臺灣博碩士論文加值系統

研究背景與目的：
　　全民健保的醫療利用有集中於少數人身上的情形，其中以洗腎病人為代表，台灣洗腎病人的盛行率約為0.2%，而因慢性腎臟病而洗腎的費用每年約277億元，是所有單一治療項目中，比率最高、成長最快的項目之一。國外研究顯示病人的疾病負荷與醫療資源利用相關，但國內對洗腎病人並無相關研究，再加上疾病負荷愈高其醫療費用也隨之升高。因此本研究欲分析台灣洗腎病人之門診醫療資源利用情形與其疾病負荷間之關係。
研究方法：
　　本研究材料來自國家衛生研究院發行之20萬人全民健康保險承保抽樣歸人檔從2003到2005年之申報資料中的所有洗腎病人做為研究樣本，並且採用ACGs(Adjusted Clinical Groups)校正工具，將不同疾病負荷的洗腎病人做區分後，以描述性統計分析洗腎病人的門診醫療資源與疾病嚴重程度等情形，再以單因子變異數比較不同疾病負荷下洗腎病人之間的差異，最後再以複迴歸分析自變項與洗腎病人門診醫療資源利用之間的關係。
研究結果：
　　本研究以女性較多(占55.9%)，三年平均年齡分別為55.74歲~57.75歲。洗腎病人的ADGs (Aggregated Diagnosis Groups)診斷碼個數三年平均為6.5~8.0個，且洗腎病人年齡在34歲以上且有6~9個Other ADG組合項與有2個主要ADGs的人最多。最常見的共病症是高血壓、糖尿病、慢性腎絲球腎炎、皮膚炎與濕疹、慢性結膜炎與慢性缺血性心臟病等。
　　當洗腎病人每增加一個共病症(ADG)時，其門診就醫次數增加約4次。另外，主要就醫層級為醫學中心及區域醫院的洗腎病人，其門診用藥費用顯著高於基層院所。最後，疾病負荷中等(相對權重: 0.99∼1.02)與較重(相對權重: 1.03∼1.20)之洗腎病人，其門診總費用顯著高於疾病負荷較輕的洗腎病人(相對權重: 0.48∼0.98)。
結論：
　　首先為不同疾病負荷程度之洗腎病人的門診醫療資源利用不同，疾病負荷愈高者，門診醫療資源利用愈高，但洗腎病人的疾病負荷程度與主要就醫層級無顯著相關，當洗腎病人有心律不整、鬱血性心臟衰竭、缺血性心臟病等心血管疾病，或者糖尿病以及肺部及肝臟方面的共病症時，其門診醫療費用明顯較高。

Background and Objectives: Health care expenditure was concentrated on a small proportion of the population, especially dialysis patients. In Taiwan, the prevalence of dialysis patients was about 0.2% and their health care expenditure was 27.7 billion NT dollars per year. The total cost to the National Health Insurance (NHI) of treating dialysis patients is the highest among all treatment items and increases continually. According to the literature review, morbidity burdens of patients were related to medical resources but there was not published study which investigated the relationship of dialysis patients in Taiwan; moreover, the increase of the morbidity burdens resulted in the higher medical expenditure. The purpose of the study was to examine the relationship between the ambulatory medical utilization and morbidity burdens of dialysis patients.
Methods: The study used claims data for a representative sample of 200,000 people randomly selected from all beneficiaries enrolled in Taiwan’s National Health Insurance (NHI) between 2003 and 2005. We used ACG Case-Mix adjustment System to classify different morbidity burden groups. Then, the study used descriptive statistics to analyze the ambulatory medical utilizations and morbidity burdens and used One-Way ANOVA to compare the dialysis patients of different morbidity burden groups. Finally, we used multiple regressions to analyze the relationship among independent variables and outpatient medical utilization of dialysis patients.
Results: In this study we included 298 dialysis patients (female 55.9%) with a mean age of 55.7 to 57.8 years old in three years. The average numbers of ADGs (Aggregated Diagnosis Groups) were 6.5 to 8.0 in three years. Most of the dialysis patients were above 34 years old with 6~9 other ADG and 2 major ADGs. The most frequent co-morbidities were hypertension､diabetes､chronic glomerulonephritis､dermatitis､chronic conjunctivitis and chronic ischemic heart disease. With the increase of co-morbidity as measured by the number of ADG, the dialysis patients increased their outpatient visits. Besides, if the dialysis patients went to medical centers or regional hospitals more frequently, their outpatient drug expenditures were statistically higher than these to the primary care facilities. The total outpatient expenditures of dialysis patients in the moderate (Local Weight: 0.99∼1.02) and high morbidity groups (Local Weight: 1.03∼1.20) were statistically higher than the low morbidity groups (Local Weight: 0.48∼0.98).
Conclusion: First, the dialysis patients with higher morbidity burdens had higher ambulatory health care utilizations. Second, the morbidity burdens were not significantly related to patients’ choice of hospital levels. Third, morbidity burden was one of the important factors affecting the ambulatory health care utilization. Finally, when dialysis patients had cardiac arrhythmias､congestive heart failure､ischemic heart disease､diabetes､lung disease or liver disease, their ambulatory expenditures were statistically higher than the population average.

論文電子檔著作權授權書……………………………………………i
論文審定同意書………………………………………………………ii
誌謝……………………………………………………………………iii
中文摘要………………………………………………………………iv
英文摘要………………………………………………………………vi
目錄…………………………………………………………………viii
圖目錄…………………………………………………………………x
表目錄…………………………………………………………………xi
第一章 緒論………………………………………………………1
第一節 研究背景與動機…………………………………………1
第二節 研究問題…………………………………………………4
第三節 研究重要性………………………………………………4
第四節 研究目的…………………………………………………4
第二章 文獻探討…………………………………………………5
第一節 國內洗腎病人發展與醫療資源利用……………………5
第二節 洗腎病人之疾病負荷……………………………………8
第三節 診斷基礎校正工具………………………………………12
第四節 Adjusted Clinical Groups於國內外之應用與分析…17
第三章 研究設計與方法…………………………………………20
第一節 研究架構…………………………………………………20
第二節 研究假設…………………………………………………21
第三節 研究材料及對象…………………………………………21
第四節 研究工具…………………………………………………24
第五節 研究變項操作型定義……………………………………26
第六節 分析方法…………………………………………………28
第四章 研究結果…………………………………………………30
第一節 描述性統計分析…………………………………………30
一、 洗腎病人人口學屬性……………………………………30
二、 洗腎病人之門診醫療資源利用情形……………………30
三、 洗腎病人之疾病負荷情形………………………………33
第二節 洗腎病人人口學屬性以及三年之醫療資源利用之差異…41
一、洗腎病人三年門診醫療資源利用之差異……………………41
二、洗腎病人人口學屬性與門診醫療資源利用之差異…………44
第三節 洗腎病人疾病負荷程度與醫療資源利用之關係………49
第四節 影響洗腎病人醫療資源利用之因素與線性關係………53
第五章 討論………………………………………………………59
第六章 結論與建議………………………………………………66
第一節 研究限制…………………………………………………66
第二節 結論………………………………………………………66
第三節 建議………………………………………………………67
參考資料
　中文參考文獻………………………………………………………69
　英文參考文獻………………………………………………………70

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