臺灣博碩士論文加值系統

背景：自閉症譜系障礙 (Autism spectrum disorders, ASD)，其典型三項特徵分別為具社會性互動障礙、溝通障礙與行為、興趣及活動的模式相當侷限重複而刻板。由於目前對於疾病的認識以及精神障礙鑑定機構的經驗與技術越來越進步，造成泛自閉症障礙者有逐年增加的趨勢。實證研究指出，泛自閉症相較於一般兒童醫療資源耗用高，但若從孩童期開始及早發現、確診，及早接受早期療育，對日後整體包括社會、教育資源的耗用都具成本抵銷與成本效益。泛自閉症者通常可於三歲以前確診，由於年紀過小，醫師可得診斷資訊不足加以其家長對於發生原因不清與心理調適因素影響而四處求醫，不僅增加醫療利用情形，也因就醫而浪費時間與無法對症下藥，延誤黃金治療時間以及合適的方式進行療育。
目的：本研究藉由混合方法論，結合健保資料庫分析與訪談，以瞭解泛自閉症者於確診前後之門診醫療利用情形，進而探討該障礙者就醫行為與影響因素。
方法：本研究採回溯性世代研究法，使用國家衛生研究院所提供之全民健康保險學術研究資料庫2005年百萬承保抽樣歸人檔中的資料檔，觀察2003至2005年出生者至2010年止，為泛自閉症確診者共182人，分析探討泛自閉症者兒童確診前後一年之醫療利用情形；搭配深入訪談共8名家長，瞭解其影響醫療資源利用之因素。資料收集整理後以威爾克森符號等級檢定、以及複迴歸、卜瓦松迴歸等統計方法檢驗相關研究假說，並以質性訪談輔助解釋其結果。
結果：確診後的泛自閉症兒童對醫療的需求整體增加，其平均醫療費用也增加。確診時間的前後、是否有其他合併症與是否有獲得政府補助（包括身障手冊與重大傷病卡）為影響泛自閉症兒童醫療利用的主要因素，就醫機構層級別也會影響復健科的醫療利用，但是否有其他合併症與復健療育次數無顯著影響。
結論：醫療與社會福利資源的介入為影響泛自閉症障礙就醫次數與醫療費用之重要因素，建議相關單位推廣政策資訊，鼓勵並提供需要的孩童及早接受復健療育。

Background: Autism spectrum disorder (ASD), which are characterized as having a typically characterized by social deficits, communication difficulties, stereotyped or repetitive behaviors and interests, and in some cases, cognitive delays. There is evidence that understanding of the disease , the broadening of the concept, the expansion of diagnostic criteria, the development of services, and improved awareness of the condition have played a major role in explaining this increase, although it cannot be ruled out that other factors might have also contributed to that trend. Empirical research indicates that annual expenses for children with autism spectrum disorder
were more than for other children. Children with ASD have a substantial burden of medical illness, but if detected early start from childhood, early diagnosis, early intervention as soon as possible, on the future using social, educational resources are cost-offset and cost-effectiveness. ASD are usually diagnosed before the age of three, but too young for physicians have insufficient information before making a decision about the diagnosis. In the other hands, psychological adjustment factors effect parents'' behavior. Not only increasing medical utilization, but also because psychological adjustment factors waste time by delaying medically recommended treatment and early intervention.
Objective: This research combines National Health Insurance Research Database (NHIRD) analysis and interviews. The main purpose of this research is to analyze the health care utilization of the ASD patients before and after they were diagnosed, and related factor of healthcare- seeking behavior.
Methods: This research used claims data file of 1 million sampled registry from Taiwan National Health Insurance Research Database(NHIRD). A total of 182 ASD children from 2003 to 2010 were included in the study. With SAS 9.2 software, this study tested the hypotheses by Wilkerson signed rank test, multiple linear regression, and Poisson regression. Combined qualitative depth interviews method to understand 8 interviewee why impact on their healthcare-seeking behavior process. Data were collected from January to March 2013. The method of content analysis and editing analysis were employed for analysis.
Results: The ambulatory expenditure of ASD children after diagnosis was significantly higher than they did before diagnosis. The factors associated with ASD children healthcare utilization include before and after the diagnosis time, whether there are other comorbidities and whether there is access to government grants (including the Physical and Mental Disability Handbook and Catastrophic Illness Card). Medical institution level also affects health care utilization of the Division of Rehabilitation Medicine.
Conclusion: Medical and social welfare resources provided are important factors on healthcare-seeking behavior, in order to reduce the financial burden and mental stress of the family and let them have more energy to plan for their children’s life earlier. Therefore, the related policy on the promotion information is the need to encourage and provide children receiving early rehabilitative intervention.

中文摘要 I
Abstract II
圖目錄 VI
表目錄 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 3
第三節 研究重要性 4
第二章 文獻探討 5
第一節 簡介泛自閉症 5
第二節 早期療育 11
第三節 混合方法論 19
第四節相關實證研究 21
第三章 研究材料與方法 31
第一節 研究設計與研究架構 31
第二節 研究假說 32
第四節 研究變項與操作型定義 35
第五節資料處理與統計方法 42
第六節 質性訪談 43
第四章 研究結果 47
第一節 描述性統計 47
第二節 雙變項統計分析 52
第三節 多變項統計分析 56
第四節 深入訪談結果 72
第五章 討論 78
第一節 研究方法之討論 78
第二節 研究結果之討論 79
第三節 混合方法之訪談與量化研究結果綜合討論 83
第四節 研究限制 86
第六章 結論與建議 87
第一節 結論 87
第二節 建議 88
參考文獻 89
附件 94

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