全民健康保險家庭醫師整合性照護計畫與照護連續性對照護結果之影響

Abstract

研究背景： 全民健保的實施提升了民眾的就醫可近性與自由度，然而伴隨逛醫師與就醫次數高的狀況，可能會造成民眾接受片斷式的醫療照護服務等問題。為了鼓勵提供病患周全性、協調性與連續性的照護服務，健保署從2003年開始實施「全民健康保險家庭醫師整合性照護計畫」，唯開辦至今各界對於此計畫的成效尚無共識，且尚未有研究探討家醫計畫能提高照護連續性，卻無助於照護結果背後的原因。 研究目的： 本研究主要評估家醫計畫之成效、比較不同照護連續性的診所其病人照護結果之差異，並探討病人照護連續性是否會影響到參加家醫計畫與病人照護結果之相關性。 研究方法： 本研究使用全民健康保險研究資料庫之2011年至2013年的資料，以研究對象參加家醫計畫與否分成介入組與對照組，為了降低選樣偏差、增加介入組與對照組之可比較性，以傾向分數配對挑選合適的對照組個案；另外，本研究也建構心血管疾病與糖尿病患者兩個次樣本，以疾病別的過程面品質指標進行分析。統計分析係使用負二項迴歸模型與羅吉斯迴歸進行分析。 研究結果： 研究發現有參加家醫計畫者、高照護連續性對病人、以及高照護連續性診所的病患，都有較少的潛在可避免急診次數。此外，病人照護連續性會影響到參加家醫計畫與否與病人潛在可避免急診次數的相關性。在心血管與糖尿病病人的次樣本中，我們並未發現參加家醫計畫的病人有較佳的過程面照護表現，只發現在糖尿病患次樣本中，照護連續性高的病人或診所會有較高比例的「較少因腎病就醫」。 結論： 相較於過程面品質指標，家醫計畫的介入對結果面品質指標（潛在可避免急診）的改善有顯著較佳的影響。衛生主管機關可以參考本研究發現，修改照護品質的評核指標與財務誘因的設計。

Background: The implementation of the National Health Insurance (NHI) increased the public's accessibility to care and freedom of choice accompanied by doctor shopping and high number of physician visits that may lead to fragmented medical care. In order to promote comprehensive, coordinated and continuous care services, the NHI Administration has implemented the Family Physician Integrated Care Program since 2003. However, there is no consensus on the effectiveness of this program yet, and no study has investigated the reason behind the fact that the program can improve continuity of care but does not improve health care outcomes. Objectives: The purposes of this study were to evaluate the effect of the Family Physician Integrated Care Program, to compare the patients' health care outcomes among clinics with different levels of continuity of care, and to investigate whether patients' continuity of care may affect the relationship of the integrated program participation and patients' health care outcomes. Methods: The National Health Insurance Research Database from 2011 to 2013 was used for this study. Patients who were enrolled in the Family Physician Integrated Care Program were classified as the intervention group and those who had never participated in the program were classified as the comparison group. In order to reduce selection bias and increase the comparability between the intervention and comparison groups, we conducted propensity score matching to select proper subjects for the comparison group for analysis. Two sub-groups including patients with cardiovascular diseases and diabetes mellitus respectively were analyzed by using disease specific process-based quality measures. The negative binomial regression model and Logistic regression were used in the study. Results: We found that patients enrolled in the Family Physician Integrated Care Program, patients with high continuity of care scores, and clinics with higher continuity of care scores tended to have fewer potentially avoidable emergency department visits. In addition, patients' continuity of care had modification effect on the relationship of the program participation and patients' potentially avoidable emergency department visits. However, in the two sub-group samples, the integrated care program enrolment did not show positive effects on process-based quality measures. Except that in the diabetes sub-group, higher continuity of care at either patient or clinic level might lead to higher rate in 'less medical attention for nephropathy'. Conclusions: Compared with process-based quality indicators, the Family Physician Integrated Care Program showed significant effect on better health outcome (potentially avoidable emergency department visits). According to the findings of this study, health authority may consider modifying the quality evaluation indicators and financial incentives for the Family Physician Integrated Care Program.