臺灣博碩士論文加值系統

研究目的：
探討個案醫院民國99-101年住院病人自動出院於品質管理介入前、後之變化情形，並以中斷性時間序列分析方法評估介入後之成效。

研究方法：
研究對象為中部某大型公立精神科專科教學醫院，調查期間為自民國99年1月1日起至101年12月31日止的精神科住院照護出院的病人出院件數﹝共計2,862人次﹞，本研究採回溯性介入評估研究，為類實驗設計之中斷性時間序列設計。在控制病人特質﹝住院天數、住院次數、年齡、性別、病人來源、住院到出院日數、首次入院﹞、疾病相關特質（出院類型、重大傷病、診斷分類、合併酒藥癮）後，以二元邏輯斯迴歸分析品質管理介入措施前後之自動出院發生率變化趨勢是否有顯著的差異。

研究結果:
99年到101年之自動出院發生率分別為5.73%、4.24%、5.44%。100年及101年介入後有關急診入院、無重大傷病、住院日數0-7天及首次入院之自動出院發生率與99年介入前自動出院發生率均有明顯下降趨勢。在控制病人特性及疾病特性後，以傳統介入前後比較方式檢定結果顯示醫療品質改善計畫對於降低自動出院率並沒有顯著成效，但以中斷性時間序列方式檢定結果中顯示醫療品質改善計畫介入前自動出院率已有明顯下降趨勢，介入前每增加一個月其發生自動出院的機率低10%﹝OR=0.9；95%CI: 0.826, 0.98﹞，而介入後自動出院率雖低於介入前的水準，但其變化的趨勢並沒有明顯的上升或下降。

結論：
本研究以中斷性時間序列分析較傳統的介入前後比較方式更能檢測出醫療品質管理措施介入後的成效，未來可作為品質介入措施評估的研究設計參考。

Objective
This study explored the changes in the rate of discharge against medical advice (AMA) of inpatients before and after quality management interventions in a case hospital from 2010 to 2012, analyzing the effects thereof by using an interrupted time series design.

Method
This study was conducted at a large-scale public psychiatry teaching hospital from January 1, 2010 to December 31, 2012, during which 2862 inpatients discharged from the psychiatry department. This retrospective study involves evaluating interventions, employing an interrupted time series design as a quasi-experimental design. After controlling for patient characteristics (days of hospitalization, number of hospitalization, age, sex, source of patient, length of stay, and first-time admission) and disease-related characteristics (type of discharge, catastrophic illness, diagnosis, and concurrent drug or alcohol abuse), a binary logistic regression was used to analyze whether the rate of AMA was significantly altered after quality management interventions were introduced.

Results
The rates of AMA were 5.73%, 4.24%, and 5.44 % for 2010, 2011, and 2012, respectively. After controlling for patients’ characteriatics and disease-related characteristics, the traditional before-after analysis showed that intervention exerted a non-significant influence on AMA. However, the results of the interrupted time series test showed that before the health care quality improvement plan was introduced, the AMA rate already in a significant decrease trend, that is, each additional month before an intervention decreases the probability of AMA by 10%(OR = 0.9; 95% CI: 0.826, 0.98), making AMA rates after intervention lower than those prior to the intervention. Nevertheless, the overall trend of AMA after the intervention didn’t change significantly.

Conclusion
Our study supported that an interrupted time series analysis is superior to traditional tests for evaluating quality management intervention measures. In the future, the findings herein can be used as a study design reference for evaluating quality intervention measures.

第一章 前言 1
第一節 研究背景 1
第二節 研究動機 2
第二章 文獻探討 4
第一節 平衡計分卡 4
第二節 平衡計分卡應用在醫療產業之研究 6
第三節 自動出院之定義、趨勢及相關因素 8
第四節 中斷性時間序列設計（INTERRUPTED TIME-SERIES DESIGN） 15
第三章 研究方法 18
第一節 研究架構 18
第二節 研究設計 19
第三節 資料的收集來源及保管 23
第四節 研究變項定義 24
第五節 資料分析方法 27
第四章 研究結果 29
第一節 基本屬性資料之描述 29
第二節 自動出院發生率分析 34
第三節 出院類型之雙變項分析 40
第四節 自動出院病人之邏輯斯迴歸分析 42
第五章 討論 45
第一節 出院病人自動出院發生率及其特性 45
第二節 影響出院類型之雙變項分析 46
第三節 介入前後自動出院病人之邏輯斯迴歸分析 47
第六章 結論與建議 48
第一節 結論 48
第二節 建議 49
第三節 研究限制 49
參考文獻 51
附錄一：臨床試驗證明書 56
附錄二：ICD-9-CM分類 57

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