臺灣博碩士論文加值系統

背景
台灣自全民健保開辦以來，民眾的就醫方便性與可近性已獲得大幅改善，於是如何在有限的醫療資源下創造高品質的醫療服務是我們現今面臨的課題。以氣喘照護為例，雖然衛生署國民健康局早在各專科醫學會的合作下出版了台灣氣喘診療指引，但臨床指引的落實與執行程度卻不甚理想，各醫院間病人感受的醫療品質也差異甚大。因此本研究以氣喘住院病人為研究對象，探討國內醫院在氣喘住院品質結構面、過程面與結果面品質的現況以及各層面間的關聯性。
目的
探討台灣氣喘住院醫療的品質狀況，並分析過程面品質、醫院結構面品質與病人報告之結果面的相關性。
方法
本研究以2002年與2004年全民健保出院病人服務調查中氣喘病人調查結果為研究材料，並配合病人住院時醫令與費用資料，建構7項臨床指引執行度(guideline adherence)指標代表照護過程面品質狀況。並納入醫院評鑑醫院自填項目的內容，進行病人層次與醫院層次之醫療品質描述性與推論性統計分析。
結果
不同評鑑等級與權屬別醫院的病人滿意度結果，在病人層次與醫院層次上均有統計上顯著的差異。過程面品質方面，在7項氣喘住院臨床指引執行指標中，以給予全身性類固醇的執行比率(83.13%)為最高，PEF量測(16.87%)為最低，平均每位病人在醫療過程中臨床指引執行項目為3.42項。另外病人出院後是否會因氣喘再入院的情形，也與病人接受服務之臨床指引執行程度(guideline adherence)有關。醫院層次分析結果，臨床指引執行程度平均分數為3.44分，公立醫院與法人醫院其臨床指引執行程度平均分數顯著高於私人醫院之平均分數。
相關分析部份，臨床指引執行程度得分與醫師面、病人面及環境面之病人滿意度平均分數顯著相關，醫院層次上臨床指引執行程度平均分數則與病人滿意度分數、護理人員大學學歷以上比率顯著相關。以複回歸分析，醫院ICU平均住院日、護理人員大學學歷(含)以上比率、醫院權屬別等變項可解釋臨床指引執行程度得分(依變項)的變異；臨床指引執行程度得分、ICU平均住院日、ICU死亡率、醫院評鑑等級等變項則可解釋病人滿意度分數的差異。
結論
氣喘住院病人滿意度會因就醫醫院之評鑑等級與權屬別而有所差異，而住院期間照護的實質過程與臨床指引的建議處置仍有一定程度的差距。建議未來研究者可以對完整的氣喘照護過程與結果做進一步的分析追蹤。

關鍵字：氣喘 醫療品質 臨床指引 病人滿意度

Abstract
Background:
Although the convenience and access to healthcare have been greatly improved since the implementation of National Health Insurance in Taiwan, the quality of healthcare is still a crucial issue. Take asthma care as an example; the national clinical guideline on the management of asthma was published by DOH (department of health) Taiwan in 2001. The rate of guideline adherence is still poor and the quality among hospitals varys significantly from patients’ perspective. In this study we try to explore the structure, process and outcome perspectives of care quality for asthma inpatients in Taiwan and analyze the relationships among these 3 dimensions of quality measure.
Method:
We conducted 2 surveys of asthma inpatients service to investigate patients’ satisfaction and process of care in 2002 and 2004. To measure the process of care, we established 7 indicators in accordance with asthma clinical guidelines. Furthermore, we intergrated the self-reported hospital accreditation data for descriptive and inference analyses.
Results:
There are significantly differences of patient satisfaction scores on hospitals with distinctive accreditation level and ownership. Among the 7 indicators of guideline adherence, the highest rate of adherece is “systemic steroid given” (83.13%), while the rate of “PEF measurement” is the lowest. The average items (score) of guideline suggested treatment received by patients are 3.42 out of 7. In addition, the rate of readmission for the same disease was associated with the degree of adherence to the guideline suggested treatment.
In correlation and regression analyses, there are significant correlations between (1) guideline aherence score and patient satisfaction score (2) guideline adherence score and proportion of nurses with undergraduate or higher degree. The average of ICU lenth of stay, the proportion of nurses with undergraduate or higher degree and the ownership of hospital are significant independent variables to the guideline adherence score in the multiple regression model, while the hospital accreditation level, the guideline adherence score, and the average LOS and deathrate of ICU are significant independent variables to patient satisfaction score.
Conclusion:
Patient satisfaction scores of asthma inpatients vary among hospitals with different accreditation level and ownership. Moreover, the condition of asthma guideline adherence is not satisfactory. Further studies should be done to investigate the comprehensive measure of quality of asthma care.
Keywords: asthma, quality of care, clinical guideline, patient satisfaction

第一章 前 言 1
第一節 研究背景與動機 1
第二節 研究目的 2
第三節 研究流程 3
第二章 文獻探討 4
第一節 氣喘疾病現況 4
一、 氣喘的病因及分類 4
二、 氣喘流行病學 4
三、 氣喘的治療目標與處置計畫 5
四、 氣喘控制與治療方式 6
第二節 醫療照護品質相關研究 8
一、 醫療照護品質的定義、層面與品質指標 8
二、 醫院評鑑與結構面品質 14
三、 臨床指引與過程面品質 17
四、 病人報告醫療結果與結果面品質 20
五、 醫療品質層面間相關性研究 24
第三節 國內外氣喘醫療現況相關研究 27
第三章 研究方法 31
第一節 研究假設 31
第二節 研究架構 32
第三節 研究對象與研究材料 33
一、 研究對象 33
二、 研究材料 33
三、 研究變項與操作型定義 36
第四節 資料處理與分析方法 43
一、 資料處理 43
二、 分析方法 44
第四章 研究結果 45
第一節 樣本描述 45
第二節 氣喘住院病人滿意度調查結果 51
第三節 氣喘住院病人醫療過程面品質結果 61
第四節 醫療品質層面間相關推論分析 71
第五章 研究討論 82
第一節 研究限制 82
一、 研究樣本限制 82
二、 資料內容限制 82
第二節 結果討論 84
一、 氣喘病人滿意度結果討論 84
二、 臨床指引執行程度結果討論 84
三、 品質相關性討論 85
第六章 結論與建議 88
第一節 結論 88
第二節 政策建議 89
第三節 未來研究建議 90
參考文獻 91
附錄 96
全民健保出院服務調查問卷-氣喘病人 96
住院醫療費用清單暨醫令清單明細檔 103

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英文部分：
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