臺灣博碩士論文加值系統

背景：在國際間提倡「以病人為中心」的醫療照護氛圍下，病人觀點的醫療品質測量逐漸受到關注。近年來各國積極發展病人經驗調查，如美國的CAHPS(Consumer Assessment of Healthcare Providers and Systems)、英國的PPE(Picker survey of patient experiences questionnaire)等，臺灣雖有「病人報告之醫院品質調查」，但無大規模定期的執行調查，相關研究也尚有不足。
研究目的：本研究欲比較主觀評價與客觀的照護結果評估的關聯性，爰透過探討「病人住院經驗」與「照護結果指標」的相關性以獲得解釋。同時，藉由分析研究對象就醫醫院的特質、人口學特徵及疾病狀況等，瞭解影響病人經驗的因子。
研究方法：本研究為橫斷性調查研究。透過健保署於2018-2019年在全國進行的「住院病人就醫經驗調查」委託計畫，獲得研究對象在住院期間的病人經驗資料，包含對醫院的整體評分及推薦程度等。接著，與健保申報資料連結，瞭解研究對象出院後的醫療利用情形，包含3日內再急診及30日內再入院，做為照護結果的指標。透過檢定及迴歸分析，驗證病人經驗與照護結果的關聯性。
研究結果：最終納入研究N=3,244。羅吉斯迴歸的結果顯示，在控制醫院特質和病人特質等變項後，醫院整體評分給予高分者，30日內再入院的OR=0.728、中等組OR=0.804，顯示相較於低分組再入院的風險較低，但相關性未達統計上顯著。在推薦意願方面，願意推薦醫院者再入院OR=1.169 (95%CI=0.736-1.857)，兩者間無顯著的關聯性。此外，其他特質包含醫院層級、教育程度、調查方式、入院管道、就醫科別、是否接受手術及住院天數，經統計與整體評分和推薦意願顯著相關，為病人評價可能的影響因子。
結論：雖然本研究顯示病人住院經驗調查結果與專業面照護指標無顯著相關，卻也象徵病人觀點的醫療品質測量是重要且無可取代的。建議衛生主管機關應定期辦理病人經驗調查，並做為醫療院所費用給付的參考，以改善病人觀點的醫療品質，提升以病人為中心照護。

Objectives: Delivering patient-centered care is an important issue of health care system worldwide. Meanwhile, patient experience is thought to be a key quality metric that represents patients’ perception of healthcare quality. The purpose of this study is to determine whether patients’ perception of their care correlates with healthcare outcomes, and what are the key characteristics of hospitals and patients that associated with better experience.
Methods: A cross-sectional study was conducted using the Patient Experience of Hospital Care survey (PEHC) in 2018-2019. Among patients aged 20 or older, data of two overall ratings: global rating and recommendation of the hospital were collected. Then, 3-day emergency department visit and 30-day readmission were examined as the indicators of the quality of hospital care. A multivariable logistic regression analysis was performed to determine the association between patient-reported measures and short-term healthcare outcomes.
Results: The sample included 3,244 patients. In adjusted analyses, the odds of 30-day readmission were lower among patients in the highest global rating group relative to the least, although the association was not significance (Odds ratio [OR] for readmission, 0.728; 95% confidence interval [CI], 0.454-1.168). On the other hand, the odds of readmission were higher in patients who would recommend the hospital, but there’s no significant association (OR, 1.169; 95% CI, 0.736-1.857). In addition, the results revealed that patient-reported overall ratings were associated with hospital accreditation levels, education level, survey modes, admission route, medical department, surgery and length of stay.
Conclusions: Since there’s no significant association between patient experience and objective outcomes, this finding suggests that patients’ perception information can be a meaningful and unique healthcare quality indicator. We are hopeful that regular reporting of patient experience survey will improve patient-centered care.

目錄
口試委員會審定書 I
謝 辭 II
摘 要 III
Abstract IV
第一章 緒論 1
第一節 研究背景 1
第二節 研究重要性 2
第三節 研究目的 3
第二章 文獻回顧 4
第一節 病人就醫經驗調查 4
第二節 影響病人就醫經驗之因素 9
第三節 病人評價與照護結果之關聯性研究 13
第四節 文獻回顧小結 21
第三章 研究方法 22
第一節 研究設計 22
第二節 研究架構及研究假說 23
第三節 研究材料 24
第四節 變項操作型定義 26
第五節 統計分析方法 33
第四章 研究結果 34
第一節 描述性統計 34
第二節 雙變項分析 41
第三節 多變項分析 55
第五章 討論 69
第一節 研究結果討論 69
第二節 研究假說驗證 77
第三節 研究限制 78
第六章 結論與建議 80
第一節 結論 80
第二節 建議 82
參考文獻 84
附 錄 94
圖目錄
圖3-1 研究架構圖 23
圖4-1 樣本篩選流程圖 35
表目錄
表2-1 病人就醫經驗之影響因素文獻整理 11
表2-2 病人評價與照護結果之關聯性文獻整理 18
表3-1 研究變項之操作型定義 31
表4-1 描述性統計：樣本特性分析(N=3,244) 39
表4-2-1 雙變項分析：3日內再急診與病人評價、醫院及病人特質(N=3,244) 47
表4-2-2 雙變項分析：30日內再入院與病人評價、醫院及病人特質(N=3,244) 49
表4-2-3 雙變項分析：醫院整體評分與醫院特質、病人特質(N=3,244) 51
表4-2-4 雙變項分析：推薦意願與醫院特質、病人特質(N=3,244) 53
表4-3-1 多變項分析：30日內再入院之羅吉斯迴歸分析(N=3,244) 59
表4-3-2 多變項分析：出院櫃台發放─30日再入院之羅吉斯迴歸(N=1,510) 61
表4-3-3 多變項分析：郵寄問卷─30日內再入院之羅吉斯迴歸分析(N=1,734) 63
表4-3-4 多變項分析：郵寄問卷─整體評分之羅吉斯迴歸分析(N=1,734) 65
表4-3-5 多變項分析：郵寄問卷─推薦意願之羅吉斯迴歸分析(N=1,734) 67
附錄二 原始問卷總樣本的特性分析(N=11,202) 101
附錄三 串聯健保資料庫後樣本的特性分析(N=4,992) 103
附錄四 調查方式之次群體分析結果(N=4,992) 105
附錄五 多變項分析：3日內再急診之羅吉斯迴歸分析(N=3,244) 107
附錄六 出院櫃台發放(整體評分)－30日再入院之羅吉斯迴歸分析(N=1,510) 109
附錄七 出院櫃台發放(推薦意願)－30日再入院之羅吉斯迴歸分析(N=1,510) 111
附錄八 郵寄問卷－整體評分之複迴歸分析(N=1,734) 113
附錄九 雙變項分析：出院後不良照護結果(再急診或再入院)(N=3,244) 115
附錄十 多變項分析：出院後不良照護結果(再急診或再入院)(N=3,244) 117
附錄十一 樣本特性分布比較表 119
附錄十二 共線性檢定：變異數膨脹因子(Variance Inflation Factor, VIF) 121

朱育增、吳肖琪（2010）。回顧與探討次級資料適用之共病測量方法。台灣公共衛生雜誌，29(1)，8-21。doi:10.6288/TJPH2010-29-01-02
吳肖琪、吳義勇、朱慧凡、林嘉彥、李鐘祥、張錦文、藍忠孚（2002）。我國醫院醫療品質指標使用之情形。醫療品質，2(2)，1-14。doi:10.29759/HQ.200204.0008
吳昀麇、呂宗學、林先和（2017）。全球疾病負擔研究中的健康照護品質排名－以慢性腎臟病為例。台灣公共衛生雜誌，36(4)，315-318。doi:10.6288/TJPH201736106064
李宜恬（2015）。病人住院經驗與忠誠度之相關性研究–以南部某區域醫院為例（碩士論文）。取自華藝線上圖書館系統。（系統編號U0011-2107201520151900）doi:10.6832/KMU.2015.00086
李芳菁（2019）。病人滿意度調查之意見反應分析。彰化護理，26(2)，8-11。doi:10.6647/CN.201906_26(2).0003
李芳菁、蘇子舜、陶阿倫（2018）。HCAHPS病人住院經驗調查結果初探。彰化護理，25(2)，35-41。doi:10.6647/CN.201806_25(2).0006
邱尚志、張鈺旋、王復中、黃佩珊、李麗惠、林寬佳（2018）。病人經驗調查之國際趨勢與國內發展展望。醫院雙月刊，51(1)，12-25。
姚開屏、蕭宇佑、郭耿南、鄭守夏（2010）。病人報告之醫院品質：問卷發展與信效度分析。台灣公共衛生雜誌，29(5)，440-451。doi:10.6288/TJPH2010-29-05-07
張珉溦（2016）。探討影響癌症病人就醫經驗與整體評價之因素（碩士論文）。取自華藝線上圖書館系統。（系統編號U0001-0707201616452500）doi:10.6342/NTU201600762
陳佩妮、鄭守夏、鍾國彪、林王美園（1997）。台灣地區醫療品質指標適用性之探討。中華公共衛生雜誌，16(2)，133-142。doi:10.6288/CJPH1997-16-02-03
陶阿倫、李芳菁、張旭東、許瑋真、蘇子舜（2010）。病人對服務品質之期待與缺口分析。醫療品質雜誌，4(2)，43-50。doi:10.30160/JHQ.201003.0032
游宗憲、賴美淑（2009）。建構醫療品質指標方法文獻之回顧。台灣醫學，13(2)，174-180。doi:10.6320/FJM.2009.13(2).12
潘靜雲、柯純卿、陳季員、劉雅瑛、曾英芬、金繼春（1996）。南部某家醫院病人對醫院服務滿意度的調查。中華公共衛生雜誌，15(3)，249-258。doi:10.6288/CJPH1996-15-03-07
衛生福利部中央健康保險署。全民健康保險醫療品質資訊公開網。網址：https://www.nhi.gov.tw/AmountInfoWeb/index.html
鄭嘉惠、郭書麟、王拔群（2013）。病人住院經驗調查結果初探－以某醫學中心為例。醫療品質雜誌，7(6)，99-102。
謝慧欣、鄭守夏、丁志音（2000）。住院病患對就醫選擇資訊之需求：初步調查發現。中華公共衛生雜誌，19(6)，437-445。doi:10.6288/CJPH2000-19-06-04
魏玉容、鍾國彪、鄭守夏（2005）。醫療品質評估的發展－從專業評鑑到報告卡系統。台灣公共衛生雜誌，24(4)，275-283。doi:10.6288/TJPH2005-24-04-01 
AHRQ. Consumer Assessment of Healthcare Providers and Systems (CAHPS). Available at: https://www.ahrq.gov/cahps/surveys-guidance/index.html. Accessed December 20, 2021.
Anhang Price R, Elliott MN, Zaslavsky AM, et al. Examining the Role of Patient Experience Surveys in Measuring Health Care Quality. Med Care Res Rev 2014;71:522-54.
Barber RM, Fullman N, Sorensen RJD, et al. Healthcare access and quality index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: A novel analysis from the global burden of disease study 2015. The Lancet (British edition) 2017;390:231-66.
Barnett ML, Song Z, Landon BE. Trends in Physician Referrals in the United States, 1999-2009. Arch Intern Med (1960) 2012;172:163-70.
Beattie M, Murphy DJ, Atherton I, et al. Instruments to measure patient experience of healthcare quality in hospitals: a systematic review. Syst Rev 2015;4:97-.
Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med 2011;24:229-39.
Borghans I, Kleefstra SM, Kool RB, et al. Is the length of stay in hospital correlated with patient satisfaction? Int J Qual Health Care 2012;24:443-51.
Boulding W, Glickman SW, Manary MP, et al. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care 2011;17:41-8.
Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44(5):681-92.
Chen CC, Cheng SH. Hospital competition and patient-perceived quality of care: Evidence from a single-payer system in Taiwan. Health policy (Amsterdam) 2010;98:65-73.
Cheng SH, Ho YC, Chung KP. Hospital quality information for patients in Taiwan: can they understand it? Int J Qual Health Care 2002;14:155-60.
Chow A, Mayer EK, Darzi AW, et al. Patient-reported outcome measures: The importance of patient satisfaction in surgery. Surgery 2009;146:435-43.
CMS. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS. Accessed December 20, 2021.
Coulter A, Seagroatt V, McPherson K. Relation between general practices' outpatient referral rates and rates of elective admission to hospital. BMJ 1990;301:273-6.
Covinsky KE, Rosenthal GE, Chren M-M, et al. The relation between health status changes and patient satisfaction in older hospitalized medical patients. J Gen Intern Med 1998;13:223-9.
Damiani G, Federico B, Venditti A, et al. Hospital discharge planning and continuity of care for aged people in an Italian local health unit: does the care-home model reduce hospital readmission and mortality rates? BMC Health Serv Res 2009;9:22-.
de Vos MS, Hamming JF, Boosman H, et al. The Association Between Complications, Incidents, and Patient Experience: Retrospective Linkage of Routine Patient Experience Surveys and Safety Data. J Patient Saf 2019;17:e91-e7.
de Vries H, Elliott MN, Hepner KA, et al. Equivalence of Mail and Telephone Responses to the CAHPS® Hospital Survey. Health Serv Res 2005;40:2120-39.
Donabedian A. The Quality of Care: How Can It Be Assessed? JAMA 1988;260:1743-8.
Dong N, Eisenberg JD, Dharmarajan K, et al. Relationship Between Patient-Reported Hospital Experience and 30-Day Mortality and Readmission Rates for Acute Myocardial Infarction, Heart Failure, and Pneumonia. J Gen Intern Med 2019;34:526-8.
Dottino JA, He W, Sun CC, et al. Centers for Medicare and Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and gynecologic oncology surgical outcomes. Gynecol Oncol 2019;154:405-10.
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ open 2013;3:e001570.
Elliott MN, Lehrman WG, Goldstein E, et al. Do Hospitals Rank Differently on HCAHPS for Different Patient Subgroups? Med Care Res Rev 2010;67:56-73.
Elliott MN, Lehrman WG, Goldstein EH, et al. Hospital survey shows improvements in patient experience. Health affairs 2010;29:2061-7.
Fenton JJ, Jerant AF, Bertakis KD, et al. The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med (1960) 2012;172:405-11.
Goldstein E, Farquhar M, Crofton C, et al. Measuring Hospital Care from the Patients' Perspective: An Overview of the CAHPS® Hospital Survey Development Process: Measuring Hospital Care from the Patients' Perspective. Health Serv Res 2005;40:1977-95.
HCAHPS. Hospital Consumer Assessment of Healthcare Providers and Systems online. Available at: https://www.hcahpsonline.org/. Accessed December 20, 2021.
Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001. PMID: 25057539.
Isaac T, Zaslavsky AM, Cleary PD, et al. The Relationship between Patients' Perception of Care and Measures of Hospital Quality and Safety: Relationship between Patients' Perception of Care and Other Measures. Health Serv Res 2010;45:1024-40.
Jenkinson C, Coulter A, Bruster S, et al. Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Qual Saf Health Care 2002;11:335-9.
Jenkinson C, Coulter A, Bruster S. The Picker Patient Experience Questionnaire: development and validation using data from in-patient surveys in five countries. Int J Qual Health Care 2002;14:353-8.
Jha AK, Orav EJ, Zheng J, et al. Patients' Perception of Hospital Care in the United States. N Engl J Med 2008;359:1921-31.
Kennedy GD, Tevis SE, Kent KC. Is There a Relationship Between Patient Satisfaction and Favorable Outcomes? Ann Surg 2014;260:592-600.
Kupfer JM, Bond EU. Patient satisfaction and patient-centered care: necessary but not equal. JAMA 2012;308(2):139-40.
Lasserson D, Smith H, Garland S, Hunt H, Hayward G. Variation in referral rates to emergency departments and inpatient services from a GP out of hours service and the potential impact of alternative staffing models. Emerg Med J 2021;38(10):784-8.
Leonardsen ACL, Grøndahl VA, Ghanima W, et al. Evaluating patient experiences in decentralised acute care using the Picker Patient Experience Questionnaire; methodological and clinical findings. BMC Health Serv Res 2017;17:685-.
Lobo Prabhu K, Cleghorn MC, Elnahas A, et al. Is quality important to our patients? The relationship between surgical outcomes and patient satisfaction. BMJ Qual Saf 2018;27:48-52.
Maher DP, Wong W, Woo P, et al. Perioperative Factors Associated with HCAHPS Responses of 2,758 Surgical Patients. Pain medicine (Malden, Mass) 2015;16:791-801.
Mazurenko O, Collum T, Ferdinand A, et al. Predictors of Hospital Patient Satisfaction as Measured by HCAHPS: A Systematic Review. J Healthc Manag 2017;62:272-83.
McClelland LE, Vogus TJ. Compassion Practices and HCAHPS: Does Rewarding and Supporting Workplace Compassion Influence Patient Perceptions? Health Serv Res 2014;49:1670-83.
Meterko M, Wright S, Lin H, et al. Mortality among Patients with Acute Myocardial Infarction: The Influences of Patient-Centered Care and Evidence-Based Medicine. Health Serv Res 2010;45:1188-204.
Orindi BO, Lesaffre E, Quintero A, et al. Contribution of HCAHPS Specific Care Experiences to Global Ratings Varies Across 7 Countries: What Can be Learned for Reporting These Global Ratings? Med Care 2019;57:e65-e72.
Otani K, Waterman B, Dunagan WC. Patient satisfaction: how patient health conditions influence their satisfaction. J Healthc Manag 2012;57:276-93.
Parast L, Elliott MN, Hambarsoomian K, et al. Effects of Survey Mode on Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey Scores. J Am Geriatr Soc 2018;66:546-52.
Rajah R, Ahmad Hassali MA, Jou LC, Murugiah MK. The perspective of healthcare providers and patients on health literacy: a systematic review of the quantitative and qualitative studies. Perspect Public Health 2018;138(2):122-32.
Rao M, Clarke A, Sanderson C, et al. Patients' own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. BMJ 2006;333:19-22.
Rathert C, Wyrwich MD, Boren SA. Patient-centered care and outcomes: a systematic review of the literature. Med Care Res Rev 2013;70(4):351-79.
Robinson S, Howie-Esquivel J, Vlahov D. Readmission Risk Factors after Hospital Discharge Among the Elderly. Popul Health Manag 2012;15:338-51.
Sacks GD, Lawson EH, Dawes AJ, et al. Relationship Between Hospital Performance on a Patient Satisfaction Survey and Surgical Quality. JAMA surgery 2015;150:858-64.
Sofaer S, Crofton C, Goldstein E, et al. What Do Consumers Want to Know about the Quality of Care in Hospitals? Health Serv Res 2005;40:2018-36.
Sofaer S, Firminger K. Patient perceptions of the quality of health services. Annu Rev Public Health 2005;26:513-59.
Tevis SE, Kennedy GD. Patient satisfaction: does surgical volume matter? J Surg Res 2015;196:124-9.
Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg 2015;261:2-8.
WHO. The world health report 2000: health systems: improving performance. Geneva: World Health Organization, 2000.
Wong ELY, Leung MCM, Cheung AWL, et al. A population-based survey using PPE-15: relationship of care aspects to patient satisfaction in Hong Kong. Int J Qual Health Care 2011;23:390-6.