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研究生:黃麟珠
研究生(外文):Lynn-Chu Huang
論文名稱:台灣地區透析院所照護品質之探討
論文名稱(外文):An investigation of quality care among Dialysis Centers
指導教授:吳肖琪吳肖琪引用關係
指導教授(外文):Shiao-Chi Wu
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:衛生福利研究所
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:2004
畢業學年度:92
語文別:中文
論文頁數:1
中文關鍵詞:透析末期腎病品質死亡率
外文關鍵詞:dialysisESRDqualitymortality rate
相關次數:
  • 被引用被引用:3
  • 點閱點閱:193
  • 評分評分:
  • 下載下載:0
  • 收藏至我的研究室書目清單書目收藏:4
1999年台灣整體透析盛行率高居世界第二,慢性腎衰竭病患雖佔總保險人口0.15%,但其門住診透析的醫療費用就佔約5.6%健保總費用。慢性透析病患的醫療支出及住院率較高,許多國家會加強透析品質監控以減少住院率及死亡,本研究嘗試以健保透析申報資料,探討國內透析院所的照護品質。利用88年加密之「門診處方醫令明細檔」中透析醫令與「門診處方及治療明細檔」、「全民健保承保人口資料檔」、「全國戶政資料檔」、87、88年「死亡檔」等,進行分析,因透析病患可能有試醫行為,本研究依據病患88年至相同地點透析超過75%來定義忠實透析病患,並以病患至各透析院所透析比例採用加權方式計算機構的死亡率,且利用死亡率殘差值、標準化死亡比等方式來評量機構間的照護品質。
研究結果:88年忠實透析病患的比例佔透析病患84.15﹪。新病患中65~74歲、有高血壓、惡性腫瘤的病患忠誠度較低;舊病患中女性、有偶者、有其他心血管疾病的病患忠誠度較高,但有糖尿病等合併症者的忠誠度較低。控制病患及區域特質,機構特質如教學評鑑別等,發現病患有較低的死亡危險性。機構檔案分析結果,透析院所的平均粗死亡率為10.0%,死亡率較高的機構,儘管控制病患特質後,仍有較高的死亡率,教學評鑑別、機構的服務量、忠實透析病患比例會影響機構的照護品質,且標準化死亡比等方法亦可篩選出死亡率較高的透析機構。
建議政府應宣導並教育病患避免至多家透析院所接受治療,且避免選擇病患服務量太低的機構,以確保照護品質;健保局可利用機構死亡率、忠實透析病患比例作為品質指標,評量各透析院所照護品質之差異;透析院所應加強與男性、65~74歲、有合併症者的醫病關係,以滿足病患的照護需求。
Taiwan’s prevalence of chronic dialysis placed second around the world in 1999. Although patients with end stage renal disease (ESRD) were only 0.15% of the total insurants, their medical costs were 5.6% of the total medical cost. Other than the cost, the hospitalization rate for these patients was also higher. Many countries place surveillance on dialysis outcome to prevent over hospitalization and the high death rate associated with the disease. The purpose of this study was to assess quality of care among dialysis centers in Taiwan, we used the database for 1999 national health insurance inpatient and outpatient medical benefit, as well as the death records to analyze comparing types of treatment outcome among dialysis centers, such as the differences between observed and expected mortality rates, and standardized mortality ratio. Patients with end-stage renal disease could have doctor shopping behaviors, by using administrative data, patients were categorized as having a regular source of care if they made 75% or more of their total dialysis treatment within the same place.
The result indicated that among the chronic dialysis patients, 84.15% had a regular source of care. For new patients who were 65~74 years and having comorbidity ( hypertension, malignancy), the rate of having a regular source of care is lower than other groups. For old patients who were female, married and having other cardiovascular disease, the rate of having a regular source of care is higher than other groups. But old patients who have comorbidity (eg, diabetes) , the rate of having a regular source of care is lower than other groups. Significant lower risk of death were found for facilities such as hospital accreditation when controlling for patients and regional variables. The result for facility profile analysis showed that crude mortality in these centers was 10.0% when controlling for patients characteristics, many dialysis centers with the highest unadjusted death rates remained among the facilities with the highest adjusted mortality. Dialysis centers with higher service volume and higher proportion of patients with a regular source of care could affect quality of care. The technique of standardized mortality ratio (SMR)should be able to identify outliner centers.
This study suggested that the government should encourage and educate dialysis patients to have a regular source of care and not to receive treatments in the dialysis center with lowest service volumes. The Bureau of National Health Insurance could use the facility mortality rate, the proportion of patients having a regular source of care in dialysis centers as quality indicators of care and to identify variations in quality among different dialysis centers. The dialysis centers should strengthen their relationships with patients who are male, 64~75 years ,divorced, widowed, new patients, or having comorbidity by improving medical staff relation to meet patients’ demand.
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