研究對象，探討於論病例計酬制度下，臨床路徑的實施對住院日數、醫療資源耗用及醫療品質的影響，重要的結果如下：
1.臨床路徑實施後平均住院日數升高，但與實施前無顯著差異
2.臨床路徑實施後住院總醫療費用升高，其中病房費、診察費、麻醉費、治療處置費、藥事服務費等費用升高，且前後有顯著差異
3.實施臨床路徑不會影響(降低)醫療品質
對於出現路徑實施後住院日數及醫療費用升高可能的原因為：醫療單位沒有嚴格按照臨床路徑進行，致路徑效益不佳；嘗試使用腹腔鏡手術於較複雜個案，導致醫療費用升高。建議個案醫院應嚴格遵行醫護相關單位所訂定之臨床路徑，提昇個案管理師應有之功能，以達到合理控制住院日數、降低醫療費用及確保醫療品質之功能。

In order to release the financial pressure of medical care, the National Health Insurance Bureau had altered payment system from fee-for-service to case payment for certain in-patient case. Facing the challenge of payment system changes, several strategies of hospital management have been proposed; among which, clinical pathway is supposed to be an effective management tool for hospitals.
This study focused on the implementation of clinical pathway of laparoscopic hysterectomy. One hundred thirty-three patients before the implementation of clinical pathway (from Jan. 2001 to Jun. 2001) and 132 patients after the implementation of clinical pathway (from Jan. 2002 to Jun.2002) in a major medical center were selected as the targets population. The purposes of this study were to investigate the effect of implementation of clinical pathway on the control of the length of stay, inpatient medical expenditures, and quality of medical care. The major finding were as follows:
1. The length of stay increased after the implementation of clinical pathway, but there was no significant difference between before and after implementation of clinical pathway.
2. The inpatient medical expenditures increased after the implementation of clinical pathway, among which, ward fee, diagnosis fee, anesthesia fee, therapy and treatment fee, and dispensing fee had increased, and significant differences between before and after implementation of clinical pathway were found..
3. The implementation of clinical pathway did not have significant influence (decrease) on the quality of medical care.
The possible reasons for the increase of the length of stay and medical expenditures were: 1) The medical unit did not strickly follow the clinical pathway and lead to the low efficiencies; 2) gynecologists tended to undergo the laparoscopic hysterectomy on complicated cases, which caused the increase of the medical expenditures. In order to control the length of stays in a reasonable range, reduce inpatient medical expenditures, and maintain the quality of medical care, this study strongly suggested that the gynecologists of case hospital should comply with the clinical pathway strickly, and enhance the function of case managers.

目　　　錄
誌　　謝……………………………………………………………….. i
中文摘要……………………………………………………………….. ii
英文摘要………………………………………………………………...iii
目　　錄…………………………………………………….………….. v
第一章　緒論
第一節　研究背景及動機……………………………………….. 1
第二節　研究的重要性及預期貢獻…………………………….. 4
第三節　研究目的與研究問題………………………………….. 6
第四節　研究流程……………………………………………….. 7
第二章 文獻探討
第一節　名詞解釋……………………………………………….. 8
第二節　醫療保險支付制度與費用控制………………………. 11
第三節　國內外論病例計酬制度實證研究……………………. 18
第四節　臨床路徑………………………………………………. 23
第五節　臨床路徑之發展與實施………………………………. 26
第六節　臨床路徑實施之效益…………………………………. 28
第七節 臨床路徑之變異性……………………………………. 30
第八節 臨床路徑推動常見之問題與困難……………………. 31
第九節　國內外實施臨床路徑之經驗…………………………. 33
第三章　研究方法與材料
第一節　研究假說………………………………………………. 38
第二節　研究設計及研究架構…………………………………. 39
第三節　研究變項及操作型定義………………………………. 41
第四節　研究對象及資料收集…………………………………. 44
第五節　資料處理及分析………………………………………. 45
第四章　研究結果………………………………….…………… 46
第一節　醫師特質分析………………………………….……… 47
第二節　病人特質分析…………………………………………. 49
第三節　疾病特質分析…………………………………………. 50
第四節　臨床路徑對醫療資源耗用的影響……………………. 52
第五節　臨床路徑對醫療品質之影響…………………………. 55
第六節　病人特質、疾病特質、醫師年資對住院日數與
醫療品質之影響分析………………………………….. 56
第七節　不同醫師對住院日數與醫療費用之影響分析………. 57
第五章　討論及建議
第一節　實施臨床路徑之效益評估……………………………. 63
第二節　研究限制………………………………………………. 69
第三節　建議……………………………………………………. 70
參考文獻
中文部分…………………………….……………………………… 72
英文部分…………………………….……………………………… 75
附錄
附錄1…………………………….…………………………………. 78
附錄2…………………………….…………………………………. 79
附錄3…………………………….…………………………………. 81
附錄4…………………………….…………………………………. 84

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