臺灣博碩士論文加值系統

研究背景：心臟疾病為台灣2014年十大死因第二名，為引導醫療服務提供者提供整體性醫療照護，論質計酬逐漸受到重視。台灣於2012年5月實施全民健康保險急診品質提升方案，期望藉財務獎勵提升急診急性心肌梗塞病患照護品質。目前國內針對該方案研究較少，且尚未探討對於急診急性心肌梗塞且接受介入性心導管治療病患的醫療費用與照護結果之影響。

研究目的：探討全民健康保險急診品質提升方案對於急診急性心肌梗塞且接受介入性心導管治療病患醫療費用與照護結果之影響。

研究方法：本研究利用全民健康保險研究資料庫2005年承保抽樣百萬歸人檔進行次級資料分析，擷取2008年至2013年第三季期間資料，以急診急性心肌梗塞接受介入性心導管治療病患做為研究對象。使用分段廣義估計方程式(Generalized estimating equations, GEE)，探討全民健康保險急診品質提升方案對於急診急性心肌梗塞且接受介入性心導管治療病患醫療費用與照護結果之影響。

研究結果：全民健康保險急診品質提升方案實施後，急診急性心肌梗塞且接受介入性心導管治療病患住院期間醫療費用、30天死亡及30天再入院表現均無顯著差異。

結論：全民健康保險急診品質提升方案對於急診急性心肌梗塞且接受介入性心導管治療病患醫療費用及照護結果於研究期間可能影響不顯著。

Background：Heart disease was ranked second in the top ten leading causes of death in Taiwan in 2014. To encourage medical service providers in providing holistic medical care, hospital administrators have increasingly emphasized pay for performance. Taiwan implemented a project in May 2012, aiming to elevate the quality of emergency department (ED) care covered by the National Health Insurance. Specifically, financial incentives were formulated in an attempt to enhance ED quality of care for patients with acute myocardial infarction (AMI). Currently, few studies have examined the project, and no study has explored the project’s influence on the medical costs and care outcomes of patients with AMI who have received percutaneous coronary intervention(PCI).
Objective：To research the impact of the P4P program in the ED on costs and outcomes of PCI.
Method：This study used the 2005 claim data of the National Health Insurance Research Database of 1 million beneficiaries for secondary data analyses. The data of patients with AMI who have received PCI between 2008 and the third quarter of 2013 were retrieved. A segmented generalized estimating equation was used to investigate the influence of the project aimed at enhancing ED care quality on the medical costs and care outcomes of patients with AMI who have received PCI.
Results：There are no significant improvements in hospitalization cost, 30-day mortality and all cause 30-day readmission after implementing P4P program in the ED.
Conclusion：There are no significant improvements after the implementation of P4P program in the ED on costs and outcomes of PCI.

誌謝 i
中文摘要 ii
Abstract iii
目錄 iv
表目錄 vi
圖目錄 viii
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 文獻回顧 5
第一節 論質計酬介紹 5
第二節 急性心肌梗塞簡介 10
第三節 急性心肌梗塞相關論質計酬介紹 17
第四節 論質計酬照護成效實證研究 31
第五節 總結 42
第三章 研究方法與設計 43
第一節 研究設計 43
第二節 研究架構 44
第三節 研究假說 45
第四節 資料來源與研究對象 46
第五節 研究變項操作型定義 49
第六節 資料處理流程 52
第七節 統計方法 53
第四章 研究結果 55
第一節 描述性分析結果 55
第二節 雙變項分析結果 62
第三節 多變項分析結果 74
第五章 討論 77
第一節 研究方法討論 77
第二節 研究結果討論 80
第三節 研究限制 84
第六章 結論與建議 85
第一節 結論 85
第二節 建議 86
參考文獻 87

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