臺灣博碩士論文加值系統

衛生福利部國民健康署從2019年起推動「建構延緩失能之長者友善照護模式試辦計畫」，對高齡長者參照「長者整合性照護指引（ICOPE）」進行評估，分別有認知、行動、營養、視力、聽力、憂鬱、用藥、生活目標等八大面向進行評估篩選，經由評估篩選及早發現長者健康問題，再依長者之功能缺失，制定個人化之健康管理及轉介服務，除了整合醫療資源，減少頻繁就醫與重複用藥以外，也可以因為早期發現潛在的健康問題，避免緊急就醫或住院治療的情形，其成效值得進一步探討。
本研究目的在評估65歲以上之門診及住院病患，接受長者友善照護計畫下，進行相關評估轉介與追蹤處置後，對醫療服務利用的影響，作為評估長者友善照護計畫介入之成效。
研究屬病歷回溯研究，採縱貫性回溯研究法，搭配差異中的差異法研究設計，以南投某區域醫院 2021 年 3月到 8月年齡大於等於65歲之門診及內外科住院病房，接受長者友善照護服務病患者為研究組樣本，包含169位門診病患及134位住院病患，並以同一期間其他未接受長者友善照護病患1比1依性別、年齡等因素配對抽樣為對照組，探討病患於研究區間長者友善照護前後6個月內，其醫療利用次數、醫療利用費用的差異。
在門診的費用與次數上，長者友善照護介入後，呈現減少的趨勢，但未達統計學意義；在住院的費用與次數上，則是有增加的情形，但是也無明顯統計上的差異。
長者友善照護等因素與住院醫療利用費用及次數差值之多元迴歸分析，其中長者友善照護、高血壓、心臟病、腎臟病、疾病權重及榮民有正相關，而年齡、男性、糖尿病、腦血管疾病、重大傷病及低收入有負相關。長者友善照護介入前後住院醫療利用費用及次數以t檢定顯示，除了男性對就醫次數有達到顯著負相關、其餘各變相皆未達顯著。
以羅吉斯迴歸估計長者友善照護對個案6個月死亡與否之影響，加入年齡、性別、是否有同時罹患糖尿病、高血壓、心臟病、腎臟病和腦血管疾病、疾病權重值(RW值)、重大傷病、低收入及榮民身分等變項來觀察長者友善照護與個案死亡的關聯，發現相較於加入友善服務之住院病患，未加入者其死亡風險是加入者之5.65倍。
面對高齡長者複雜的照護需求，傳統的急性醫療照護模式已無法滿足，長者友善照護模式於門診服務部分對於費用降低可能有成效，住院部分雖無法降低醫療費用，但卻有效降低長者之死亡風險，可見導入長者友善照護模式有其益處。

The National Health Service of the Ministry of Health and Welfare has promoted the "Pilot Project to Build an Elder-Friendly Care Model for Delaying Disability" since 2019. Eight aspects including nutrition, vision, hearing, depression, medication, and life goals are evaluated and screened. Through evaluation and screening, the health problems of the elderly can be detected early. According to the functional deficit of the elderly, the personalized health management and referral services are developed. In addition to integrating medical resources, reducing medical visits and repeated medication, it can also avoid medical emergency or hospitalization, because of early detection of potential health problems.
The purpose of this study was to evaluate the impact of outpatients and inpatients over the age of 65 who received the elderly-friendly care program, and the impact on the medical utilization after related evaluation, referral, and follow-up treatment, and to evaluate the effectiveness of the intervention of the elderly-friendly care program.
The research is a retrospective study of medical records. The longitudinal retrospective research method is adopted, and the research design is matched with the difference in difference method. From March to August 2021, the outpatients and inpatients in the wards of a regional hospital in Nantou, aged 65 years or older, accept the elderly. Patients with friendly care service patients are the sample of the research group, including 169 outpatients and 134 inpatients, and other patients who did not receive elder-friendly care during the same period were sampled 1:1 as the control group to explore the elderly in the study area. Differences in the frequency of medical use and the cost of medical use within 6 months before and after friendly care.
In terms of the cost and frequency of outpatient services, the elderly-friendly care intervention showed a decreasing trend, but it did not reach statistical significance; in terms of the cost and frequency of hospitalization, there was an increase, but there was no significant statistical difference.
Multivariate regression analysis of elderly-friendly care and other factors and the difference in hospitalization medical utilization costs and times, among which elderly-friendly care, hypertension, heart disease, kidney disease, disease weight value (RW value) and veterans are positively correlated, while age, male, diabetes, cerebrovascular Illness, major injury, and low income were negatively associated. The cost and frequency of hospitalization medical utilization before and after the intervention of elderly-friendly care were shown by t test, except that males had a significant negative correlation with the number of medical visits, and the other disguised forms were not significant.
Logistic regression was used to estimate the effect of elderly-friendly care on whether the case died or not at 6 months, adding age, gender, whether there was co-morbidity with diabetes, hypertension, heart disease, kidney disease and cerebrovascular disease, RW value, major illness, low income, and veteran status to observe the relationship between elderly-friendly care and death. It revealed that compared with inpatients who joined the friendly service, the risk of death for those who did not join was 5.65 times that of those who joined.
Facing the complex care needs of the elderly, the traditional acute medical care model can no longer meet the needs of the elderly. The elderly-friendly care model may be effective in reducing costs for outpatient services. Although hospitalization cannot reduce medical costs, it can effectively reduce the death of the elderly. Risk, it can be seen that the introduction of the elderly-friendly care model has its benefits.

中文摘要……………………………………………………………… I
Abstract………………………………………………………………... III
目錄………………………………………………………………….… IV
表目錄………………………………………………………………… VI
圖目錄………………………………………………………………… VIII
第一章 前言
第一節 研究背景與動機………………………………………….… 1
第二節 研究目的……………………………………………………. 3
第二章 文獻探討
第一節 高齡友善及ACE 長者急性照護………………………….. 4
第二節 影響醫療利用與費用之因素探討………………………… 6
第三節 差異中的差異法之相關研究……………………………… 11
第三章 研究方法
第一節 研究架構………………………………………………….… 13
第二節 研究假設……………………………………………….…… 14
第三節 研究設計與研究對象………………………………….…… 15
第四節 研究變項……………………………………………….…… 18
第五節 資料分析方法………………………………………………. 19
第六節 研究倫理考量…………………………………………..…... 20
第四章 研究結果
第一節 研究對象基本特性………………………………………… 21
第二節 長者友善照護影響醫療利用費用之差異………………… 25
第三節 長者友善照護影響醫療利用次數之差異………………… 29
第四節 長者友善照護介入對於醫療利用差異的分析…………… 33
第五節 長者友善照護介入對於醫療利用費用與次數差值之影響因素….. 37
第六節 長者友善照護介入對於服務對象死亡與否之影響……… 42
第五章 研究討論
第一節 長者友善照護介入對於醫療利用之影響因素……………. 42
第二節 長者友善照護介入對於服務對象死亡之影響因素………. 44
第三節 研究限制……………………………………………………. 45
第六章 結論與建議
第一節 結論………………………………………………………….. 46
第二節 建議………………………………………………………….. 47
參考文獻……………………………………………………………… 48
附錄
附錄一 人體試驗委員會計畫同意書………………………………. 54


 
表目錄
頁碼
表2-1 高齡友善及老人急性照護相關文獻…………………………… 5
表2-2 影響醫療利用與費用因素之相關文獻…………………………. 8
表2-3 差異中的差異法相關文獻………………………………………. 12
表3-1 共病症相關診斷代碼及中英文名稱……………………………. 16
表3-2 研究變項…………………………………………………………. 18
表4-1門診個案基本特徵…………………………………...………….. 22
表4-2住院個案基本特徵……………………………………...……….. 24
表4-3接受長者友善照護門診個案前後醫療費用……………………. 25
表4-4未接受長者友善照護門診個案前後醫療費用…………………. 26
表4-5接受長者友善照護住院個案前後醫療費用……………………. 27
表4-6未接受長者友善照護住院個案前後醫療費用…………………. 28
表4-7接受長者友善照護門診個案前後醫療次數……………………. 29
表4-8未接受長者友善照護門診個案前後醫療次數…………………. 30
表4-9接受長者友善照護住院個案前後醫療次數……………………. 31
表4-10未接受長者友善照護住院個案前後醫療次數………………... 32
表4-11長者友善照護與醫療費用及次數差異的分析………………... 35
表4-12介入前後180天醫療利用DID之迴歸結果………………….. 36
表4-13 長者友善照護介入對於門診醫療利用費用差值之影響因素... 37
表4-14長者友善照護介入對於門診醫療利用次數差值之影響因素... 38
表4-15長者友善照護介入對於住院醫療利用費用差值之影響因素... 40
表4-16長者友善照護介入對於住院醫療利用次數差值之影響因素... 41
表4-17長者友善照護介入對於服務對象死亡與否之影響…………… 43



 
圖目錄
頁碼
圖2-1 差異中的差異法………………………………………………… 11
圖3-1 研究架構圖……………………………………………………… 13

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