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研究生:陸鳳屏
研究生(外文):Feng-Ping Lu
論文名稱:老年病況與醫療服務使用
論文名稱(外文):Geriatric Conditions and Health Care Utilization
指導教授:吳淑瓊吳淑瓊引用關係
指導教授(外文):Shwu-Chong Wu
口試委員:陳慶餘林正介藍祚運
口試日期:2013-07-26
學位類別:博士
校院名稱:國立臺灣大學
系所名稱:健康政策與管理研究所
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:2013
畢業學年度:101
語文別:中文
論文頁數:226
中文關鍵詞:老年病況認知功能異常憂鬱症狀跌倒尿失禁疼痛醫療服務利用
外文關鍵詞:geriatric conditioncognitive impairmentdepressive symptomsfallsurinary incontinencepainhealth services research
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研究背景: 老年病況、多重慢性疾病、與身體功能障礙皆為重要老年健康議題,老年病況不僅在老年族群中盛行率高,且對老年人之身心健康有重大影響,研究亦發現老年病況與醫療服務利用有關。近年來國外已發展出針對社區中具有老年病況及複雜健康照護需求者之照護模式,並證實可減少其醫療服務利用及提升照護品質。台灣醫療體系正面臨人口快速高齡化的挑戰,但老年病況與醫療服務使用之相關研究仍在起步階段,且先前之研究結果彼此間並不一致,亟須有實證資料以提供政策上規劃老年照護服務之參考。
研究目的: 一、瞭解老年病況之盛行率與分布情形,及其與多重慢性疾病及身體功能障礙間之關係;二、瞭解老年病況對於醫療服務使用之影響;三、探討已有老年病況者醫療服務利用之影響因素。
研究方法: 本研究之樣本取自2005年「國民健康訪問暨藥物濫用調查」中65歲以上之社區長者共2,668位,樣本具縣市代表性,且經加權後可具全國代表性; 受訪者中1,729位有簽署串聯健保檔同意者,並串聯其2005年至2007年健保申報資料,分析老年病況對於2005年度及追蹤兩年之醫療服務使用影響。根據研究目的,選取社區老人中盛行率高的五種老年病況進行分析,即認知功能異常、憂鬱症狀、跌倒、尿失禁、及疼痛等,並另以老年病況群集型態分組作為自變項。醫療服務使用變項包括西醫門診、急診、住院之使用及費用,並將醫療費用先取自然對數轉換後進行分析。研究架構參考安德遜行為模式,在控制前傾、使能、需要及健康相關行為等因素後,探討老年病況對於醫療服務使用之影響。最後分析在已有老年病況者中,何種因素顯著影響其醫療服務利用。統計方法根據依變項之分布特性,分別使用邏輯斯複迴歸模式、廣義線性模式、多變項複迴歸模式、以及廣義估計方程式進行分析。
研究結果: 在老年病況之盛行率方面,有認知功能異常者為22.4%;有憂鬱症狀者為13%;去年一年曾發生跌倒者為21.3%,其中約四成為跌倒兩次以上者;尿失禁之盛行率為23.8%;疼痛之盛行率為32.4%。總樣本中36.8%的老年人無任何老年病況,約三成具有一種老年病況,三成之老年人同時具有兩種以上老年病況,樣本中8.4%無法自答簡易智能測驗或憂鬱量表。有憂鬱症狀者最常併有其他老年病況。在老年病況之相關因素方面,人口特質中之女性、未受教育者、無偶者、居住於都市化程度較低之地區者、及收入較低者與老年病況有關。慢性疾病及身體功能障礙與老年病況有正相關,但三者間之人口特質分布仍有差異。有兩種以上慢性疾病者中,超過一半以上有老年病況並存,而日常生活活動功能障礙者幾乎都有老年病況並存。在全部老年樣本中,高達四成同時有兩種以上慢性疾病及一種以上老年病況並存。
在老年病況與醫療服務使用部分,在控制其他影響醫療服務使用的變項後,發現認知功能異常與門診、急診、住院服務使用無顯著相關。憂鬱症狀在控制其他變項後,顯著與較高之門診、急診、住院服務使用有關,使用率分別較無憂鬱症狀者高出25%、64%、及43%。跌倒在控制其他變項後,仍與較高之門診、急診服務使用有關。尿失禁對於醫療服務使用的影響,在控制慢性疾病數及身體功能等因素後即減弱。疼痛在控制其他變項後,仍有較高之西醫門診使用及多重就醫風險,但並未使用較多之急診與住院服務。在控制其他變項後,有兩種以上老年病況者較無任何老年病況者之門診使用次數高出兩成,而急診次數則高出五成,且多重就醫的風險較高。無法自答簡易智能測驗或憂鬱量表者之門診使用率,並未高於無任何老年病況者,但急診使用率為無任何老年病況者之1.7倍。在追蹤資料分析部分,樣本之整體醫療服務使用有隨追蹤時間而上升的趨勢,老年病況對於醫療服務使用之影響大致與橫斷面研究結果相同,但影響隨追蹤時間而降低。
在老年病況與醫療費用部分,在控制其他變項後,憂鬱症狀仍顯著與較高之急診與住院費用有關;跌倒與較高之西醫門診費用、急診費用、及總醫療費用有關;疼痛僅與較高之西醫門診費用有關。有兩種以上老年病況者、及無法自答簡易智能測驗或憂鬱量表者,較無任何老年病況者之急診費用顯著為高。
在有老年病況者之醫療服務利用影響因素分析方面,需要因素仍是最顯著的影響因素,其次是使能因素中之福利身分。影響其是否使用西醫門診服務之顯著因素為需要因素中之慢性疾病數;影響其是否使用急診服務與住院服務之顯著因素為需要因素中之身體功能障礙。在健康相關行為因素方面,有不良健康行為者較少使用西醫門診服務,但使用較多之急診及住院服務。
結論與建議: 老年病況盛行率與慢性疾病相近,且常有並存情形,老年照護相關人員皆應熟悉相關之評估及處置。此外,老年族群健康狀態異質性高,應依據不同之健康特性規劃照護服務與目標: 針對已有多重慢性病者,應積極預防老年病況的發生;已有老年病況者,應預防相關之併發症及失能;而已有身體功能障礙者幾乎皆併有老年病況,建議將老年病況之偵測及處置納入長期照護體系中,以延緩身體功能惡化、改善生活品質。憂鬱症狀、跌倒皆顯著與較高之醫療服務使用有關,應為政策介入的重點。而針對有兩種以上老年病況者、無法自答簡易智能測驗或憂鬱量表者、及老年病況有併身體功能障礙者,建議應發展創新照護模式,加強門診及社區中之對於健康問題之偵測及處置,以減少此族群對於急性醫療資源之耗用。

Background
Geriatric conditions, or so-called geriatric syndromes, were common but often overlooked in clinical practice. Geriatric conditions reflect impaired capacity of an individual to maintaine homeostasis when exposed to internal or external challenges. Common geriatric conditions among community-dwelling older adults included cognitive impairment, depressive symptoms, falls, urinary incontinence, and persistent pain. These conditions exert negative impact on several health outcomes, such as quality of life, physical function, and health care utilization. Several programs have been developed to provide comprehensive care for older aults with geriatric conditions and complex healthcare needs, which demonstrated decrease in emergency department visits and hospitalization, as well as improvement in quality of care. However, the association between geriatric conditions and health care utilization in Taiwan remained unanswered.
Methods
We used data from the 2005 wave National Health Interview Survey with linkage to National Health Insurance database (year 2005 to 2007). In total, 2,668 community-dwelling older adults completed the interview and 1,729 of them signed consent to link to National Health Insurance database. We aimed to examine the association between geriatric conditions (i.e. cognitive impairment, depressive symptoms, falls, urinary incontinence, and persistent pain) and the utilization of outpatient physician services, emergency department (ED) visits, and inpatient services. We applied Andersen behavior model to examine factors that associated with utilization of services. Covariates included age, sex, education, marital status, living arrangement, number of chronic morbidities, functional status, income, urbanization level, beneficiary status, and health behavior. Logistic regression model were used to model dichotomous outcomes. Poisson regression was used to model count data. Costs were transformed based on natural log and analyzed by multivariate regression models. Generalized estimating equations were used to analyze longitudinal data.
Results
After weighted to national level, the prevalence of cognitive impairment was 22.4%, and 13% for depressive symptoms, 21.3% for falls, 23.8% for uninary incontinence, and 32.4% for persistent pain. Overall, 36.8% of the older adults had no geriatric conditions, one-third of them had one geriatric condition, and another one-third had two or more geriatric conditions. Older women had more geriatric conditions than men. Those with depressive symptoms were most likely to have coexisting geriatric conditions. Low socioeconomic status was associated with geriatric conditions. Overall, 40% of older adults had coexisting multimorbidities and geriatric conditions.
After adjustment for covariates, depressive symptoms, falls, and persistent pain were significantly associated with higher utilization of outpatient services. Depressive symptoms and falls were associated with higher utilization of ED services. Those with two or more geriatric conditions, compared to those without, had higher ED visits. For inpatient services, those with depressive symptoms compared to those without had higher inpatient services utilization.
Falls and persistent pain were significantly associated with higher costs of outpatient services after adjustment. The association between depressive symptoms and outpatient costs diminished after adjusted for chronic diseases and functional status. Depressive symptoms and falls were significantly associated with higher ED costs. Depressive symptoms were associated with higher inpatient costs. Those with two or more geriatric conditions had higher ED costs compared to those without geriatric conditions.
Among those with geriatric conditions, factors that significantly associated with utilization of healthcare services were needs factors (i.e. number of chronic diseases and functional status) and beneficiary status. Older adults with unhealthy behaviors had higher utilization of ED and inpatient services, but had lower outpatient services utilization. Among those with two or more geriatric conditions, higher income was associated with less ED utilization and costs.
Conclusions
Geriatric condtions were common and often co-existed with multimorbidities and physical impairment. Depressive symptoms, falls, and having two or more geriatric conditions were significantly associated with higher healthcare utilization and costs, especially ED services. Care programs for older adults should address early detection and management of geriatric conditions, particularly in community and ambulatory settings.


口試委員會審定書 i
誌 謝 ii
中文摘要 iii
英文摘要 vi
表目錄 xii
圖目錄 xvii
第一章 緒論 1
第一節 研究背景 1
第二節 研究目的 5
第二章 文獻探討 6
第一節 老年醫學之發展 6
一、老年醫學發展歷史 6
二、老年醫學之內涵與應用 8
第二節 老年病況 10
一、老年病況概念簡介 10
二、老年病況之種類 11
三、老年病況盛行率及其對於健康之影響 12
四、老年病況之測量 16
第三節 老年病況、多重慢性疾病、及失能之關係 21
一、老年病況與多重慢性疾病之關係 21
二、老年病況與失能之關係 23
三、老年病況與多重慢性疾病、失能之關係 25
第四節 影響老年人醫療服務使用之因素 26
一、前傾因素 27
二、使能因素 28
三、需要因素 28
四、健康相關行為對於醫療服務利用之影響 29
五、老年病況對於醫療服務利用之影響 29
第五節 研究啟示 35
第三章 研究方法 37
第一節 研究架構及研究假說 37
第二節 資料來源及研究對象 39
一、2005年國民健康訪問暨藥物濫用調查 39
二、全民健康保險資料庫 40
三、分析樣本選取 40
第三節 研究變項定義與測量 42
一、老年病況 42
二、醫療服務使用 43
三、與醫療服務使用相關變項 45
第四節 研究設計及分析方法 47
一、研究子題一 47
二、研究子題二 47
三、研究子題三 49
第四章 研究結果 50
第一節 台灣地區老年病況、慢性病與失能之分布 50
一、樣本特性描述 50
二、人口特質與老年病況之關係 60
三、慢性疾病、失能、與老年病況之關係 64
四、小結 65
第二節 老年病況與醫療服務使用 75
一、樣本之當年度醫療服務使用狀況 75
二、老年病況與當年度醫療服務使用情形 83
三、老年病況與當年度醫療服務使用之關係 93
四、老年病況與追蹤兩年之醫療服務使用 108
第三節 有老年病況者醫療服務利用之影響因素探討 130
一、有認知功能異常者之醫療服務利用影響因素分析 130
二、有憂鬱症狀者之醫療服務利用影響因素分析 141
三、有跌倒者之醫療服務利用影響因素分析 152
四、有尿失禁者之醫療服務利用影響因素分析 163
五、有疼痛者之醫療服務利用影響因素分析 174
六、有兩種以上老年病況者之醫療服務利用影響因素分析 185
第五章 討論 196
第一節 研究結果與討論 196
一、老年病況、慢性病與失能之分布 196
二、老年病況與醫療服務使用 201
三、有老年病況者醫療服務使用之影響因素探討 205
第二節 研究限制 207
第三節 政策啟示 209
參考文獻 211



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