臺灣博碩士論文加值系統

過去有許多探討市場競爭與醫療品質之文獻，其結論卻不甚一致。近年來，台灣的透析人口數逐年增加，儘管過去有諸多討論透析品質之文章，但多數研究以存活分析和病人知覺品質等結果面作為品質之衡量，此衡量方式著重在病患之治療成效及其自身知覺品質。故本研究將以透析感染率作為過程面之品質指標，分析市場競爭對透析品質之影響。
本研究採固定半徑法來定義市場，並以賀芬達指數(HHI)衡量競爭程度。研究資料為2004~2011年健保資料庫重大傷病檔的門診資料，根據ICD-9確立病患是否有感染，並設立實證模型，以月和季作為時間單位，估計市場競爭對透析感染率的影響，以及當市場競爭程度變化時對感染率之影響。
研究結果指出，當市場的HHI愈高，病患感染機率較低，即市場競爭愈劇烈，病患的透析感染機率較高，透析品質較差，且該結果不因依變數為連續變數或間斷變數、市場半徑之定義不同和時間單位不同而有改變。透過本研究之結果，隨著透析院所的市場競爭加劇，透析品質卻下降，其中醫護人力是否不足或分配不均，進而影響病患之醫療品質，增加其感染的風險，值得衛生主管機關重視。

A large amount of literature has investigated the relationship between market competition and quality of medical care. However, the results from these studies are conflicting. Recently, the number of patients who receive dialysis treatment has been increasing year by year. Although many studies have previously investigated the quality of dialysis treatment, the majority of these studies focused on measuring the survival rate and satisfaction levels of patients as a means of measuring the quality of the dialysis treatment. These types of measurement determined only the outcome of treatment as well as the subjective opinions of patients. In this study, the rate of infections resulting from dialysis treatment was used as a measurement of treatment quality and the effect of market competition on quality of dialysis treatment was investigated.
The present study used the Fixed Radius Method to define market areas and the Herfindahl-Hirschman Index (HHI) to determine the level of market competition. Clinical data for the period of 2004 to 2011 were obtained from the Registry for Catastrophic Illness Patients, National Health Insurance Research Database. ICD-9 codes were used to determine if the patients suffered from infections. An empirical model was created, in which months and seasons were used as units of time, to estimate the effect of market competition on the rate of infection resulting from dialysis treatment. We measured the effect of changes in market competition on the rates of infection resulting from dialysis
Our study indicated that a higher HHI was related to a lower rate of infection. This means that for higher levels of market competition, the rates of infection would be higher and the quality of dialysis treatment would be lower. In addition, this result did not change when the dependent variables were continuous or discrete variables, when the defined market radius changed, or when different units of times were used. This study demonstrated that market competition amongst dialysis clinics led to reductions in the quality of dialysis treatment. It is worth recommending that major health departments further investigate whether the increased rate of infection resulting from dialysis treatment and hence, the reduced quality of medical care, was due to insufficient numbers of medical staff or insufficient staff allocation.

目 錄
指導教授推薦書…………………………………………………………
口試委員會審定書………………………………………………………
誌謝…………………………………………………………………………………iii
中文摘要…………………………………………………………………………iv
英文摘要………………………………………………………………………… v
第一章 緒論 - 1 -
第一節 研究背景與動機 - 1 -
第二節 研究目的 - 4 -
第二章 文獻探討 - 5 -
第一節 醫療市場競爭之測量 - 5 -
一、 市場範圍之界定 - 6 -
二、 市場競爭程度之測量 - 12 -
第二節 醫療市場之競爭型態 - 15 -
第三節 市場競爭與醫療品質 - 18 -
第四節 透析品質的評估 - 22 -
第三章 研究方法 - 24 -
第一節 實證模型 - 24 -
第二節 研究資料及變項說明 - 28 -
第四章 研究結果 - 32 -
第一節 描述性統計 - 32 -
第二節 估計結果 - 41 -
第五章 結論與建議 - 59 -
第一節 結論與討論 - 59 -
第二節 研究限制及建議 - 61 -
參考文獻 - 64 -

圖目錄
圖1-1 歷年各國ESRD之發生率與盛行率…………………………………. 2

表目錄
表2-1:不同市場範圍劃分方法之優缺點比較……………………………… 11
表2-2:競爭程度測量指標之優缺點比較…………………………………... 14
表2-3:國內外市場競爭與醫療品質之相關文獻…………………………... 21
表3-1:變項名稱及其定義說明…………………………………………… 31
表4-1：歷年ESRD透析病患特性……………………………………….. 36
表4-2：歷年ESRD透析感染病患特性……………………………………37
表4-3：歷年透析醫療院所數……………………………………………..38
表4-4：歷年透析市場百分比(依競爭程度) ………………………………. 39
表4-5歷年競爭市場之平均競爭家數(依競爭程度) ………………………. 40
表4-6：市場競爭程度對透析感染機率的影響分析結果(以月為單位) ……… 46
表4-7：市場競爭程度對透析感染機率的影響分析結果(以月為單位) ……….48
表4-8：市場競爭程度對透析感染機率的影響分析結果(以季為單位) ……….49
表4-9：市場競爭程度對透析感染機率的影響分析結果(以季為單位) ……….50
表4-10：不同市場競爭程度對透析感染機率的影響分析結果(以月為單位) … 51
表4-11：不同市場競爭程度對透析感染機率的影響分析結果(以月為單位) … 52
表4-12：不同市場競爭程度對透析感染機率的影響分析結果(以季為單位) … 53
表4-13：不同市場競爭程度對透析感染機率的影響分析結果(以季為單位) … 54
表4-14：市場競爭變化對透析感染機率的影響分析結果(以月為單位) ………55
表4-15：市場競爭變化對透析感染機率的影響分析結果(以月為單位) ………56
表4-16：市場競爭變化對透析感染機率的影響分析結果(以季為單位) ………57
表4-17：市場競爭變化對透析感染機率的影響分析結果(以季為單位) ………58

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