臺灣博碩士論文加值系統

　　總額支付制度後，醫院急診部門之地位日益重要，因此，瞭解急診部門影響醫療耗用及醫療品質之原因，成為各醫務管理者的重要任務，而急診部門又以非計劃性返診指標最為重要且最常被討論。
　　本研究參考Donabedian(1988)之醫療服務品質評估模式，利用北區某醫學中心之急診病患與批價等資訊，以結構及過程兩大構面，探討影響急診部門中非計劃性返診之相關因素。共收集140,393筆資料，研究期間為2005年1月1日至2005年12月31日。
　　結果發現：(一)急診部門中非計劃性返診之病患，其平均醫療耗用確實比一般急診病患來得高，也造成了急診部門中無效率的管理；(二)在結構面與過程面，病患性別、病患年齡、抵達班別、疾病別、就醫科別、醫師性別和滯留時間與處置次數等因素，均與非計劃性返診有顯著相關，而在進一步之分層分析中發現，精神疾患、腫瘤以及老年人、兒童、中低醫療投入等特性之組合為高危險之族群。
　　總結來說，非計劃性返診之病患顯著增加急診部門醫療耗用的負擔，而分析結果也顯示其耗用是可以避免的，因此，本研究提出以下幾點建議：(一)醫院管理上，對於高危險群之病患，以個案追蹤、衛教輔導以及資訊系統強化之方式，減少此部份之醫療耗用；(二)加速住院流程或輔導轉院等，使有需求之患者能即時接受更一步之治療，提高整體的醫療品質。

　　The management of emergency room has become an important issue in a medical setting under global budget payment system. Both issues in medical cost containment and quality control are not dilemma for hospital administrators to any further extent because of the policy requirements. Therefore, the unplanned revisit following an emergency visiting is selected as a succinct indicator for medical quality of emergency room patients.　
　　This research has adopted the model of health service quality reported by Donabedian to evaluate the quality of emergency service. A total of 140,393 visits in the year of 2005 extracted from database of emergency room were used to further analyze. The objectives of this study are two folds. Firstly, the difference of total medical consumptions between patients of non-revisiting and unplanned revisiting in emergency room was investigated. Secondly, the associated factors of unplanned revisits were studied from the aspects of quality dimensions such as structure, process, and outcome.
　　The major findings of this analysis are summarized as follows.
1.The medical consumption of unplanned revisit was 7,444 NT 　　dollars per visit higher than 3,214 of non-revisiting patients. The hiking of medical consumption was in part attributable to inefficiency of management in emergency room.

2.Further examination of cases unplanned revisit, the study has demonstrated that factors such as sex, age, arriving time, causes of disease, numbers of treatment, and length of stay were significantly associated.

3.Patients diagnosed with manifestation of psychological disorders and cancers are likely to revisit again. Those who were inadequately treated are tended to come back with the same reason. A U-shape relationship was observed in the variable of age while examining the factors associating with unplanned revisit of emergency room.

　　The study has further elaborated that unplanned revisiting can be avoided in some extents hence reducing the medical consumption. Strategies were derived to enhance efficiency of management. Professional training, information platform, and process improvement were advised as key plans for the goal to be met.

第一章　緒論 1
第一節　研究背景與動機 1
第二節　研究目的 4
第三節　預期貢獻 5
第二章　文獻探討 6
第一節　急診醫療服務 6
第二節　醫療品質指標 11
第三節　非計劃性返診指標之重要性 15
第四節　非計劃性返診的影響因素 17
一、結構面之影響因素 17
二、過程面之影響因素 19
第三章　研究材料與方法 21
第一節　研究材料及對象 21
一、研究材料 21
二、研究對象 24
第二節　研究假設 25
第三節　研究方法 26
第四節　研究變項與操作型定義 27
第四節　研究變項與操作型定義 28
第四章　研究結果 30
第一節　研究樣本基本特性描述 31
一、急診病患特性 31
二、看診醫師特性 32
三、過程面 33
第二節　醫療耗用 38
第三節　非計劃性返診之相關因素 40
一、單變量分析 40
二、多變量分析 44
第四節　非計劃性返診之高危險族群 52
一、病患年齡與疾病別組合 52
二、就醫科別與疾病別組合 54
三、滯留時間與處置項目數組合 55
第五章　討論 60
第一節　非計劃性返診之高危險族群 61
一、相關因子 61
二、高危險族群 66
三、於管理上的意涵 67
第二節　研究限制 69
第六章　結論與建議 70
第一節　結論 70
第二節　建議 72
參考文獻 74

英文部份
Baker R, “Practice assessment and quality of care”, Journal of the Royal college of general practitioners-occasional paper, 39, pp. 1-30, 1992.
Compbell SM, Roland MO, Buetow SA, “Defining quality of care”, Social Science and Medicine, 35,7, pp. 857-868, 2000.
Cutler D.M. and R.J. Zeckhauser, Handbook of Health Economics, pp. 563-643, North Holland, 2000.
Decker Kandall D, Strategy for data collection bilingual communities, pp. 243-48, Horsleys Green, 1991.
Donabedian A, “The quality of care: How can it be assessed”, Journal of the American Medical Association. 8,4, pp. 401-407, 1988.
Evaline A, Alessandrini MD, et al, “Return visits to a pediatric emergency department”, Pediatric Emergency Care, 20, pp. 166-171, 2004.
Graff L, Mucci D, Radford MJ, “Decision to hospitalize: objective diagnosis-related group criteria versus clinical judgment”, Ann Emerg Med, 17, pp. 943-952, 1988.
Goleman D, Emotional intelligence: working with emotional intelligence, Bantom Books, New York, 1998.
Hanlon JJ, Pickette GE, Public Health and Administration and Practice, CV Mosby Co, pp. 711, 1978.
Hu SC, “Analysis of patient revisits to the emergency department”, American journal of emergency medicine, 10, pp.366-370, 1992.
Hung SC, Chew G, Kong CT, et al, “Unplanned emergency department revisits within 72 hours”, Journal of Taiwan emerg Med, 6, pp. 230-237, 2004.
Kazandjian VA, Lawthers J, Cernak CM, et al, “Relating outcome to process of care: The Maryland Hospital Association’s Quality Indicator Project”, Joint Commission Journal on Quality Improvement, 19, pp. 530-538, 1993.
Keith, MD Bocka JJ, Kobernick MS, et al, “Emergency department revisits”, Ann Emerg Med, 18, pp. 964-968, 1989.
Lerman B, Kobernick MS, “Return visits to the emergency department”, Journal of Emerge Med, 5, pp. 359-362, 1987.
Liaw SJ. Michael J. Bullard. Hu PM. Chen JC. Liao HC, “Rates and causes of emergency department revisits within 72 hours”, Journal of Formos Med Assoc, 98, pp. 422-25, 1999.
Lynn SG, Hockberger RS, kellermann A, et al, “A report from the American college of emergency physicians task force on hospital overcrowding and emergency department overload”, American College of Physician, September 1989.
Mancini Gale, “Emergency care and the law, an Aspen System Corporation”, pp. 43-50, 1981.
Mastard CA, et al, “Emergency department use as a component of total ambulatory care: a population perspective”, CMAJ, 158, pp. 49-55, 1998.
Miro O Antonio MT, Jimenez S, et al, “Decreased health care quality associated with emergency department overcrowding”, Eur J Emerg Med, 6, pp. 105-107, 1999.
Rusnak RA, Stair TO, Hansen K, et al, “Litigation against the emergency physician: common features in cases of missed myocardial infarction”, Ann Emerg Med, 18, pp. 1029-1039, 1989.
Steffen GE, “Quality medical care: A definition”, Journal of the American Medical Association, 260, 1, pp. 56-61, 1988.
Sylvie C, “Intervention to decrease emergency department crowding: Does it have an effect on return visits and hospital readmissions” Annals of Emergency Medicine, 41, pp. 173-185, 2003.
Tarlov AR, Ware JE, Greenfiled S, Nelson EC, Perrin E, Zubkoff M, “The medical outcomes study: An application of methods for monitoring the results of medical care”, Journal of the American Medical Association, 262, 2, pp. 925-30, 1989.


中文部份
丁修文，「急診醫療結果面品質影響因素之探討－以某區域教學醫院兒科氣喘急診病患為例」，國立中山大學，碩士論文，民國九十三年。
李玉春，「全民健保門診前瞻性支付制度之研究－門診病人群組之可行性分析」，行政院衛生署委託研究計劃，民國八十七年。
李文正、廖訓禎、廖浩欽、楊坤儒、林忠順、駱聰成，「急診72小時內再回診病人誤診的比率和原因」，台灣急診醫學會醫誌，第四卷，105-110頁，民國九十一年。
沈希哲等，「由TQIP資料探討台灣地區非計劃性重返急診相關醫療品質特性」，財團法人醫院評鑑暨醫療品質策進會，台北，民國八十七年。
吳肖琪，「評估醫院醫療品質指標」，行政院研究發展考核委員會，台北，民國八十八年。
林富滿(2000)，「台灣醫療品質指標系統的建立與時佳醫療機構可行性測試結果」，台北醫學大學，碩士論文，民國八十九年。
李芳年(2000)，「急診病人的資源耗用-以台北市某區域教學醫院為例」，國立陽明大學，碩士論文，民國八十九年。
胡勝川，「急診醫學今日與未來」，台灣醫界，第四十卷第一期，57-58頁，民國八十六年。
莊逸洲、黃崇哲，醫療機人力資源管理，華杏出版社，台北，民國八十九年。
莊逸洲、黃崇哲，醫院功能與管理－門診、急診、住院，華杏出版社，台北，民國九十四年。
黃金安、賴其勛、翁瑞宏、胡為雄、楊大羽，「病患非計劃性重返急診之因素分析－以病人觀點探討」，台灣急診醫學會醫誌，第六卷，306-313頁，民國九十三年。
廖熏香、楊漢泉，「淺談台灣醫療品質指標計劃」，醫院，第三十二卷，7-11頁，民國八十九年。
顏瑞昇、石富元、蔡光超、陳石池、陳文鍾，「回診的急診病患：分析危險因子和回診原因」，中華民國急救加護醫學會雜誌，第十四卷，93-98頁，民國九十二年。
臺大醫院醫療品質審議委員會(1998)，「品管計劃與指標之建立與實施」，臺大醫院醫療品質管理模式之建議，臺北，民國八十七年。


網頁部份
行政院衛生署,醫療機構現況及醫院醫療服務量統計摘要(93)，線上檢索日期2006/5/20，網址：http://www.doh.gov.tw/statistic/index.htm。
中央健康保險局,總額支付制度之意涵，線上檢索日期2005/12/5, 網址：http://www.nhi.gov.tw/webdata/webdata.asp?menu=9 &menu_id= 176&webdata_id=895