臺灣博碩士論文加值系統

研究背景：台灣自1995年3月起開始實施全民健康保險制度之後，大幅降低民眾就醫時的財務障礙，增加就醫民眾的可近性與選擇性，使全體國民都能獲得最基本的醫療保障，但也因此造成整體醫療費用支出上升。由於SARS疫情的爆發，為落實分級轉診制度，提升基層診所照護品質，健保局自2003年開始實施家庭醫師試辦計畫。文獻指出，儘管民眾對家醫計畫有中高滿意度，多數醫師也給予肯定，但收案照護的人數僅佔台灣人口比例不到一成，診所的參與率不到三成。此外，也缺乏研究探討臺灣現況之下有多少基層診所能夠承擔家庭醫師的功能。

研究目的：基層醫療在管理與協調病人照護中被賦予核心的角色，因此本研究欲透過台灣基層診所之病人複雜度以及提供基層醫療服務項目之比例來探討臺灣現況之下有多少基層診所能夠承擔家庭醫師的功能。

研究方法：本研究採橫斷式研究法，以2009年至2013年全民健康保險資料庫進行分析。本研究以基層診所診斷、檢查、病人特徵、藥物和其他治療，在量性、變異性和多樣性變化進行病人複雜度之計算。此外，本研究參考國外使用之基層照護品質指標，進而歸納出十一項基層醫療服務項目。經由線性回歸和羅吉斯回歸來檢定基層診所各科別和都市化程度與病人複雜度以及提供服務項目之關係，以及基層醫師各專科別和人口學特徵與提供服務項目之關係。

研究結果：由基層診所科別和醫師專科別的分布來看，2009年至2013年間家醫科和內科之占率逐年下降，耳鼻喉科和其他專科之占率則逐年增加。基層診所逐年往都市化程度高的地區集中。接著，研究結果顯示診所病患的診斷和藥物在量性、變異性和多樣性面向上皆有逐年增加的趨勢，病人複雜度為內科診所的複雜度最高，其次是家醫科。且病人複雜度與診所所在地區的都市化程度成反比。基層醫療服務項目的分析結果顯示，西醫基層診所提供各項服務之比例為：成人健檢39.81%、老人流感疫苗25.75%、子宮頸抹片檢查10.17%、乳癌篩檢0.55%、空腹血脂42.08%、醣化血色素36.37%、微量白蛋白尿30.46%、眼睛檢查8.51%、糞便潛血檢查18.73%、大腸直腸鏡檢查1.68%、戒菸門診9.44%。其中，家醫科和內科診所能提供服務項目之比例平均最高，且除了乳癌篩檢、眼睛檢查和直腸結腸鏡檢查外，診所所在地區之都市化程度與診所提供基層醫療服務項目之比例皆呈現反比。

結論與建議：整體而言，台灣基層家醫科和內科診所最接近家庭醫師的角色，但現況之下以達成的比例來說，能夠提供一半以上基層醫療服務項目的診所僅約一成，確實還有很大的進步空間。因此，本研究建議台灣未來在擬定分級醫療策略時，應將提升基層醫療服務量能作為首要目標，尤其應加強高都市化程度地區的診所。

Background: Taiwan’s National Health Insurance System was implemented in March 1995. The system has drastically reduced the financial barriers to medical treatment and increased accessibility and choice of health-care providers so that all citizens can get the most basic medical care. This has, of course, resulted in an increase in overall medical expenses. When the SARS epidemic hit Taiwan, the NHI implemented a classification referral system called the Family Physician Trial Plan in order to enhance the quality of care at primary care clinics. The Family Physician Trial Plan has been in place since 2003. Previous literature has pointed out that although the public and most physicians have reported high satisfaction with the medical plan, the number of people receiving care through this plan accounts for less than 10% of the population of Taiwan, while the clinic participation rate is less than 30%. In addition, there is a lack of research regarding how many primary care clinics can take on the functions of family physicians under current conditions in Taiwan.
Objectives: The primary care system is responsible for the management and coordination of patient care. This study will explore how many primary care clinics are able to take on the functions of family physicians. This will be accomplished through exploring patient complexity and the services provided by primary care clinics in Taiwan.
Methods: Data from 2009 to 2013 were obtained from Taiwan’s National Health Insurance Research Database. In this study, we calculated patient complexity using different dimensions, including quantity, variability and diversity. We assessed patient complexity in terms of diagnoses, exams, patient characteristics, medications and other therapies provided by primary care clinics. In addition, we referenced the quality care indicators used in other countries, and then summed up eleven primary care services indicators. Through linear regression and logistic regression, we examined the relationships between division, urbanization and patient complexity and services provided by primary care clinics. We also took into account the relationship between physicians’ specialty, demographic characteristics and primary care services.
Results: The distribution of primary care clinics and physicians between 2009 and 2013 reveals that the proportion of family medicine and internal medicine providers declined every year, while ENT and other specialties increased every year. Primary care clinics also tend to be concentrated in highly urbanized areas. The quantity, variability and diversity of diagnoses and medications per visit of primary care clinics are also increasing every year. Patient complexity is the highest for internal medicine providers, followed by family medicine. The degree of urbanization in the area where the clinic is located is inversely proportional to patient complexity. The results suggest that the eleven primary care services that primary care clinics can provide are: Adult health examination 39.81%, elderly influenza vaccine 25.75%, pap smears 10.17%, breast cancer screening 0.55%, fasting blood lipids 42.08%, glycosylated hemoglobin 36.37%, microalbuminuria 30.46%, eye examination 8.51%, fecal occult blood test 18.73%, colorectal examination 1.68%, and smoking cessation clinic 9.44%. Family medicine and internal medicine provide the highest proportion of primary care services, and in general, the degree of urbanization in the clinics is inversely proportional to the ratio of clinics providing primary care services.

Conclusions: Overall, family medicine and internal medicine clinics in Taiwan are able to take on the functions of primary care providers, but only about 12% of the primary care clinics provide more than half of primary care services. Ideally, primary care services could be spread more evenly between providers. Any effort to improve the referral system should be aimed at strengthening the clinics that aren’t currently able to meet primary care service needs. This is particularly true of primary care clinics in highly urbanized areas.

致謝 i
摘要 ii
目錄 vi
圖目錄 viii
表目錄 ix
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 基層醫療 5
第二節 病人複雜度 12
第三節 基層醫療服務項目 19
第四節 綜合回顧整理 33
第三章 研究方法 34
第一節 研究設計與研究架構 34
第二節 研究假說 36
第三節 研究變項之定義與操作型定義 37
第四節 資料來源與處理 46
第五節 統計分析 51
第四章 研究結果 54
第一節 研究樣本特性分佈 54
第二節 病人複雜度 60
第三節 基層醫療服務項目 69
第四節 多變項分析 97
第五章 討論 117
第一節 研究結果討論 117
第二節 假說驗證 129
第三節 研究限制 131
第六章 結論與建議 133
第一節 結論 133
第二節 建議 135
參考文獻 136
附件一 NAMCS對應代碼 147

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