(3.239.33.139) 您好!臺灣時間:2021/03/08 18:26
字體大小: 字級放大   字級縮小   預設字形  
回查詢結果

詳目顯示:::

我願授權國圖
: 
twitterline
研究生:張玉蓉
研究生(外文):Yu-Jung Chang
論文名稱:高血壓醫療給付改善方案對高血壓病患可避免住院的影響
論文名稱(外文):Impact of Pay for Performance on Hypertensive Patient’s Avoidable Hospitalization.
指導教授:李玉春李玉春引用關係
指導教授(外文):Yue-Chune Lee
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:2010
畢業學年度:98
語文別:中文
論文頁數:103
中文關鍵詞:高血壓醫療給付改善方案可避免住院傾向分數
外文關鍵詞:The Pay for Performance Program for Hypertensionavoidable hospitalizationpropensity score
相關次數:
  • 被引用被引用:7
  • 點閱點閱:948
  • 評分評分:系統版面圖檔系統版面圖檔系統版面圖檔系統版面圖檔系統版面圖檔
  • 下載下載:0
  • 收藏至我的研究室書目清單書目收藏:5
健保局於2006年於基層診所推行高血壓醫療給付改善方案(論質支付),藉由財務誘因來提高醫療服務提供者對高血壓之照護品質,目前國內在探討高血壓相關研究中:多數僅侷限於部份區域或單一機構內,未針對全國性樣本或施行於全國的高血壓醫療給付改善方案進行研究,因此本研究針對全國代表性樣本,以可避免住院為指標,評估高血壓論質計酬支付政策之成效。
本研究採準實驗設計,研究期間為2005-2008年,將有加入方案者視為實驗組、未加入方案者視為對照組,利用照護結果的差異中差異法(differences in differences, DID):比較兩組在介入前後可避免住院發生狀況之差值後,以控制介入前兩組之差異。本研究以國家衛生研究院提供的全民健保資料庫中的:門診處方及治療明細檔(CD)、住院醫療費用清單明細檔(DD)、門診醫令明細檔(OO)、特約藥局處方及調劑明細檔(GD)、特約藥局處方調劑醫令檔(GO)、承保資料檔(ID)、及醫事機構基本資料檔(HOSB),串檔後觀察介入方案前一年、及介入方案後兩年之可避免住院情形。參考Aday &Andersen第三代行為模式為架構,其自變項為年代及介入組別,依變項採The Agency for Healthcare Research and Quality (AHRQ, 2009)的可避免住院指標,控制變項以 Greedy propensity score的配對法來校正,依據高血壓病患特質(年齡、性別、投保金額、固定就醫、高血壓疾病嚴重度、共病指數、及醫療院所特性,來預測是否加入試辦計畫,計算每個個案加入試辦計畫之傾向分數(以Logistic Regression),並依據傾向分數以1:4的比例(未加入者為加入者之四倍)配對挑選未加入方案者當做控制組。其中高血壓疾病嚴重度係參考Gonella的疾病分期概念自行發展的測量;共病指數是依Clark於1995年的Chronic disease score計算出);醫療院所特性包括層級別、權屬別、分局別。資料分析使用SAS9.2版,描述性統計包含次數分配、百分比等了解配對前後樣本之資料特性;推論性統計包含:卡方檢定、McNemar test、Fisher exact test、及廣義估計方程式(generalized estimating equations, GEE),來分析介入方案對可避免住院與否之相關性。
兩組在以傾向分數配對後,實驗、對照組分別為1116及4464人,兩組特性皆未達統計顯著差異;GEE分析結果顯示,介入方案當年和後一年的可避免住院發生危險比分別是未介入前一年的3.16及2.06倍,但無顯著差異。
本研究結果未能支持假說,意即介入方案並未能顯著降低高血壓病患高血壓相關的可避免住院,但因可避免住院的發生率並不高,加上研究樣本數不多,統計效力可能不足,因此此研究結果尚待後續研究驗證。本研究觀察時間短,且因採次級料庫分析,無法得到確切的臨床檢驗值、及醫療提供者對方案的態度行為等的相關資料,實屬本研究之研究限制。建議政策規劃者需再謹慎評估高血壓論質計酬方案,以做為是否繼續推動之參考。

The Bureau of the National Health Insurance (BNHI) has implemented ’The Pay for Performance Program for Hypertensive patients’ in clinics since 2006, it draw financial incentives up to encourage medical provider to provide better quality of health care. Mainly domestic Hypertension related studies were confined to some geographic areas or single institution, and there was no assessment about this program. This study evaluates the effectiveness of this program via avoidable hospitalization for nationally representative samples.
A quasi experimental study to compare the incidence of avoid hospitalization before and after the intervention to control the differences between the two groups before intervention using differences in differences approach was conducted those who joined the program as the experimental group, those who did not as the control group during 2005-2008. Incidences of avoidable hospitalization were observed one year before and/or two years after the intervention program. Based on NHI claim database based on the third-generation Aday & Andersen behavioral model, the independent variable was interaction of year and group, the dependent variables were the hypertension related avoidable hospitalization defined by The Agency for Healthcare Research and Quality (AHRQ). Greedy propensity score matching method was applied to calibrate characteristics of the hypertensive patients (age, gender, the insured amount, having regular source of medical care, severity of illness developed based on Gonella disease staging concept, the co-morbidity index of Clark Chronic disease score in 1995), and hospital characteristics (level, ownership, and location of the hospital)based on logictic regression analysis. Control group was matched to experimental group based on propensity score by ratio a 4 to 1. Data were analyzed using SAS9.2. Descriptive statistics included frequency, percentage and other information about the characteristics of the sample before and after matching; Inferential statistics include: chi-square test, McNemar test, Fisher exact test, and generalized estimating equations (GEE).
There were 1116 persons in experimental and 4464 in control groups of propensity score matching. These two groups didn’t have significantly difference on patients’ and hospital characteristics; GEE analysis showed the likelihood to have avoidable hospitalization of the experimental groups were 3.16 and 2.06 time during the year and one year after the intervention. However the results were not significant.
The results failed to support the hypothesis. This means that this program failed to significantly hospitalization. However, due to low incidence of avoidable hospitalization, small sample sizes, our results should be verified in the future. Limitation of this study include: short duration; lack of clinical examination data and information on attitude and behavior of the providers toward intervention program. Future studies should be conducted by policy makers to further evaluate the effect of this program, so as to decide whether to implement this program continuously in the future.
第一章 緒論 1
第一節 研究背景與研究動機 1
第二節 研究目的 3
第三節 研究問題 3
第四節 研究重要性 4
第二章 文獻探討 5
第一節 高血壓疾病 5
第二節 高血壓疾病論質計酬制度及其相關研究 19
第三節 可避免住院的發展及其相關研究 26
第四節 健康服務利用模式 35
第五節 傾向分數propensity score 38
第三章 研究方法 43
第一節 研究設計 43
第二節 研究架構 44
第三節 研究假說 45
第四節 研究對象及樣本 46
第五節 資料來源 47
第六節 變項定義與測量 48
第七節 資料處理流程 52
第八節 統計分析 55
第四章 研究結果 56
第一節 基本資料描述 56
第二節 雙變項分析 59
第三節 多變項分析 62
第五章 討論 72
第一節 研究方法之討論 72
第二節 研究結果之討論 76
第三節 研究限制 81
第六章 結論與建議 82
第一節 結論 82
第二節 建議 83
第七章 參考文獻 84
附錄一:本研究之高血壓罹病嚴重度 89
附錄二:全民健康保險高血壓醫療給付改善方案 90
附錄三:AHRQ_PQI指標 96
一、中文文獻

中央健康保險局(2007).94年高血壓門診用藥指標.全民健康保險專業醫療服務品質報告,1-47。

中央健康保險局(2010年2月12日).2008年全民健康保險統計動向. http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx?now_fod_list_no=10904&class_no=440&level_no=3 。

中央健康保險局(2009年10月28日).藥理分類代碼. http://www.nhi.gov.tw/webdata/webdata.asp?menu=3&menu_id=56&webdata_id=1107 。

中央健康保險局(2010).醫療給付改善方案專區.http://www.nhi.gov.tw/inquire/query11.asp?menu=1&menu_id=8&WD_ID=263。

方俞尹(2009).全民健康保險氣喘醫療給付改善方案長期影響評估.臺北:臺灣大學衛生政策與管理研究所,未發表之碩士論文。

王俊雄、紀櫻珍、吳振龍、施奕仲&薛亞聖(2006).高血壓疾病管理之臨床結果及醫療費用評估.北市醫學雜誌,3(3),248-259。

王俊雄、紀櫻珍、吳振龍、施奕仲&薛亞聖(2007).高血壓病患疾病管理之臨床應用.北市醫學雜誌,4(2),9-20。

王馨儀(2006).氣喘門診照護對可避免住院之影響.臺北:國立臺灣大學醫療機構管理研究所,未發表之碩士論文。

史青平(2006).可預防住院之研究-以闌尾炎破裂或穿孔為例.臺北:國立臺灣大學醫療機構管理研究所,未發表之碩士論文。

朱育增&吳肖琪(2010).回顧與探討次級資料適用之共病測量方法.臺灣公共衛生雜誌,29(1),8-21。

行政院衛生署(2009).衛生統計系列(一)死因統計.台北:行政院衛生署。

行政院衛生署全民健康保險醫療品質委員會(2007a).二代健保之論質計酬.醫療品質雜誌,1(1),54-56。

行政院衛生署全民健康保險醫療品質委員會(2007b).配合二代健保之論質計酬.爭審相關論述,1-10。

行政院衛生署國民健康局(2005).高血壓防治手冊-高血壓偵測控制與治療流程指引.http://www.health99.doh.gov.tw/media/public/pdf/21446.pdf 。

行政院衛生署國民健康局(2009年7月17日).國內首次具全國代表性之高血壓、高血糖、高血脂發生率公布.http://www.doh.gov.tw/CHT2006/DM/DM2_p01.aspx?class_no=25&now_fod_list_no=10518&level_no=2&doc_no=72222 。

李玉春(2005).台灣地區醫療院所糖尿病照護品質之監控及比較研究.行政院衛生署國民健康局科技研究發展計畫。

李玉春(2006).全民健保支付與管理制度對病人就醫品質之影響:以可避免之住院為例.行政院衛生署九十五年度科技研究計畫。

李宣緯、葉玲玲&黃達夫(2006).台灣高血壓門診診療型態之分析探討.臺灣公共衛生雜誌,25(3),201-213。

林文德、謝其政、邱尚志、吳慧俞&黃一展(2010).以傾向分數配對法評估糖尿病論質計酬方案之成效.台灣衛誌,29(1),54-64。

侯艷妃(2008).照護連續性與可避免住院之相關性研究.臺北:國立台灣大學衛生政策與管理研究所,未發表之碩士論文。

張雪芬(2003).論質計酬試辦計畫成效初探-以肺結核疾病為例.台中:私立中國醫藥學院醫務管理學研究所,未發表之碩士論文。

梁亞文、陳芬如&鄭瑛琳(2008).台灣可避免住院及其病患社經狀態.台灣衛誌,27(1),81-90。

陳宗泰、鍾國彪&賴美淑(2007).另一種流行趨勢—論成效計酬的趨勢與展望.臺灣公共衛生雜誌,26(5),353-370。

陳建仁(2002).台灣地區高血壓.高血糖.高血脂盛行率調查計畫.台北:行政院衛生署國民健康局。

黃昱瞳(2008).全民健保部分負擔制度對幼童、年長者及慢性病患健康之影響.臺北:國立陽明大學衛生福利研究所,未發表之博士論文。
黃馨玉(2006).可避免住院之研究─ 以細菌性肺炎為例.臺北:國立臺灣大學醫療機構管理研究所,未發表之碩士論文。

劉貞娟、翁慧卿&蔡魯(2006).氣喘疾病管理在醫療資源耗用, 臨床指標改善與自我照護能力的影響.福爾摩莎醫務管理雜誌,2(1),36-46。

劉雅文(2008).以2005年承保抽樣歸人檔分析高血壓病人之重複醫療資源利用情形.臺北:臺灣大學醫療機構管理研究所,未發表之碩士論文。

劉鳳儀(2003).以慢性病藥物處置為基礎之門診利用風險校正模式.高雄:高雄醫學大學公共衛生學研究所,未發表之碩士論文。

蔡佳希(2007).台灣可避免住院情況之整體性分析.高雄:國立中山大學醫務管理研究所,未發表之碩士論文。

蔡雙卉(2006).可避免住院研究-以急性腎盂腎炎為例.臺北:國立臺灣大學醫療機構管理研究所,未發表之碩士論文。


二、 英文文獻

Agabiti, N., Pirani, M., Schifano, P., Cesaroni, G., Davoli, M., Bisanti, L., et al. (2009). Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy. BMC Public Health, 9(1), 457.
Agency for Healthcare Research and Quality, A. (2007). AHRQ Quality Indicators-Guide to Prevention Quality Indicators (Revision 3.1). Rockville, MD: AHRQ.
Andersen, R. (1995). Revisiting the behavioral model and access to medical care: does it matter? Journal of health and social behavior, 36(1), 1-10.
Backus, L., Moron, M., Bacchetti, P., Baker, L., & Bindman, A. (2002). Effect of managed care on preventable hospitalization rates in California. Medical care, 40(4), 315-324.
Begley, C., Slater, C., Engel, M., & Reynolds, T. (1994). Avoidable hospitalizations and socio-economic status in Galveston County, Texas. Journal of Community Health, 19(5), 377-387.
Billings, J., Zeitel, L., Lukomnik, J., Carey, T., Blank, A., & Newman, L. (1993). Impact of socioeconomic status on hospital use in New York City. Health Affairs, 12(1), 162.
Brown, A., Goldacre, M., Hicks, N., Rourke, J., McMurtry, R., Brown, J., et al. (2001). Hospitalization for ambulatory care-sensitive conditions: a method for comparative access and quality studies using routinely collected statistics. Canadian journal of public health, 92(2), 155-159.
Bullano, M., Kamat, S., Willey, V., Barlas, S., Watson, D., & Brenneman, S. (2006). Agreement between administrative claims and the medical record in identifying patients with a diagnosis of hypertension. Medical care, 44(5), 486.
Campbell, S., Reeves, D., Kontopantelis, E., Sibbald, B., & Roland, M. (2009). Effects of pay for performance on the quality of primary care in England. New England Journal of Medicine, 361(4), 368-378.
Chobanian, A., Bakris, G., Black, H., Cushman, W., Green, L., Izzo Jr, J., et al. (2003). Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 42(6), 1206.
Clark, D., Korff, M., Saunders, K., Baluch, W., & Simon, G. (1995). A chronic disease score with empirically derived weights. Medical care, 33(8), 783-795.
Cochran, W. (1968). The effectiveness of adjustment by subclassification in removing bias in observational studies. Biometrics, 295-313.
Corrigan, J., Donaldson, M., Kohn, L., Maguire, S., & Pike, K. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: The Institute of Medicine.
D'Agostino Jr, R. (2007). Propensity scores in cardiovascular research. Circulation, 115, 2340-2343.
Donabedian, A. (1997). The quality of care: How can it be assessed? Archives of Pathology & Laboratory Medicine, 121, 11-16.
Doran, T., Fullwood, C., Gravelle, H., Reeves, D., Kontopantelis, E., Hiroeh, U., et al. (2006). Pay-for-performance programs in family practices in the United Kingdom. New England Journal of Medicine, 355(4), 375-384.
Fields, L., Burt, V., Cutler, J., Hughes, J., Roccella, E., & Sorlie, P. (2004). The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension, 44, 1-7.
Fu, A., Qiu, Y., Radican, L., Yin, D., & Mavros, P. (2010). Impact of Concurrent Macrovascular Comorbidities on Healthcare Utilization in Patients with Type 2 Diabetes in Europe: A Matched Study. Diabetes, Obesity and Metabolism, 12, 631-637.
Gonnella, J., Hornbrook, M., & Louis, D. (1984). Staging of disease: a case-mix measurement. Jama, 251(5), 637-645.
Keating, N., Zaslavsky, A., Herrinton, L., Selby, J., Wolf, R., & Ayanian, J. (2007). Quality of diabetes care among cancer survivors with diabetes. Medical care, 45(9), 869-875.
Kosuke Iwasaki, F., & Actuary, C. (2009). Ambulatory-care-sensitive admission rates: A key metric in evaluating health plan medical-management effectiveness. Milliman research, 1-12.
Kozak, L., Hall, M., & Owings, M. (2001). Trends in avoidable hospitalizations, 1980-1998. Health Affairs, 20(2), 225-232.
Lenfant, C., Chobanian, A., Jones, D., & Roccella, E. (2003). Seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7): resetting the hypertension sails. Hypertension, 41(6), 1178.
Lin, W., & Huang, I. (2010). Continuity of diabetes care is associated with avoidable hospitalizations: evidence from Taiwan's National Health Insurance scheme. International Journal for Quality in Health Care, 22(1), 3-8.
MacKnight, C., & Rockwood, K. (2001). Use of the chronic disease score to measure comorbidity in the Canadian Study of Health and Aging. International Psychogeriatrics, 13(S1), 137-142.
Marshall, M., Leatherman, S., & Mattke, S. (2004). Selecting Indicators for the Quality of Health Promotion, Prevention and Primary Care at the Health Systems Level in OECD Countries. OECD Health Technical Papers.
Martens, E., de Boer, A., Pestman, W., Belitser, S., Stricker, B., & Klungel, O. (2007). Comparing treatment effects after adjustment with multivariable Cox proportional hazards regression and propensity score methods. Pharmacoepidemiology and drug safety, 17(1), 1-8.
McElduff, P., Lyratzopoulos, G., Edwards, R., Heller, R., Shekelle, P., & Roland, M. (2004). Will changes in primary care improve health outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK. Quality and Safety in Health Care, 13(3), 191-197.
Meddings, J., & McMahon, L. (2008). Measuring Quality in Pay-for-Performance Programs: From One-Size-Fits-All Measures to Individual Patient Risk-Reduction Scores. Disease Management &# 38; Health Outcomes, 16(4), 205-216.
Millett, C., Gray, J., Bottle, A., & Majeed, A. (2008). Ethnic disparities in blood pressure management in patients with hypertension after the introduction of pay for performance. Annals of Family Medicine, 6(6), 490-496.
Nera, A., Monica, P., Patrizia, S., Giulia, C., Marina, D., Luigi, B., et al. (2009). Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy. BMC Public Health, 9(457), 1-8.
Niti, M., & Ng, T. (2003). Avoidable hospitalisation rates in Singapore, 1991–1998: assessing trends and inequities of quality in primary care. Journal of Epidemiology and Community Health, 57(1), 17.
Parsons, L. (2000). Using SAS software to perform a case-control match on propensity score in an observational study. Paper presented at the Proceedigs of the Twenty-Sixth Annual SAS Users Group International Conference., Cary, NC: SAS institute Inc.
Parsons, L. (2004). Performing a 1: N case-control match on propensity score. Paper presented at the Proceedings of the Twenty-Sixth Annual SAS Users Group Intermational Conference., Cary, NC: SAS Institute Inc.
Putnam, K., Buist, D., Fishman, P., Andrade, S., Boles, M., Chase, G., et al. (2002). Chronic disease score as a predictor of hospitalization. Epidemiology, 13(3), 340-346.
Quam, L., Ellis, L., Venus, P., Clouse, J., Taylor, C., & Leatherman, S. (1993). Using claims data for epidemiologic research: the concordance of claims-based criteria with the medical record and patient survey for identifying a hypertensive population. Medical care, 31(6), 498-507.
Rizza, P., Bianco, A., Pavia, M., & Angelillo, I. (2007). Preventable hospitalization and access to primary health care in an area of Southern Italy. BMC Health Services Research, 7(134), 1-8.
Rosenbaum, P., & Rubin, D. (1983). The central role of the propensity score in observational studies for causal effects. Biometrika, 70(1), 41-55.
Rosenthal, M., Fernandopulle, R., Song, H., & Landon, B. (2004). Paying for quality: providers' incentives for quality improvement. Health Affairs, 23(2), 127-141.
Rutstein, D., Berenberg, W., Chalmers, T., Child, C., Fishman, A., & Perrin, E. (1976). Measuring the quality of medical care. A clinical method. New England Journal of Medicine, 294(11), 582.
Schneeweiss, S., & Maclure, M. (2000). Use of comorbidity scores for control of confounding in studies using administrative databases. International Journal of Epidemiology, 29(5), 891-898.
Shi, L., Samuels, M., Pease, M., Bailey, W., & Corley, E. (1999). Patient characteristics associated with hospitalizations for ambulatory care sensitive conditions in South Carolina. Southern medical journal, 92(10), 989-998.
Von Korff, M., Wagner, E., & Saunders, K. (1992). A chronic disease score from automated pharmacy data. Journal of Clinical Epidemiology, 45(2), 197-203.
Walsh, J., McDonald, K., Shojania, K., Sundaram, V., Nayak, S., Lewis, R., et al. (2006). Quality improvement strategies for hypertension management: a systematic review. Medical care, 44(7), 646-657.
Wang, T., & Vasan, R. (2005). Epidemiology of uncontrolled hypertension in the United States. Circulation, 112(11), 1651-1662.
Weissman, J., Gatsonis, C., & Epstein, A. (1992). Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. Jama, 268(17), 2388.
Whitworth, J. (2003). World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens, 21(11), 1983-1992.
Young, G., White, B., Burgess Jr, J., Berlowitz, D., Meterko, M., Guldin, M., et al. (2005). Conceptual issues in the design and implementation of pay-for-quality programs. American Journal of Medical Quality, 20(3), 144-150.
Zhan, C., Miller, M., Wong, H., & Meyer, G. (2004). The effects of HMO penetration on preventable hospitalizations. Health Services Research, 39(2), 345-361.


連結至畢業學校之論文網頁點我開啟連結
註: 此連結為研究生畢業學校所提供,不一定有電子全文可供下載,若連結有誤,請點選上方之〝勘誤回報〞功能,我們會盡快修正,謝謝!
QRCODE
 
 
 
 
 
                                                                                                                                                                                                                                                                                                                                                                                                               
第一頁 上一頁 下一頁 最後一頁 top
系統版面圖檔 系統版面圖檔