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研究生:蔡君婷
研究生(外文):Chun-Ting Tsai
論文名稱:出院後重返加護病房病人之病人特性及其醫療資源耗用
論文名稱(外文):Patient Characteristics and Medical Resources Utilization of Intensive Care Patients Who Discharged from Hospitals and then Readmitted to Intensive Care Units
指導教授:薛亞聖薛亞聖引用關係
指導教授(外文):Ya-Seng Hsueh Ph. D.
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:醫療機構管理研究所
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2004
畢業學年度:92
語文別:中文
論文頁數:111
中文關鍵詞:病人安全以病人為中心加護病房醫療品質醫療資源耗用重返加護病房品質指標健康保險
外文關鍵詞:Patient safetyPatient centered careIntensive care unitMedical qualityMedical resources utilizationReadmission to ICUQuality indicatorHealth insurance
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摘要
加護病房是收治病情較嚴重與危急病人的醫療救護單位,也是醫院中醫療人力、儀器設備最為密集,耗用醫院大量資源的地方,隨著老年人口的增加,對加護病房的需求也相對提高,如1994年美國的加護病床雖只佔所有病床的10%,加護醫療所耗用的資源卻高達醫療支出的30%。另一方面,由於健康保險對於醫療申報費用的管控,病人在加護病房留置過久,醫療申報費用也會遭到刪減,造成醫院財務上的損失。但若過早將病人移出加護病房,除了可能會因病情不穩定而重返加護病房,且耗費更多的醫療資源,造成病人及醫院財務上的損失。
由於重返加護病房,不但對醫療資源的耗用有相當程度的影響,在醫療品質上更有監控管理的積極意義,故美國急救加護醫學會已將重返加護病房列為重要的品質指標,而醫策會亦將非計畫性重返加護病房列為TQIP的急性照護的品質指標。但是隨著支付制度及以「病人為中心」的醫療照護整合觀念的改變,在評估整體住院醫療品質及醫療資源使用情形時,不能只觀察該病人在當次住院的情形,而是應該觀察這個病人在這此健康照護組織,甚至是在整個醫療體系中所遭受到的待遇,以及最後得到的健康產出結果,因此本研究針對出院後重返加護病房的病人進行現況的探討,並進一步分析其病人特性及其醫療資源利用及耗用。
本研究採用次級實證資料分析,透過全國性的健保申報資料庫對不同層級醫院間及跨院間出院後重返加護病房進行探討,除了瞭解台灣地區加護病房病人整體及出院後重返之現況,評估加護病房病人出院後重返的醫療資源重複使用之現象,並探討出院後重返加護病房作為品質指標的適當性。
研究結果顯示,出院後重返加護病房的危險因子,在人口性別分佈以男性居多、在年齡分佈則以65歲以上的老人族群居多。在疾病型態分佈上,以心血管疾病、呼吸道疾病為主,其次為敗血症、消化道疾病;在慢性病方面,則以慢性肝病及肝硬化及糖尿病為主,而疾病次診斷數越多,其出院後重返的機率則越高。
另外,從研究結果中發現:有出院後重返的前次住院之住院天數較其他加護病房住院人次的住院天數短,則有可能是因為在前一次住院的健康狀態未穩定即出院,而造成出院後重返加護病房的現象發生。而從出院後重返不同家醫院的死亡分佈來看,其出院後重返醫院的評鑑層級越較原醫院低,則死亡率越高,若以層級間轉院的角度來看,大部分出院後重返不同醫院往高層級或往同層級的醫院,此現象應該是合理的,但少部分轉往較低層級的醫院,無法獲得以較佳儀器設備的高密集加護醫療服務,導致其存活率下降,則推論可能有病人傾棄的現象存在。
因為健保資料庫欄位缺損,導致本研究無法更進一步針對同一次住院重返加護病房的情形進行探討,因此本研究建議衛生行政當局保留健保資料庫醫令起迄日欄位,並增添有關病人臨床資訊,如APACHE Ⅱ的診斷碼及分數的欄位,則能透過資料庫分析,對轉入及轉出加護病房的病患進行評估,對日後病人管理及學術研究則有莫大助益。此外,本研究結果發現出院後重返加護病房病人的死亡率、醫療資源利用及耗用情形的確明顯較其他加護病房住院人次高,因此建議可將「出院後重返加護病房」納入整體住院醫療品質指標的監測,但不宜作為獎懲醫院的工具,否則恐會造成刮脂效應的產生;另一方面,應加強分級醫療及確立轉診制度,並以「病人為中心」作醫療資訊的整合,則可減少及降低可避免的醫療費用支出。
Abstract
The intensive care units (ICUs) are the medical units which admit critical patients. ICU requires intensive manpower and equipment in the hospital, and utilizes a significant portion of hospital resources. With the increase of aging population, the demand for ICUs grows. Taking an example of the United States, though the number of ICU beds accounted for 10% of all hospital beds, the resources the intensive care utilizes were accounted for 30% of health expenditure in 1994. On the other hand, due to the tight control of health insurances expenditures, the longer the LOS in ICUs are, the more possible the medical claims would be cut down and damage to hospital finance. However, excessively early transferring from ICUs will not only readmit the patients back to ICUs, but also utilize more medical resources, and damage to patients and hospital finance.
The management of readmission to ICU can improve the utilization of medical resources; it has positive influence on medical quality control at the same time. According to these, the Society of Critical Care Medicine Task has set it as one of the important quality indicators, and Taiwan Joint Commission on Hospital Accreditation also has set it as an intensive care indicator of the Taiwain Quality Indicator Project (TQIP). However, with the payment system and the integrated patient centered health care orientation changing, we not only observe the patients’ status of admission, but also the treatment and final health outcome in one’s HMO, even the whole health care system while evaluating the medical quality of admission and medical resources utilization. Therefore, this study discusses the present condition of patients who discharged from hospitals and then readmitted to ICUs, and analyzed their characteristics and medical resources utilization.
This is a secondary empirical data analysis study. Through the analysis of nation-wide NHI database, we probe the present situations of the post-discharging readmission to ICUs in the same and different hospitals among multi-level hospitals, in order to understand the ICU patients in Taiwan and their readmission to ICUs. Also, we would like to appreciate the appropriateness of taking post-discharging readmission to ICUs as one of the quality indicators.
The results show that gender, age, and disease pattern are the risk factors of post-discharging readmission to ICUs. Male and aged 65 years old and upper take the majority of these patients. We discover that cardiovascular and respiratory diseases are their major diagnoses, septicemia, and gastroinstinal diseases appear the next. In the chronic disease diagnoses, chronic liver diseases and liver cirrhosis often give the priority. Notably, the more the second diagnoses are, the higher the probability of post-discharging readmission to ICUs is.
Furthermore, the results show that the patients with post-discharging readmission to ICUs experience had shorter LOS in their preceding hospitalization than the ones without this experience. The reason to explain these could be the excessively early transferring of the patient whose unstable health conditions and it brought out the later readmission to ICUs. Judging from the death rate of post-discharging readmission to ICUs in different hospitals, we find higher mortality in lower level hospital where the patients readmitted to ICUs. It is reasonable that most patients readmitted to ICUs in higher or the same level hospitals, but the results show that there are still a little ones readmitted to lower level hospitals, lacking of better equipments and higher density intensive care service, the survival rate of the readmitted patients dropped, indicating that patient dumping might exist. Due to the column loss of NHI database, we cannot discuss the readmission to ICUs in the same hospitalization for further. Besides, this study finds that the patients who discharged from hospitals and then readmitted to ICUs have higher mortality and medical resources utilization.
According to the above findings, this study suggests that the health related authorities should keep the columns denote the tire of beginnings and endings of the medical orders, and add the clinical information related to the patients, such as the diagnostic codes and scores of APACHE II. Thus, by analyzing the database, we can evaluate the patients admit to or transfer from ICUs, and benefit to patient management and academic researches in the future. This study also suggests that we can absorb the concept, post-discharging readmission to ICUs management, in the monitor of total admission medical quality, but we should avoid to use it as part of the bonus-penalty system in case of the cream skimming effect. On the other side, we should enhance the system of differential medical facilities and referral, and integrate the patient centered medical information, so that we can decline the avoidable health expense.
目 錄
致謝......................................................Ⅰ
中文摘要..................................................Ⅳ
英文摘要..................................................Ⅵ
目錄......................................................Ⅷ
圖表目次..................................................Ⅸ
第一章 緒論...............................................1
第一節 研究緣起.........................................1
第二節 研究動機 .........................................4
第三節 研究目的 .........................................6
第二章 文獻探討...........................................7
第一節 加護病房之資源配置及資源耗用.....................7
第二節 加護病房住出院標準..............................13
第三節 重返加護病房相關研究............................17
第四節 病人傾棄之發生原因及影響........................26
第五節 文獻總結........................................28
第三章 研究方法..........................................29
第一節 研究設計........................................29
第二節 概念性架構......................................34
第三節 研究假說 ........................................35
第四節 研究變項........................................36
第五節 研究材料與方法..................................37
第六節 統計方法 ........................................40
第四章 研究結果..........................................41
第一節 台灣地區加護病房病人之現況......................41
第二節 台灣地區加護病房病人出院後重返之現況............59
第五章 綜合討論..........................................86
第一節 出院後重返加護病房病人之分佈....................86
第二節 出院後重返加護病房病人之醫療資源利用與耗用......91
第三節 出院後重返加護病房之危險因子....................94
第四節 研究限制........................................96
第六章 結論與建議........................................98
第一節 結論............................................98
第二節 建議...........................................103
參考文獻.................................................106
圖 表 目 次
表目錄
表2-1-1 工業國家加護病床統計.............................8
表2-1-2 台灣地區加護病床統計.............................9
表2-2-3 民91年臺灣地區醫院病床數及加護病床數
─按評鑑等級分...................................9
表2-1-4 各國加護病床佔床率及住院天數統計................11
表2-1-5 臺灣地區歷年醫院醫療服務量統計─平均住院日......12
表2-1-6 民91年臺灣地區醫院患者佔床率及平均住院日數
─按評鑑等級別分................................12
表3-4-1 研究變項與操作型定義............................36
表3-5-1 90年設有加護病床醫院分佈情形....................38
表4-1-1 台灣地區90年整體及不同評鑑層級別加護病房病人
之病人特性......................................46
表4-1-2 台灣地區90年不同權屬別及教學性質加護病房病人
之病人特性......................................47
表4-1-3 90年加護病房病人疾病診斷分佈....................48
表4-1-4 90年醫學中心加護病房之疾病診斷分佈..............49
表4-1-5 90年區域醫院加護病房之疾病診斷分佈..............50
表4-1-6 90年地區醫院加護病房之疾病診斷分佈..............51
表4-1-7 台灣地區90年整體及不同評鑑層級別加護病房病人
之醫療資源耗用..................................52
表4-1-8 台灣地區90年不同權屬別及教學性質加護病房病人
之醫療資源耗用..................................53
表4-1-9 90年加護病房病人住院人次死亡人數統計............54
表4-1-10 90年加護病房病人之病人平均年齡..................54
表4-1-11 90年加護病房病人不同性別之年齡分佈..............55
表4-1-12 90年加護病房病人住院人數、住院日數及死亡人數....55
表4-1-13 90年加護病房病人醫療資源利用....................56
表4-2-1 有無出院後重返加護病房經驗病人之年齡分佈........68
表4-2-2 有無出院後重返加護病房經驗病人之病人特性........68
表4-2-3 出院後連續重返加護病房病人之性別分佈............69
表4-2-4 出院後連續重返加護病房病人之年齡分佈............69
表4-2-5 出院後重返與其他加護病房住院人次之觀察值特性分佈70
表4-2-6 出院後重返加護病房病人疾病診斷分佈..............71
表4-2-7 出院後重返加護病房病人「是否因原疾病診斷重返醫院」
之分佈..........................................72
表4-2-8 因原住院診斷出院後重返之疾病診斷分佈............73
表4-2-9 出院後重返加護病房之前後次住院醫療資源耗用......74
表4-2-10 其他住院人次之醫療資源耗用與出院後重返加護病房
前次住院之比較..................................74
表4-2-11 其他住院人次之醫療資源耗用與出院後重返加護病房
後次住院之比較..................................75
表4-2-12 不同出院後重返加護病房類型之年齡分布............75
表4-2-13 「重返同一家醫院」與「重返不同家醫院」
之病人特性(1)................................76
表4-2-14 「重返同一家醫院」與「重返不同家醫院」
之病人特性(2)................................76
表4-2-15 「重返同一家醫院」之疾病診斷分佈................77
表4-2-16 「重返不同家醫院」之疾病診斷分佈................78
表4-2-17 「重返同一家醫院」與「重返不同家醫院」
之醫療資源耗用.................................79
表4-2-18 出院後重返同一家醫院之病人特性分佈(1).........80
表4-2-19 出院後重返同一家醫院之病人特性分佈(2).........80
表4-2-20 出院後重返不同家醫院之病人特性分佈(1).........81
表4-2-20 出院後重返不同家醫院之病人特性分佈(2).........81
表4-2-22 出院後重返同一家醫院之醫療資源耗用..............82
表4-2-23 出院後重返不同家醫院之醫療資源耗用..............83
表4-2-24 連續出院後重返加護病房之住診類型分佈............84
圖目錄
圖1-1-1 2002非計畫性重返加護病房.........................3
圖2-2-1 台灣地區歷年醫院醫療服務量統計─平均住院日......11
圖3-1-1 加護病人出院後重返加護病房流程示意圖............29
圖3-2-1 研究架構概念圖..................................34
圖3-5-1 資料篩檢及研究對象選取流程 .....................39
圖4-1-1 90年加護病房病人住加護病房情形..................58
圖4-1-2 90年加護病房住院檢查與診察費用佔總醫療費用比例..58
圖4-2-1 連續出院後重返加護病房之住診類型分佈(1).......84
圖4-2-2 連續出院後重返加護病房之住診類型分佈(2).......85
圖4-2-3 連續出院後重返加護病房之住診類型分佈(3).......85
參考文獻
【英文部分】
Angus, D.C. (1998). Grappling with intensive care unit quality: Does the readmission rate tell us anything ? Critical Care Medicine, 26(11), 1779-1780.
Ansell, D.A., Schiff, R.L.(1987) Patient dumping status, implications, and policy recommendations. Journal of the American Medical Association, 257(11), 1500-1502.
Baigelman, W., Katz, R., & Geary G. (1983) Patient readmission to critical care units during the same hospitalization at a community teaching hospital. Intensive Care Medicine, 9,253-256.
Chen, L. M., Martin, C. M., Morrison, T. L., & Sibbald, W. J. (1999). Interobserver variability in data collection of the APACHE II score in teaching and community hospitals. Critical Care Medicine, 27(9), 1999-2004.
Chen, L. M., Martin, C. M., Keenan, S. P., & Sibbald, W. J. (1998). Patients readmitted to the intensive care unit during the same hospitalization: Clinical features and outcomes. Critical Care Medicine, 26(11), 1834-1841.
Cooper, G.S., Sirio, C. A., Rotondi, A. J. (1999). Are readmissions to the intensive care unit a useful measure of hospital performance? Medical Care, 37(4), 399-408.
Dawson, J.A. (1993) Admission, discharge, and triage in critical care. Principles and practice. Critical Care Clinics. 9(3):555-74.
Dawson, S., & Runk, J. A. (2000). Right Patient? Right Bed? A Question of Appropriateness. Advanced Practice in Acute & Critical Care, 11(3), 375-385.
Durbin, C. G. & Jr, Kopel RF. A (1993) Case-control study of patients readmitted to the intensive care unit. Critical Care Medicine, 21, 1547-1553.
Groeger, J.S., Strosberg, M.A., Halpern, N.A., Raphaely, R.C., Kaye, W.E., Guntupalli, K.K., Bertram, D.L., Greenbaum, D.M., Clemmer, T.P., Gallagher, T.J., et al. (1992) Descriptive analysis of critical care units in the United States. Critical Care Medicine, 20(6), 846-863.
Halpern, N.A., Wang J.K., Alicea M., & Greenstein R.(1994) Critical care medicine: observations from the Department of Veterans Affairs'' intensive care units. Critical Care Medicine, 22(12), 2008-2012.
Halpern, N.A., Bettes, L., & Greenstein, R.(1994)Federal and nationwide intensive care units and healthcare costs: 1986-1992. Critical Care Medicine, 22(12), 2001-2007.
Keenan, S.P., Dodek, P., Chan, K., Simon, M., Hogg, R.S., Anis, A.H., Spinelli, J.J., Tilley, J., Norena, M., Wong, H.(2004) Intensive care unit survivors have fewer hospital readmissions and readmission days than other hospitalized patients in British Columbia. Critical Care Medicine. 32(2), 391-398.
Kellermann, A.L., Hackman, B.B.(1988) Emergency department patient ‘puming’: an analysis of interhospital transfer to Regional Medical Center at Memphis, Tennessee. American Journal of Public Health, 78(10), 1287-1292.
Knaus, W.A., Draeper, E.A., Wagner, D.P. & Zimmerman, J.E.(1985) APACHE Ⅱ: A severity of disease classification system. Critical Care Medicine, 13(10), 818-829.
Konarzewski, W. (2000). Continuing to use APACHE II scores ensures consistency. British Medical Journal, 321(7257), 383.
Kramer, D. J. ( 2001). Intensive care unit frequent fliers: Morbidity and cost. Critical Care Medicine, 29(1), 207-208.
Lin, H.C., Chen, C.C., Kuo, N.W., Chang, Y.P. (2002) A review of literature on patient dumping. New Taipei Journal of Medicine, 4(3), 145-150.
Luthi, J.C., Burnand, B., McClellan, W.M., Pitts, S.R., Flanders, W.D.(2004) Is readmission to hospital an indicator of poor process of care for patients with heart failure? Quality & Safety in Health Care. 13(1), 46-51.
Relman, A.S.(1986) Texas eliminates dumping. A start toward equity in hospital care. New England Journal of Medicine, 314(9), 578-579.
Robert, J.W. , Sandra, L.K., Vincent, A.O., Melissa, S., Susan, J.S. ,& Joseph, F.D. (2003)Impact of intensive care unit (ICU) drug use on hospital costs: a descriptive analysis, with recommendations for optimizing ICU pharmacotherapy. Critical Care Medicine, 31(1 Suppl),S17-24.
Rosenberg, A. L., & Watts, C.M. (2000). Patients readmitted to intensive care units: A systematic review of risk factors and outcomes. Chest, 118(2), 492-502.
Rosenberg, A. L., Hofer, T. P., Hayward, R. A., Strachan, C., & Watts, C. M. (2001). Who bounces back? Physiologic and other predictors of intensive care unit readmission. Critical Care Medicine, 29(3), 511-518.
Rosenberg, A. L., Zimmerman, J. E., Alzola, C., Draper, E. A., & Knaus, W. A. (2000). Intensive care unit length of stay: Recent changes and future challenges. Critical Care Medicine, 28(10), 3465-3473.
Shann, F. (2000). Mortality prediction model is preferable to APACHE. British Medical Journal, 320(7236), 714.
Smith, G.., Nielsen, M. (1999) ABC of intensive care criteria for admission. British Medical Journal, 318(5), 1544-1547.
Society of Critical Care Medicine Task Force on Guidelines. (1988) Recommendations for intensive care unit admission and discharge criteria. Critical Care Medicine, 16,807-808.
Sznajder M., Aegerter P., Launois R., Merliere Y., Guidet B., & CubRea. (2001) A cost-effectiveness analysis of stays in intensive care units. Intensive Care Medicine, 27(1),146-153
Schlesinger, M., Bentkover, J., Blumenthal, D., Musacchio, R., Willer, J.(1987) The privatization of health care and physicians’ perceptions of access to hospital services. Milbank Quarterly, 65(1), 25-58.
Schlesinger , M., Dorwart, R,. Hoover, C., Epstein, S. (1997) The determinants of dumping:a national study of economically motivated transfer involving mental health care. Health Service Research, 32(5), p561-590.
Shann, F. (2000). Mortality prediction model is preferable to APACHE. British Medical Journal, 320(7236), 714.
Thomas, J. W. (1996). Does risk-adjusted readmission rate provide valid information on hospital quality? Inquiry, 28, 258-264.
Tarnow-Mordi, E. O., Hau, C., Warden, A., & Shearer, A. J. (2000). Hospital mortality in relation to staff workload: A 4 year study in an adult intensive-care unit. The Lancet, 356(9225), 185-189.
Teres, D., Higgins, T., Steingrub, J., Loiacono, L., McGee, W., Circeo, L., Brunton, M., Giuliano, K., Burns, M., Gall, J.R.L., Artigas, A., Strosberg, M., Lemeshow, S. (1998) Defining a high-performance ICU system for the 21st century: a position paper.Journal of Intensive Care Medicine, 13(4),195-205.
Weissman, J.S. (1997) Commentary:economic transfers, the change face of a familiar problem. Health Service Research, 32(5), 591-598.
【中文部分】
中央健保局網站:http://www.nhi.gov.tw。
余金燕、潘德樑(2003)疾病分類實務,合計圖書出版社。
余秀芳(2003)台灣地區病人重複住院之分析。國立台灣大學衛生政策與管理研究所碩士論文。
行政院衛生署網站:http://www.doh.gov.tw/NewVersion/index.asp。
行政院衛生署(2000)全民健康保險醫療費用支付標準。
李瑞華(1999)國際疾病分類指引,南山堂出版社。
吳肖琪、吳義勇、朱慧凡等(2002)我國醫院醫療品質指標使用之情形。醫療品質雜誌,4(2),p1-14。
林世崇、丁予安、曾春典等(2001)台灣加護病房住出院標準草案之共識。中華民國重症醫學雜誌,3(3),p15-20。
林麗華(2002)加護病房分級評鑑之研究。國立陽明大學醫務管理研究所碩士論文。
范碧玉(1999)ICD-9-CM分類規則彙編,中華民國病歷管理學會。
唐高駿(1998)加護病房之使用及成本效益。臨床醫學,41(6),434-437。
陶阿倫(1998)怎麼確保加護病房之病患嚴重度資料完整正確。醫療品質雜誌1(1),p1-11。
陶阿倫、許天成(2000)加護病房評估疾病嚴重度之資料正確性。醫療品質雜誌3(2),p13-17。
陶阿倫、薛亞聖(2002)非計畫性重返病人特質及其資源耗用研究─以加護病房為例。台灣醫療品質指標理論與應用,台北:合記圖書出版社。
陶阿倫、薛亞聖(2003)成人加護病房重返與非重返病人之資源耗用及住院天數差異之研究。行政院衛生署醫政業務補助計畫─台灣醫療品質指標計畫資料探討及運用計畫。
莊玉仙(2001)加護病房病患疾病嚴重度與護理人力需求之探討,國立高雄醫學大學碩士論文。
財團法人醫院暨醫療品質策進會(2003)台灣醫療品質指標計畫─急性照護指標2002年統計年報。
鄭聰美(2002) 臺北市立綜合醫院加護病患不同時段轉出的預後比較。國立台北護理學院醫護管理學系碩士論文。
盧瑞芬、謝啟瑞(2000)醫療經濟學。學富事業文化有限公司。
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