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研究生:侯艷妃
研究生(外文):Yen-Fei Hou
論文名稱:照護連續性與可避免住院之相關性研究
論文名稱(外文):Continuity of Care and Hospitalization of Ambulatory Care Sensitivity Conditions
指導教授:鄭守夏鄭守夏引用關係
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:衛生政策與管理研究所
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:2009
畢業學年度:97
語文別:中文
論文頁數:80
中文關鍵詞:門診照護敏感病況可避免住院照護連續性指標
外文關鍵詞:Ambulatory care sensitivity conditions (ACSC)Avoidable hospitalization(Hospitalization for ambulatory care sensitivity conditions)Continuity of care (COC)
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前言:全民健保實施以來,確實增加了就醫可近性,然而國內尚未建立完整的轉診制度,doctor-shopping (逛醫師) 的情形嚴重,造成許多醫療資源的浪費。國內在醫療品質的管理上多著重於住院醫療品質的監控,然而影響整體醫療照護品質、效率的根源卻是初級醫療照護,其中「可避免住院」(Hospitalization for Ambulatory Care Sensitivity Conditions;Avoidable Hospitalization)在國際上已廣泛的作為評估初級醫療照護可近性、品質及效率的指標,而照護連續性更是影響醫療照護結果的重要因素。在缺乏完整家庭醫師制度的台灣,病人接受連續之醫療照護,是否可減少不必要的住院,進而降低醫療成本,確值得吾人進一步探討。

研究目的:本研究旨在探討國內照護連續性之相關影響因子,檢視照護連續性與住院醫療利用及可避免住院之相關性,並進一步探討是否照護連續性提高,其可避免之住院能夠減少。

研究方法:本研究採縱向研究法,利用國家衛生研究院全民健康保險學術資料庫,以2004年至2006年抽樣歸人檔為本研究之樣本母群體,取第一組總計約4萬人資料為此研究主要分析樣本。利用所推算的照護連續性指標為自變項,分為高、中、低三組,以住院醫療利用及可避免住院為依變項,檢視其住院及可避免住院之差異。其中控制變項包含年齡、性別、就醫方便性(投保地分局別、投保地醫師密度) 及醫療需求(慢性病指標和門診就醫總次數)等。

研究結果:在34728名研究對象中,2006年未曾住院者31825人,占91.64%。有住院者2903人,占8.36%。有門診照護敏感病況(Ambulatory Care Sensitivity Conditions, ACSC)住院(即可避免住院)者431人,占1.24%。若以醫師為基準,照護連續性指標平均為0.26。其中孩童、老年人、男性、有慢性病者、及高門診次數者,其醫療照護連續性指標較高。多變項邏輯斯迴歸分析顯示,照護連續性低及中間者之住院危險性及ACSC住院危險性,均較照護連續性高者為高,分別為其1.33倍、1.14倍(住院危險性),及1.96倍和1.44倍(ACSC住院危險性)。而住院、ACSC住院次數方面,經負二項迴歸分析結果亦顯示相同趨勢,且均達到統計學上顯著意義,並具有劑量反應關係。故照護連續性愈高者,其住院、ACSC住院危險性及次數均愈低。

結論:本研究發現照護連續性的高低的確對可避免住院有相當的影響,因此,如何增加國人的醫療照護連續性,改變國人的就醫習性,成為當前重要課題。
Background: The accessibility to health care in our country has improved after the implementation of National Health Insurance. Nevertheless, the doctor-shopping phenomena are still widely seen, which will erode health resource. While our major focus in monitoring the quality of hospitalization, it is the quality of primary care that determines the quality and efficiency of our healthcare system. Hospitalization for ambulatory care sensitivity conditions, the avoidable hospitalization, has been widely accepted as the indicator to evaluate the accessibility, quality and efficiency of primary care. It has been well documented that continuity of care may be an important factor related to the outcome of healthcare. Since the family doctor and patient referral system has not been well established in Taiwan, it is our major concern to interrogate the cost-effectiveness of our health care system through continuity of care and reduction of avoidable hospitalization.

Purpose: This study aims to investigate factors related to continuity of care to determine if better continuity of care will cause reduction of avoidable hospitalization.

Materials and methods: The longitudinal analysis was employed in this study. The academic database of National Health Insurance in National Health Research Institute was used. From year 2004 to 2006, there were about forty thousand records in section one as our total samples. The putative index of continuity of care (COC) was used as independent variable and divided into three groups. The hospitalization and avoidable hospitalization were the dependent variables. The controlled variables in this study included age, gender, accessibility of health care (location and physician density), and health inquiry (presence of chronic diseases and total ambulatory physician visits).

Results: In this study, a total of 34728 patients were recruited. Of which, 31825 patients (91.64%) had not hospitalized, while 2903 patients (8.36%) had hospitalized. There were 431 patients (1.24%) presented with the hospitalizations in ambulatory care sensitivity conditions (ACSC), the avoidable hospitalization. As examined with a single provider, the mean COC index was 0.26. In this cohort, high COCI could be seen in the minority, the elderly, male, patients with chronic diseases, and those of higher ambulatory physician visits. In multiple logistic regression, groups of low and moderate COCI showed higher probability both in hospitalization and ACSC hospitalization than the group of high COCI, with 1.33 and 1.14 folds in hospitalization and 1.96 and 1.44 folds in ACSC hospitalization, respectively. The result of negative-binomial regression analysis also revealed similar trend. The trend for both hospitalization risk and frequency was significant suggesting a dose-response relationship. Higher COC would present with lower risk and frequency in both hospitalization and ACSC hospitalization.

Conclusion: According to this study, the continuity of care plays an important role in hospitalization for ACSC. It is therefore an important issue to facilitate the continuity of healthcare and to promote correct pattern of doctor visit instead of doctor-shopping
口試委員會審定書……………………………………
中文摘要………………………………………………ii
英文摘要………………………………………………iv
目錄……………………………………………………vi
表目錄…………………………………………………viii
圖目錄…………………………………………………ix
第一章 緒論………………………………………………………1
第一節 前言與動機………………………………………………1
第二節 研究目的、假說與預期貢獻……………………………2
第二章 文獻探討…………………………………………………3
第一節 何謂可避免住院………………………………………3
第二節 醫療照護連續性及其測量………………………10
第三節 照護連續性與住院醫療利用及可避免住院………18
第三章 研究設計與方法…………………………………………20
第一節 研究設計與材料…………………………………………20
第二節 研究架構與對象…………………………………………21
第三節 資料處理流程……………………………………………24
第四節 資料分析方法……………………………………………27
第四章 研究結果…………………………………………………………………28
第一節 樣本特徵與各變項分布情形……………………………28
第二節 照護連續性指標與各變項相關分析……………………32
第三節 研究變項與住院及可避免住院之相關分析…………36
第四節 研究變項與住院及可避免住院之多項變分析………41
第五節 重要結果摘要……………………………………………51
第五章 討論…………………………………………………………53
第一節 綜合討論 …………………………………………………53
第二節 研究限制與建議 …………………………………………57
第六章 結 論………………………………………………………60
參考文獻……………………………………………………………61
附 錄 ………………………………………………………………66
附錄一:照護敏感病況與ICD-9-CM對照表………………………66
附綠二:健保資料之案件分類表…………………………………69
附綠三:健保六分局醫療資源密度………………………………71
附綠四:健保六分局醫療資源集散程度…………………………72
附錄五:健保六分局及其所屬轄區縣市…………………………73
附綠六:投保地醫師密度…………………………………………74
附綠七:照護連續性指標分類…………………………………75
附錄八:慢性分層分析-1 ………………………………………76
附錄九:慢性分層分析-2 ………………………………………76
附錄十:慢性分層分析-3 ………………………………………77
附錄十一:研究變項與住院次數之雙變項分析………………78
附錄十二:研究變項與可避免住院次數之雙變項分析………79
附錄十三:2004~2005年所有門診次數分布…………………80
表目錄

表2-1 門診照護敏感病況一覽表……………………………4
表2-2 照護連續性指標種類及其文獻應用情形……………13
表3-1.1健保資料庫2004-2005門診就醫資料………………23
表3-1.2 健保資料庫2006年住院資料………………………23
表3-1.3 健保資料庫2004~2006門診及住院資料……………23
表4-1 變項分布狀況…………………………………………30
表4-2.1 照護連續性指標與各變項相關分析………………34
表4-2.2 照護連續性指標中位數、平均值分布情形………35
表4-3.1住院醫療利用與各變項相關分析…………………39
表4-3.2可避免住院與各變項相關分析……………………40
表4-4.1研究變項與住院醫療利用之邏輯斯迴歸分析……44
表4-4.2研究變項與可避免住院之邏輯斯迴歸分析………45
表4-4.3研究變項與住院次數之負二項迴歸分析…………49
表4-4.4研究變項與ACSC住院次數之負二項迴歸分析 ……50
表5-1 本研究結果與文獻之比較……………………………53
圖目錄

圖1 照護連續性模型………………………………………………11
圖2 研究架構………………………………………………………21
英文部分
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中文部分
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黃馨玉(2005)。可避免住院之研究-以細菌性肺炎為例,台灣大學醫療機構管理研究所碩士論文。
劉貞娟 (2003)。全民健保氣喘疾病管理計畫成效評估--以南部某健保分局資料為例,義守大學管理科學研究所碩士論文。
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黃郁清 (2008撰寫中)。台灣照護連續性對醫療照護結果的影響,
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