臺灣博碩士論文加值系統

中文摘要
目的：本研究個案醫院從全民健保於2010年導入Tw-DRGs支付制度，即實施DRG個案管理。本研究旨在探討DRG個案管理介入後，是否能有效地改善病患醫療資源耗用以及病歷書寫之完整性。方法：採病歷回溯性研究設計，以南部某區域教學醫院之2009年至2011年Tw-DRGs第一階段導入的DRGs群組之3,665住院案例為研究對象。比較個案管理介入前後案例之平均年齡、住院天數、權重校正後醫療費用、醫療費用與給付費用之差額、CMI值與合併症或併發症編碼等之變化。結果：個案管理介入後之個案的平均醫療費用與住院天數比介入前高，平均年齡介入後之個案亦高於介入前。權重校正後醫療費用則是DRG個案管理介入後有顯著減少。DRG個案管理介入與個案之合併症或併發症編碼有顯著關聯，個案管理介入後第一年、第二年之CMI值分別為1.27與1.29都顯著高於介入前的1.03(p<.001)。介入後第一年與第二年比介入前個案的平均醫療費用差額增加分別為2,390.4點與2,151.1點，但都少於因CMI增加而增加的給付費用。結論：DRG個案管理介入有效地改善病歷書寫品質，使得合併症或併發症之編碼正確，醫院獲得合理的醫療給付，此外，有效地管控住院醫療費用的支出。因此，個案管理是Tw-DRGs支付制度下，為有效醫療照護與病歷書寫完整性的重要途徑，特別是在病歷書寫品質的提升上。

Abstract
Objectives: DRG case management has been implemented in a teaching hospital in southern Taiwan since the introduction of the system of Tw-DRGs as a payment system in 2010. The aim of this study was to determine whether DRG case management intervention could effectively improve medical resources utilization and medical documentation. Methods: The study conducted a retrospective review of 3,665 medical records of discharges that were assigned to phase I Tw-DRGs for the years 2009 to 2011. Characteristics of average age, length of stay (LOS), hospital costs, DRG weight adjusted medical expenses, the differences between the hospital costs and the payment received, comorbidities and complications coding and hospital case-mix index of post-intervention discharges were compared to the prior year in detail. Results: Higher hospital costs and longer LOS of post-intervention discharges were noticed parallel to a significantly higher average age. Comparing the post-intervention to the pre-intervention period, medical records of discharges were with more comorbidities or complication coding (p< .001); hospital case-mix index was significantly greater (p< .001), pre-intervention (1.03) vs. one-year (1.27) and two-year post-intervention (1.29). During post-intervention period, mean hospital costs significantly decreased in an analysis that adjusted for DRG weight (p< .001). There was a significant increase (p< .001) in differences between the hospital costs and the payment received during both one-year and two-year post-intervention, average increase 2,390.4 RVUs and 2,151.1 RVUs respectively, which were lower than the payment increase due to the CMI rising during post-intervention periods. Conclusions: DRG case management that improves medical documentation can lead to improvements in coding of comorbidities and complications to reflect proper case-mix index and help improve payment; moreover, DRG case management can be an effective strategy to promote the appropriate use of health service resources. Under the DRGs payment system, DRG case management might be a worthwhile option to consider, especially in keeping comprehensive and complete medical documentation for every discharge.

目錄
中文摘要 I
Abstract II
誌謝 IV
目錄 V
表目錄 VII
圖目錄 VII
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 5
第三節 名詞解釋 6
第二章 文獻探討 8
第一節 DRGs支付制度沿革 8
第二節 DRGs支付制度與病歷書寫品質 11
第三節 個案管理之發展與定義 18
第四節 DRG個案管理介入成效 24
第三章 研究方法 33
第一節 研究架構 33
第二節 研究假說 34
第三節 變項定義 34
第四節 資料來源與研究對象 36
第五節 資料分析 40
第六節 倫理考量 40
第四章 研究結果 41
第一節 描述性統計分析結果 41
第二節 醫療資源耗用變異數分析結果 47
第三節 醫療費用差額變異數分析結果 55
第四節 個案管理介入對病歷書寫品質改善之成效 58
第五章 討論與結論 63
第一節 討論 63
第二節 結論 66
第六章 研究限制與建議 69
第一節 研究限制 69
第二節 建議 69
參考文獻 71
附錄 78


表目錄
表2- 1 病歷書寫品質對於醫療給付影響之相關文獻 14
表2- 2 國內外學者對個案管理所下之定義 22
表2- 3 DRG個案管理介入成效之相關文獻 28
表3- 1 Tw-DRGs第一階段導入之消化外科項目 37
表3- 2 Tw-DRGs第一階段導入之骨科項目 38
表3- 3 Tw-DRGs第一階段導入之婦產科項目 39
表4- 1研究對象科別分佈情形 41
表4- 2 研究對象人口學特性分佈情形 45
表4- 3 個案管理介入前後之研究對象年齡變異數分析 46
表4- 4 住院天數變異數分析結果 50
表4- 5醫療費用變異數分析結果 54
表4- 6 醫療費用差額變異數分析結果 57
表4- 7 個案管理介入與有無合併症或併發症編碼之分析結果 60
表4- 8 個案管理介入前、後CMI值變異數分析結果 62
表5- 1 研究假設檢定結果 66

圖目錄
圖3- 1 研究架構圖 33

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