臺灣博碩士論文加值系統

研究目的：
中央健康保險局南區分局自2001年11月起推動「全民健康保險氣喘醫療給付改善方案試辦計畫」，期望透過此疾病管理計畫，提供最高品質的醫療照護，同時有效的控制醫療費用。本研究的目的在探討，透過照護模式是否能降低氣喘病患的發作頻率及急診與住院頻率，而減少醫療費用的支出以及病患的臨床症狀是否受到適當的控制，並供各醫療院所及健保局推廣氣喘照護或其他論質計酬方案之決策參考。
研究方法：
本研究之設計結合實驗法及問卷調查法。使用健保局南區分局2000年11月至2003年12月門診與住院費用明細檔（主診斷碼為493.xx）及同時期的氣喘個案管理資訊系統之次級資料。實驗組病患450人與對照未完成組1423人。進行實驗組前後測及實驗組與未完成組在臨床症狀及醫療資源使用情形的比較、參與計畫病患氣喘自我照護能力改善的調查，問卷回收743份（回收率14.9%）。
研究結果：
一、氣喘疾病管理的結構面
本次加入實驗並已收治病患的特約醫療院所有54家，平均參與率達15.5%；參與照護的醫師計114位，平均醫師參與率為13.2%；累計有7,067位氣喘病患陸續參與此試辦計畫，平均照護率則為8.3%。
二、氣喘疾病管理的過程面
照護計畫的執行過程中，男生(25.6%)比女生(22.0%)完成率高、0~17歲(26.7%)比18歲以上(20.9%)完成率高、醫院層級中則以基層診所完成率30.4%最高，醫學中心6.5%最低、疾病嚴重度則以重度持續性完成率36.0%最高，中度持續性21.6%最低。
三、氣喘疾病管理的結果面
（一）臨床症狀
實驗組病患疾病嚴重度在經過完整照護後確實顯著的減輕症狀，有75.9%的人病狀未再惡化已被有效的控制住，且呈現重度越高改善的成效越好；病患的PEF值在經過完整照護後，平均數由實驗後的277.78 L/min較實驗前的227.22 L/min提升了22.3%，也有顯著的增加肺部功能。
（二）醫療資源使用差異
1.實驗組醫療利用前後測比較
實驗組舊病患後測比前測的醫療資源使用上，明顯下降的有急診次數(-66.7%)、急診費用(-60.2%)、住院次數(-60.0%)、住院日數(-58.1%)；明顯增加的門診次數(84.5%)、門診費用(110.3%)、總次數(74.0%)及總費用(83.6%)主要來自於初期管理照護中大量門診次數與費用所致。
2.實驗組與未完成組醫療利用情形比較
實驗組與未完成組在後測醫療資源使用的比較，不論是舊、新個案或合併起來比較，都是門診次數、門診費用、總次數及總費用實驗組比未完成組顯著的增加(1:0.43~1:0.63)；急診及住院雖在統計上未達顯著差異，但均呈現減少趨勢且均較未完成組有更大幅度的下降(1:1.11~1:3.00)。兩組在前後測醫療資源使用差異的比較上，實驗組在急診次數、費用、住院次數、費用、日數(-50.1%~-66.7%)都比未完成組(-3.6%~-36.4%)下降幅度大。
（三)問卷結果
參加試辦計畫前對氣喘疾病之成因及疾病發生時之處理，雖然有六成以上的病患約略瞭解，但診療過程中，經由醫護人員之指導後，有提昇自我照護能力者高達95.9%，且有95.3%的病患最近三個月未再因氣喘而急診或住院，顯示加入照護計畫後的病患提昇自我照護能力的效果良好。
結論與建議：
目前健保局南區分局推行的氣喘疾病管理，無論由臨床症狀相關指標(臨床面)或醫療資源的使用情形(經濟面)及病患自我照護能力程度(人文面)的結果來看，初步成效已經顯現出來且不輸國外的成效。健保局應積極推廣氣喘疾病管理照護計畫於全國、簡化費用申報行政程序、提高照護率與完成率及持續推動轉診（檢）制度。另建議醫療院所加強對病患的自我健康管理教育、並強化院方的成本控制與品質改善照護系統。

Objectives:
The Bureau of National Health Insurance (BNHI) has been developing a disease management program on asthmas patients for better cost control while ensuring the quality of healthcare. The aim of this study was to determine the effectiveness of the asthma disease management would improve economic costs, clinical outcomes, and patients’ self-care management.
Methods:
We used the BNHI Southern Region Branch database to investigate the health service utilization (e.g., outpatient visits, emergency visits, hospitalizations, total health care expenditure, inpatient days, disease severity, Peak expiratory flow) of asthma between 11 2000 and 12 2003. The survey also included sociodemographic measures, disease severity, and hospital classification in investigating the association with health service utilization. Pretest and posttest of health service utilization were investigated for 450 patients enrolled the program for one full year, and control group of 1423 patients who did not complete the program. Vaild 743 responses for questionnaires for this program from 5000 patients with asthma for a response rate of 14.9%. Statistical analyses were performed by SPSS, Version10.0 statistic software, using chi-square test, t-test, and further 1-way ANOVA and 2-way ANOVA for bivariate analysis. Significance was accepted at the 0.05 level (two-tailed).
Results:
1.Among 7067 patients with asthma, 1955 sample were recruited in the program for 1 year and 450 patients maintained in the program at 500-day follow-up.
2.Based available 450 samples, 447 patients with asthma had efficiently controlled their asthma—related symptom and 396 patients had significant improvement in pulmonary function test.
3.There was a significant reduction in health service utilization for known asthma enrolled in asthma disease management. Those significant reductions was 58.1% ~ 66.7% in emergency visits, emergency expenditure, hospitalizations and inpatient days, compared with priori year. However, there were also increasing in total health service utilizations, total health care expenditure, outpatients visits and outpatient expenditure was 74.0%, 83.6%, 84.5%, 110.3%, respectively. Patients in the intervention group had a triple reduction in inpatient days (1:3.00), but significant increasing in outpatient visits (1:0.61), outpatient cost (1:0.50), total health service utilizations (1:0.63), and total health care expenditure (1:0.57) , compared with the control group. For the newly-diagnosed asthma cases, patients in the intervention group had significant increasing in outpatient visits (1:0.43), outpatient expenditure (1:0.49), total health service utilizations (1:0.43), and total health care expenditure (1:0.49), compared with the control group.
4.More than 95% patients in the intervention group strongly agreed or agreed that the program empowered their self-care management.
Conclusion and Suggestions:
1.These results should have greater significance in the design of future programs in BNHI, TAIWAN aimed at improving the care of people with asthma and other chronic diseases.
2.We suggest BNHI use hierarchical referral system for reducing medical resource consumption of asthma.
3.To use medical resources more appropriately, the providers should construct a center database of asthma medical utilization for further analysis patients and disease patterns, to develop their own disease management program.

目　錄
第一章　緒論
第一節 研究緣起 1
第二節 研究問題 5
第三節 研究目的 7
第四節 名詞解釋 8
第二章　文獻探討
第一節 疾病管理的理論與評估 9
第二節 氣喘之相關疾病 13
第三節 氣喘病人醫療利用之實證研究 25
第四節 氣喘疾病管理試辦計畫 32
第三章　研究方法
第一節 研究架構 37
第二節 研究假說 38
第三節 研究對象與資料來源 39
第四節 研究變項定義 41
第五節 資料處理及統計方法 45
第四章　研究結果
第一節 氣喘醫療給付改善方案試辦概況 48
第二節 病患人口學特質 50
第三節 實驗組疾病嚴重度及PEF值前後測 53
第四節 實驗組與未完成組醫療資源使用概況56
第五節 實驗組醫療利用前後測比較 63
第六節 實驗組與未完成組醫療利用情形比較72
第七節 實驗組問卷調查結果 80
第五章　研究討論
第一節 研究限制 83
第二節 研究結果之討論 86
第六章　結論
第一節 結論 92
第二節 建議 95
參考文獻
中文文獻 99
英文文獻 101
附錄
附錄A、全民健康保險氣喘醫療給付改善方案試辦計畫107
附錄B、問卷 128
附錄C、氣喘共同照護系統病患資料登錄情形129

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