臺灣博碩士論文加值系統

中文摘要
研究背景：病人在接受手術前，麻醉專科醫師依流程至病房進行術前麻醉訪視，但訪視後發現有些病人當時的生理狀況並不適合立即接受手術麻醉，因而延後手術執行，但是這樣的結果將導致病人的住院日數增加，進而提高醫療利用。另外在TW-DRG（Taiwan Diagnosis Related Groups）制度實施之下，個案醫院為了能更有效率的分配醫療資源，並持續維護醫療品質，因而開辦麻醉諮詢門診。並希望能藉由新的方式，取代現行術前麻醉病房訪視模式。
研究目的：本研究目的是比較接受麻醉諮詢門診與現行術前麻醉病房訪視在病人醫療利用、醫療品質監測指標、病人滿意度、情緒表現及擔心手術麻醉事項的差異，以探討麻醉諮詢門診執行之成效。
研究方法：本研究為橫斷研究設計，以台北某醫學中心骨科、一般外科及泌尿外科的住院手術病人為研究對象，結合自擬式結構式問卷及住院費用清單明細檔為研究資料庫，探討病人接受麻醉諮詢門診的成效。以SPSS18.0軟體進行分析，利用卡方、T檢定、單因子變異數分析、多變量變異數分析及線性複迴歸等檢定。
結果：在344位受訪者當中，麻醉諮詢門診142位，術前麻醉病房訪視202位。結果顯示接受麻醉諮詢門診的病人，其住院後的檢查費顯著低於接受術前麻醉病房訪視者（P value=0.037），但麻醉費則無顯著差異（P value=0.192）。另外接受麻醉諮詢門診的病人在情緒表現、信任感、服務感受度及衛教獲得程度比接受術前麻醉病房訪視要好（P value<0.001）；焦慮程度（P value=0.458）則無明顯差異。
結論：接受麻醉諮詢門診有助於減少病人的檢查費，並提高病人在信任感、服務感受度及衛教獲得程度方面的滿意度。未來可進一步探討醫師或護理人員本身對於麻醉諮詢門診實施的態度與認知，以瞭解其對於麻醉諮詢門診的滿意度與配合度，並提供未來醫院制定對應的政策與方針。
關鍵詞：TW診斷關聯群、麻醉諮詢門診、術前麻醉病房訪視

Abstract
Background: Patients before surgery, according to flow arrangement anesthesiologist to ward implementation of the Preoperative Anesthetic Visiting(PAV), but found some of the patients physical condition was not suitable for surgical anesthesia and post-implementation, such a result would lead to increase length of stay, thereby increasing health care utilization. In addition, the hospital established Preoperative Anesthesia Consultation Clinic (PACC) in order to be able to distribute medical resources more efficiently and ongoing maintenance of quality of care under the implementation of TW-DRG (Taiwan Diagnosis Related Groups) system. And it hopes that this new way can substitute the existing PAV mode.
Objectives: The aim of this study was to investigate whether Preoperative Anesthesia Consultation Clinic affects preoperative outcomes in terms of medical utilization, indicators of quality, patient’s satisfaction, emotional expression, and ideological concerns about anesthesia in surgical patients.
Methods: This study design was a cross-sectional study. All subjects were surgical patients and were recruited from 3 different specialty divisions (General surgery, Urological surgery, and Orthopedics surgery) in a medical center. In order to explore the effectiveness of PACC, the data were collected from questionnaire survey and computerized database of hospital. Data analysis was performed using the SPSS 18.0 and using chi-square test, Student’s t-test, ANOVA analysis, and multiple linear regression test.
Results: Out of 344 surgical patients, 142 were received PACC, and 202 were received PAV. Our results indicated that the patients of PACC had a significantly smaller amount of laboratory fees than did those of PAV (P value=0.037), but there was no significant difference in anesthesia fees (P value =0.192). Furthermore, the patients of PACC had a significantly higher performance of emotional expression, the feeling of trust, and health education than did those of PAV (P value<0.001), but there was no significant difference in the score of anxiety (P value=0.458).
Conclusions: This study demonstrated that the implementation of PACC helped to reduce the laboratory fees, improved the feelings of trust, provided better perception of health education, and obtained the higher score of the patient’s satisfaction.
Keywords: TW-DRG, Preoperative Anesthesia Consultation Clinic, Preoperative Anesthetic Visiting

第一章 緒論………………………………………………………………… 1
第一節 研究背景……………………………………………………… 1
第二節 研究動機……………………………………………………… 6
第三節 研究之重要性與必要性……………………………………… 8
第四節 研究目的……………………………………………………… 10
第五節 名詞解釋……………………………………………………… 11
第二章 文獻查證…………………………………………………………… 13
第一節 疾病嚴重度與醫療耗用及醫療品質………………………… 13
第二節 國內、外術前麻醉評估諮詢現況…………………………… 16
第三節 術前麻醉評估諮詢與醫療耗用及醫療品質………………… 18
第四節術前麻醉評估諮詢成效相關研究…………………………… 20
第三章 實施方法及進行步驟……………………………………………… 22
第一節 研究對象……………………………………………………… 22
第二節 研究架構……………………………………………………… 24
第三節 研究假設……………………………………………………… 25
第四節 研究變項操作型定義………………………………………… 26
第五節 研究工具……………………………………………………… 28
第六節 資料統計與分析……………………………………………… 35
第四章 研究結果………………………………………………………… 37
第一節 問卷發放回收情形…………………………………………… 37
第二節 受訪者基本特性描述………………………………………… 39
第三節 服務流程感受………………………………………………… 44
第四節 成效差異比較………………………………………………… 52
第五節 基本特性與病人滿意度各構面之差異探討………………… 66
第六節 基本特性與病人滿意度各構面之迴歸分析………………… 71
第五章 討論………………………………………………………………… 79
第一節 醫療耗用與品質指標的差異………………………………… 79
第二節 病人滿意度各構面的差異…………………………………… 83
第三節 其他調查結果之差異………………………………………… 88
第四節 研究限制……………………………………………………… 91
第六章 結論與建議………………………………………………………… 93
第一節 結論…………………………………………………………… 93
第二節 建議…………………………………………………………… 96
參考文獻…………………………………………………………………… 99
中文文獻……………………………………………………………… 99
英文文獻……………………………………………………………… 101
『表』目錄
（頁）
表1 國內各大醫院術前麻醉評估的現行作法…………………………… 4
表2 研究變項定義性質說明……………………………………………… 26
表3 本研究問卷各構面項目整理………………………………………… 31
表4 麻醉諮詢門診與術前麻醉病房訪視基本特性整理………………… 42
表5 麻醉諮詢門診與術前麻醉病房訪視希望了解手術麻醉媒介排序… 48
表6 麻醉諮詢門診與術前麻醉病房訪視病人情緒感受之差異………… 49
表7 麻醉諮詢門診與術前麻醉病房訪視之病人擔心事項排序………… 51
表8 麻醉諮詢門診受訪者對於等候時間之描述………………………… 52
表9 受訪者對麻醉諮詢門診流程滿意情形分佈……………………… 53
表10 麻醉諮詢門診與術前麻醉病房訪視的檢查費與麻醉費之比較… 60
表11 麻醉諮詢門診與術前麻醉病房訪視十四日再入院、三日內再急診之
情形…………………………………………………………………… 61
表12 麻醉諮詢門診與術前麻醉病房訪視之病人對服務感受度之差異… 62
表13 麻醉諮詢門診與術前麻醉病房訪視之信任感之差異……………… 63
表14 麻醉諮詢門診與術前麻醉病房訪視之病人對衛教資訊獲得差異… 64
表15 麻醉諮詢門診與術前麻醉病房訪視之病人對焦慮程度之差異… 65
表16 受訪者滿意度構面平均值之差異………………………………… 66
表17 受訪者之滿意度構面與麻醉諮詢門診流程滿意度相關分析 …… 67
表18 所有受訪者基本特性與各構面平均值差異檢定………………… 70
表19 麻醉諮詢門診受訪者基本特性平均值差異檢定………………… 71
表20 術前麻醉病房訪視受訪者基本特性平均值差異檢定…………… 72
表21 控制因素後之服務感受度複迴歸模型…………………………… 76
表22 控制因素後之信任感複迴歸模型………………………………… 77
表23 控制因素後之衛教資訊獲得程度複迴歸模型…………………… 78
表24 控制因素後之焦慮程度複迴歸模型……………………………… 79
表25 麻醉諮詢門診流程滿意度複迴歸模型…………………………… 80
『圖』目錄
（頁）
圖1 麻醉諮詢門診流程圖………………………………………………… 5
圖2 收案流程圖…………………………………………………………… 23
圖3 研究架構……………………………………………………………… 24
圖4 資料處理流程………………………………………………………… 30
『附錄』目錄
（頁）
附錄一 合併症嚴重度與ICD-9-CM 對照表……………………… 附錄一之1
附錄二 研究問卷專家效度名單………………………………… 附錄二之1
附錄三 「麻醉諮詢門診」、「術前麻醉病房訪視」病人滿意度
量表… ……………………………………………………………… 附錄三之1

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