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研究生:曾鈺真
研究生(外文):Yu-Chen Tseng
論文名稱:探討氣喘兒童家長對維持照護持續性之意願
論文名稱(外文):Willingness of parents and primary caregivers to maintain good care continuity for children with asthma
指導教授:蒲正筠蒲正筠引用關係唐高駿唐高駿引用關係
指導教授(外文):Christy PuGau-Jun Tang
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:醫務管理研究所
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2018
畢業學年度:107
語文別:英文
論文頁數:74
中文關鍵詞:氣喘照護兒童照護照護持續性願付價值
外文關鍵詞:Asthma managementpediatric carecontinuity of carewillingness to pay
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研究背景與動機
氣喘是兒童最常見的慢性疾病之一,根據國際兒童氣喘與過敏研究估計:全世界約有14 %的孩童曾有氣喘的症狀;氣喘發作不僅影響孩童及其家庭的生活品質,更增加健康保險系統及社會的負擔。即使氣喘症狀可透過持續的藥物治療及減少環境中的過敏源達到有效控制,但成效往往因病人無法依從醫囑或治療計畫而大打折扣,而照護持續性(Continuity of care)正是能迎刃而解此困境的關鍵之一。照護持續性不單指病人是否選擇固定的醫師就診,它更廣義描述病人與醫療提供者是否建立互信、密切的醫病關係。即便過去文獻普遍支持照護持續性可為病人帶來健康效益,我們卻很少探討家長是否同樣重視照護持續性對他們的影響。氣喘兒童由於生理及年齡的限制,他們的健康狀態往往受到主要照顧者對於醫療照護的觀念及知識所影響,透過本研究,我們將進一步瞭解家長對於兒童照護持續性的看法及所賦予之價值,以供後續政策制定及健康促進計畫之參考。
研究目的
探討家長對於兒童照護持續性的觀念及照護持續性對於氣喘兒童健康的影響,並進一步評估氣喘兒童家長對於照護持續性的願付價值是否較高。
研究方法
本研究採橫斷性研究設計,研究對象為全台六處不同層級醫療院所兒科門診之家長或兒童的主要照護者,資料收集方法為2017.8~2018.2 所進行之問卷調查。為減少受訪者因不熟悉兒童健康狀態而影響問卷可信度,本研究排除自稱非兒童主要照顧者亦非父母受訪者32人,最終分析樣本共825人,其中149人為氣喘兒童家長。本研究依衛生福利部所提供之2016年台灣西醫門診統計資料之兒童性別與年齡人數分層加權樣本後,以次數及百分比描述樣本人口學特質,及照護持續性問項作答情形;排除回答「孩童僅看過健兒門診」之受訪者後,我們以粗絕對配對法媒合人口學特質,並檢視家長之照護持續性觀念是否影響其願付價值;以斯皮爾曼相關係數檢視醫師連續性與願付價值等因素之相關性,再使用負二項式邏輯斯回歸估計醫師連續性對於兒童急診及住院風險;最後,我們利用多元邏輯斯回歸比較氣喘與非氣喘兒童家長對於照護持續重視程度是否不同。
研究結果
研究發現,超過80 % 的受訪者認為照護持續性對他們的孩子很重要,75 % 的家長信任孩子的兒科醫師,86 % 的家長表示過去一年偶爾、或從未更換小兒科醫師。儘管大部分的受訪者對關係持續性表達正向的看法,但近一半的家長覺得更換醫師並不會影響治療成效,甚至有30% 的家長認為更換醫師可以改善治療效果;47% 的受訪者願意多花30分鐘維持看同一位醫師就診,願付價值中位數為每月101~300元,僅38% 的家長願付價值超過每月300元。醫師信任程度、是否重視照護持續性及照護持續性的願付價值都與醫師連續性有正相關性;較少更換醫師、重視照護持續性及相信兒科醫師的家長,對於照護持續性的願付價值愈高。校正相關因素後,推估氣喘孩童曾更換醫師的一年住院風險是非氣喘孩童的4倍(IRR=2.00 vs. IRR=0.53),急診風險兩組則沒有差異(IRR=1.26 vs. IRR=1.18) ,且氣喘兒童家長對於照護持續性的願付價值並未顯著高於一般兒童的家長。
結論
研究結果顯示,儘管大部分的受訪者認同照護持續性十分重要,並普遍信任他們的兒科醫師,但多數受訪者不願意多花30分鐘或是每個月多花費多於300元維持照護持續性,家長對於照護持續性的觀念及態度亦會影響他們重視照護持續性的程度。儘管固定醫師就診有助於減少氣喘兒童的住院風險,但氣喘兒童家長對照護持續性的願付價值並未顯著高於一般兒童之家長,顯見氣喘兒童家長並未特別重視照護持續性對於孩童健康的影響。照護持續性是孩童健康照護不可忽視的一環,氣喘兒童更是需要被小心照顧的族群,健康照護系統在推廣照護持續性的同時,家長的意見應被重視並納入政策制定考量。
Background
Asthma is the world’s most common chronic disease among children. According to the International Children’s Asthma and Allergy Study, 14% of children are likely to have had an asthma attack in some point in their life. Asthma attacks can affect the quality of life of children and their families, and increase the disease burden to health care system. Although asthma symptoms can be controlled by long-term pharmacotherapy and reduction of allergens in the environment, the effectiveness is often compromised when patients have poor complacence to the treatment plan. Continuity of Care (COC) forms one of the essential components of asthma management. COC not only refers to a patient who has a fixed physician, but also, it broadly describes the patient-provider relationship. Previous studies have overwhelmingly revealed that the COC could improve patients’ health outcomes. However, few studies discuss patient’s perception and the value towards COC. In this study, we will explore a parent/primary caregiver’s attitude towards continuity, and their willingness to pay to maintain the same physician for their children.
Objectives
This study investigates explicitly a main caregiver/parent’s attitude towards COC, and their willingness to pay. We also analysed how differently the COC affects health outcomes between children with/without asthma, and compared whether asthmatic children’s caregivers/parents are more willing to spend time or pay money to maintain continuity.
Methods
A cross-sectional survey was conducted from August 2017 to February 2018. Study subjects were collected from six pediatric outpatient departments in different sites in Taiwan. This study excluded 32 participants who were neither the primary caregivers nor the parents of children. There were 825 people included; of which 149 were the parents of asthmatic children. Post-stratification weighting adjustment was utilised to calculate population estimates which were representative of pediatric patients in Taiwan. After excluding those who have only seen the outpatient visits for a regular evaluating purpose, we used the coarsened exact matching to match the basic demographic characteristics of parents and children. The relationship was examined between a parent’s concept of COC and their willingness to pay. We further used negative binomial regression to estimate the effect of provider continuity level on children’s emergency department visits and hospitalisation. The multivariate logistic regression, in turn, was employed to compare the willingness to pay for parents with asthma and non-asthma children.
Results
There were more than 80% of respondents who believed that the COC was important to their children. In total, 75% of parents trusted their physicians, and 86% of parents stated that they have seldom or never changed their pedantic physicians in the past year. Approximately half of the participants indicated that changing physicians would not affect the treatment outcome, while 47% of respondents were willing to spend 30 minutes to maintain provider continuity, and only 38% of parents were willing to pay more than NTD300 a month. A higher provider continuity level, paying attention to continuity and trusting the pediatric physicians were associated with higher willingness to pay for the COC. A four-time risk of hospitalisation was showed among asthmatic children who had changed physicians in comparison to non-asthmatic children (IRR = 2.00 vs. IRR = 0.53), while there was no difference in emergency visits between the two groups (IRR = 1.26 vs. IRR = 1.18). Parents of asthmatic children were not significantly more willing to pay for the COC than parents of non-asthmatic children.
Conclusion
While most respondents agreed that COC is important, and that they trusted their pediatric physicians, the majority of respondents were not willing to spend 30 minutes or pay little additional money a month to maintain their children seeing the same physicians. Parents’ attitudes towards COC also affect how they value provider continuity. Although regular physician visits could reduce the risk of hospitalisation for asthmatic children, the willingness to pay for asthmatic children’s parents was not significantly higher than for the parents of non-asthmatic children. COC forms a key component of children’s health care, and a parent/main caregiver is the key linkage between children and provider. Poor COC may not only be affected by inaccurate perception, but also by objective factors that parents/main caregivers may encounter. These factors should be further researched if high quality COC is to be promoted in the future, especially regarding asthma patients.
TABLE OF CONTENTS
中文摘要 I
ABSTRACT III
TABLE OF CONTENTS VI
LIST OF TABLES VII
LIST OF FIGURES IX
INTRODUCTION 1
METHODS 6
RESULTS 14
REFERENCE 65
APPENDIX 69

LIST OF TABLES
Table 1-1. Characteristics of all participants 16
Table 1-2. Participants’ characteristics, matched by provider continuity level 17
Table 1-3. Participants’ characteristics, matched by parents’ concept of the therapeutic outcome of changing physicians 19
Table 1-4. Participants’ characteristics, matched by the importance/unimportance of continuity 21
Table 1-5. Participants’ characteristics, matched by trust/non-trust in physicians 23
Table 1-6. Participants’ characteristics, matched by asthma status in children 25
Table 2. Item responses for parents' perceptions of continuity and the value placed on COC. Figures are frequencies (weighting percentage) 29
Table 3-1. Correlation matrix of COC and characteristics of all participants. 31
Table 3-2 Correlation matrix of COC and characteristics of the asthmatic group. 32
Table 3-3. Correlation matrix of COC and characteristics of the non-asthmatic group. 33
Table 4. Characteristics associated with willingness to spend time or money to maintain continuity 36
Table 5-1. Provider continuity associated with willingness to pay to maintain COC among all participant 37
Table 5-2. The effect of changing physicians for therapy associated with willingness to pay to maintain COC among all participants 38
Table 5-3. Parents’ perception of importance for continuity associated with willingness to pay to maintain COC among all participants 39
Table 5-4. Parents’ trust in pediatric physicians associated with willingness to pay to maintain COC among all participants 40

Table 6-1. The effect of COC on emergency department visits and hospitalizations among all children 42
Table 6-2. The effect of COC on emergency department visits, stratified by children’s asthma status 43
Table 6-3. The effect of COC on hospitalizations, stratified by children’s asthma status 44
Table 7-1. Characteristics independently associated with willingness to spend time or money to maintain COC among all participants. 46
Table 7-2. Characteristics independently associated with willingness to spend more than 30 minutes to maintain COC, stratified by asthma status 47
Table 7-3. Characteristics independently associated with willingness to pay more than NTD300/ month to maintain COC, stratified by asthma status 48
Table 8-1. Ordinal regression model: provider continuity associated with willingness to pay to maintain COC among all participants 50
Table 8-2. Ordinal regression model: the effect of changing physicians for therapy associated with willingness to pay to maintain COC among all participants 51
Table 8-3. Ordinal regression model: parents’ perception of importance for continuity associated with willingness to pay to maintain COC among all participant 52
Table 8-4. Ordinal regression model: parent’s trust associated with willingness to pay to maintain COC among all participants 53
Table 8-5. Ordinal regression model: asthma status associated with willingness to pay to maintain COC among all participants 54
Table 8-6. Ordinal regression model: Characteristics associated with willingness to pay to maintain provider continuity, stratified by asthma status 55


LIST OF FIGURES
Figure 1. The sample size for each site 7
Figure 2. Flow chart of sample selection 13
Figure 3. Reasons reported by participants for changing pediatric physicians 28
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