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研究生:王鶴健
研究生(外文):Hao-Chien Wang
論文名稱:醫院社會責任的實踐:以氣喘疾病管理為例
論文名稱(外文):Fulfilment of Hospital Social ResponsibilityFocusing on Asthma Management
指導教授:陳家麟陳家麟引用關係
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:商學組
學門:商業及管理學門
學類:一般商業學類
論文種類:學術論文
論文出版年:2022
畢業學年度:110
語文別:中文
論文頁數:57
中文關鍵詞:醫院社會責任氣喘疾病管理SABA過度使用溫室氣體排放C-SOP分析
外文關鍵詞:Asthma managementSABA overuseGreen House Gas emissionCarbon foot printHospital Social ResponsibilityESGC-SOP
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企業社會責任(corporate social responsibility; CSR)是企業在貢獻經濟發展的同時,承諾遵守道德規範、改善員工及其家庭、當地整體社區、社會的生活品質。聯合國全球協議2004年首次提出 ESG的概念:環境保護(Environment; E)、社會責任(Social; S)、公司治理(Governance; G)。ESG幾乎涵蓋及反映公司在社會和環境營運的所有可能要素,以及營運模式是否達到具備“永續”和“社會責任”的要求。醫療保健行業,如果能制定強而有力的ESG方法,包括氣候行動計劃(Climate Action Plan; CAP),除了可以減少這些影響,同時還可以支持許多醫療保健組織的目標:建立更健康的社區、幫助弱勢群體。氣喘是一種普遍的全球性疾病,都市化及工業化的發展使得氣喘罹病人數逐年增加。氣喘是一種氣道慢性發炎性的疾病,但是在良好的控制下,可避免症狀的發生,達到良好的生活品質。控制不佳時,往往增加急性惡化發作的頻率,除了造成病人的生活品質惡化及增加住院、死亡風險外,也造成醫療資源負擔增加。氣喘的藥物治療可分為(1)症狀緩解型藥物(主要為氣管擴張劑)可以快速緩解支氣管收縮現象及其伴隨的咳嗽、喘鳴、胸悶等症狀,短效乙二型刺激劑(Short Acting Beta-receptor Agonist; SABA)是其主要藥物;(2)症狀控制型藥物,主要為吸入型類固醇(Inhaled corticosteroid; ICS),能減少支氣管黏膜的發炎反應,可以減少氣喘惡化,屬於治本、保養的藥物。治療氣喘的藥物除了口服、針劑之外,主要都採用吸入劑型(吸入器搭配吸入藥物)的藥物。吸入型藥物有很多種,一般可以歸類為三個類別:含推進劑(propellant)的壓力定量吸入劑(Pressurized metered dose inhaler; pMDI);和另兩種不含推進劑的乾粉吸入劑(Dry powder inhaler; DPI)及緩釋型氣霧吸入器(Soft mist inhaler; SMI)。壓力定量吸入劑內含的推進劑是一種液化的壓縮氣體,擔任霧化而載送藥物的功能。最早被使用的推進劑是氟氯碳化物(chlorofluorocarbons; CFC),它們是很強的溫室氣體,兼具消耗臭氧層的特性,被蒙特羅公約所禁止。取而代之的推進劑為氫氟烷化合物(hydrofluoroalkane; HFA),雖然它們不會消耗臭氧層,但依然是具有較高的全球暖化潛勢(global warming potential; GWP)的溫室氣體。全球每年使用HFA的壓力定量吸入器約6億3千萬支,造成1千3百萬噸的二氧化碳排放,約等於2百萬歐盟人口的碳足跡。
經由文獻回顧發現現行氣喘疾病管理的焦點問題有:(1)SABA過度使用的氣喘病人比例偏高(38%);(2)病人非處方自行購買SABA的比例偏高(17.6%);(3)SABA過度處方會增加40%氣喘急性惡化發生率;(4)SABA過度處方會增加氣喘控制不佳的比率;(5)SABA過度使用會有較高的死亡風險;(6)過度使用SABA的病患排放大量的溫室氣體。我們嘗試以C-SOP管理模式,來分析氣喘疾病管理之焦點問題,並提出可能解決方案。結論:醫院和其他企業一樣,除了要善盡社會責任外,也要追求永續發展。ESG的各項目標,可被用來檢視醫院經營的成效。醫院和所有的利害關係人都要建立ESG的觀念。氣喘是一種普遍全球性疾病,臨床上已有GINA診療指引,提供具有證據醫學的最佳照護建議。遵循指引建議的氣喘疾病照護管理,可以使氣喘達到完善的控制,病人可以享有良好的生活品質,避免急性惡化、住院及死亡的風險,也減少醫療資源的耗費。避免病人過度使用SABA除了讓病人可以有較佳的氣喘控制,也可以減少不必要的溫室氣體排放,這些新觀念和作法,希望能在醫療體系各個層級建立和執行,也提供醫院在整體照顧氣喘病人中達成ESG的實踐。
CSR (Corporate Social Responsibility) is the continuing commitment by business to behave ethically and contribute to economic development while improving the quality of life of the workforce and their families as well as of the local community and society at large. The categories of ESG (Environment, Social, Governance) have covered all the requirements for a corporate to operate and preparation to achieve both the sustainability and social responsibility. In the fields of healthcare industry, especially for hospital, set up the goals for ESG including climate action plan will not only avoid the influences but also facilitate the achieving the goals such as build-up much healthier community, assist the vulnerable groups. Asthma is a common disease globally, urbanization and industrialization causing the incidence of asthma increase annually. Although asthma is a chronic airway inflammatory disease, but well control patients could lead a symptomless and high quality of life. Patients with uncontrolled asthma would have frequent exacerbation result in poor life quality, increased risk of hospitalization and mortality. They also increased the possibility of healthcare resource utilization. Inhalation medication for asthma include(1)reliever(bronchodilators)for rapid relive of symptoms by reverse bronchoconstriction. Short Acting beta-receptor agonist (SABA) is the key drug.(2)Controllers (mainly inhaled corticosteroid, ICS) have anti-inflammatory effect on bronchial mucosa and could reduce acute exacerbation. Inhalation medications is the cornerstone of asthma management. There are variety of different inhalers which could be grouped into three main categories:(1)breath-actuated or pressurized metered-dose inhaler (pMDI) ,(2)dry powder inhalers (DPIs) and(3)soft mist inhaler (SMI) . MDIs contain propellants, liquified gases providing the force to generate the aerosol cloud. Until early 1990s, MDIs contained chlorofluorocarbon (CFC) propellants, which were ozone-depleting substances, and were therefore phased out under Montreal Protocol. Pharmaceutical companies developed CFC free MDIs, replacing CFC with hydrofluoroalkane (HFA) propellants, a greenhouse gases (GHG) , have high global warming potential (GWP) . Globally, 630million HFA-based pMDIs are used annually resulting in an estimate CO2e burden of 13 million tCO2e, equal to the carbon footprint of 2 million EU citizen.
Through literature review, there are several key issues concerning asthma care were found:(1)high percentage of SABA over-user (38%) among all asthmatics;(2)high percentage of over-the-counter purchasing of SABA (17.6%) ;(3)SABA over-user had increased risk of acute exacerbation by 40%;(4)SABA over-user had poor asthma control;(5)SABA over-use had higher risk for mortality;(6)SABA over-user had high green gas emission. We plan to apply C-SOP model to analyzed these key issues & try to offer the practical solutions.

Conclusions
Hospitals, like other industries, need to fulfil the social responsibility and seek for sustainability. The categories of ESG could be used to evaluate the performance of hospitals. Hospital administrative and all the associated stockholders should built-up their ESG concept by themselves. Asthma is a common disease globally, we already have GINA guideline to provide evidence-base medicine for clinical reference. Compliance to the recommended management for asthma patients will result in good asthma control, better quality of life, avoidance of acute exacerbation, reduced risk of hospitalization and mortality. Compliant with guideline will also result in preventing the healthcare resource utilization. Avoidance of SABA overuse not only rendered patients a better asthma control but also reduced GHG emission and carbon footprint. These new concepts and practices should be conveyed to all the hospital administrative and the associated stockholders. Through the comprehensive care of asthma patient, we could also achieve the goals for fulfilment of ESG.
目錄
口試委員會審定書 i
謝誌 ii
中文摘要 iii
THESIS ABSTRACT v
目錄 ⅶ
圖目錄 ix
表目錄 x
第一章 緒論 1
第一節、研究背景 1
第二節、研究問題 6
第三節、研究目的 6
第二章 文獻探討 7
第一節、企業社會責任 7
第二節、醫療保健行業的社會責任 9
第三節、慢性呼吸道疾病 10
第四節、企業經營管理轉型成長的C-SOP架構 13
第五節、氣喘疾病管理之利害關係人種類與分析 13
第六節、行銷與行銷管理 14
第三章 氣喘疾病管理現況 15
第一節、SABINAⅢ和SABINA臺灣研究 15
第二節、臺灣健保料庫對SABA過度使用與氣喘急性惡化和死亡風險之相關性研究 26
第三節、吸入劑溫室氣體(Greenhouse gas, GHG)排放分析 34
第四章 以C-SOP分析氣喘疾病管理之焦點問題,並提出解決方案 41
第一節、臺灣胸腔暨重症加護醫學(胸重學會)簡介 41
第二節、興業領導(People) 41
第三節、策略佈局(Strategy) 43
第四節、組織協同(Organization) 48
第五節、文化形塑(culture) 49
第六節、經由氣喘疾病管理實踐ESG對應所達成聯合國永續發展目標 50
第五章 研究結論與未來展望 52
第一節、研究結論 52
第二節、未來展望 52
參考文獻 53


圖目錄
圖1. GINA針對成人及青少年病人以症狀控制及最小化未來風險為目標的個別化氣喘管理 4
圖2. 氣喘常用吸入型藥物 5
圖3. 經營管理轉型成長的C-SOP架構 14
圖4. SABINA III研究中各國病人招募的圖示 18
圖5. SABINA III中,依病人的來源和氣喘嚴重度的分佈圖 18
圖6. SABINA臺灣研究中病人的來源和氣喘嚴重度的分佈圖 19
圖7. 依氣喘嚴重度的不同,SABA處方的比率 22
圖 8. SABINA臺灣研究中,依醫師判斷之不同氣喘嚴重度,SABA處方的情形 23
圖9. SABINA III研究中各國SABA處方的狀況 23
圖10. SABA處方數量與過去12個月氣喘急性惡化發生時和氣喘控制狀況的關係 24
圖11. 氣喘急性惡化的發生率:不同SABA使用數量與氣喘急性惡化的發生率之Kaplan-Meier分析圖 25
圖12. 氣喘病人的死亡率:不同SABA使用數量與氣喘病人的死亡率的Kaplan-Meier分析圖 32
圖13. 與SABA過度使用所產生的人均GHG排放量 37
圖14. 與SABA過度使用與人均GHG排放量的關聯(A)不同地理區域、(B)不同國民所得 38
圖15. 臺灣胸腔暨重症加護醫學組織圖 42
圖16. 107 ~111年(1~5月)氣喘及COPD住院率及死亡率 43
圖17. 胸重學會發行成人氣喘指引 44
圖18. 胸重學會舉辦之氣喘醫師再教育課程 45
圖19. 胸重學會與健保署世界氣喘日記者會 46
圖20. 胸重學會和網紅合作促銷重要的氣喘知識 46
圖21. 胸重學會構建「自在呼吸健康網」成為氣喘相關的知識的重要平台 47
圖22. 團隊照顧模式進行氣喘疾病管理及其成效 49
圖23. ESG 相對應的聯合國永續發展目標 51
表目錄
表1. 2022年臺灣公佈ESG報告書之醫院 5
表2. 過去一年氣喘相關急性惡化與症狀控制依氣喘嚴重度和照顧醫師分析 20
表3. SABINA臺灣氣喘病人氣喘相關的臨床表現 21
表4. 過去12個月病人在無處方下自購SABA的狀況 24
表5. 氣喘病人使用SABA的數量與有無使用ICS狀況及病人特性分析 28
表6. 氣喘病人臨床嚴重度的分級 28
表7. 病人使用ICS和SABA的狀況和發生嚴重急性惡化的關聯 30
表8. ICS和SABA的使用與全死亡原因的關聯 31
表9. 病人SABA的使用量與全死亡原因和氣喘急性惡化的關聯 33
表10. 不同吸入劑的二氧化碳排放當量 34
表11. SABINA III研究,依GINA嚴重度分階與其SABA過度使用狀況的分析 35
表12. SABINA III研究,依不同地理區域和國家所得其SABA過度使用狀況的分析 36
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