慢性中耳炎手術論品質計酬的可行性評估

Abstract

醫療機構的績效雖然可以包括財務、流程、客戶滿意、員工成長、機構聲譽等各種面向；但總括言之，醫療機構最重要的綜合績效產出應為廣義的醫療品質；醫院的經營績效與醫護人員的工作表現如何與醫療品質相連結，是大眾關心的議題。近年來研究發現醫療給付制度與醫院績效表現有很高的關聯性，因此，依據醫院績效表現來區分保險給付等級的論調逐漸發酵，遂有論質計酬的醫療給付制度出現。台灣的全民健康保險因為單一給付系統，全國性資訊取得較容易（全民健康保險申報資料），本研究嘗試針對耳鼻喉科的單一疾病，利用全民健保險資料庫來分析慢性中耳炎住院病患的醫療品質及相關影響因素，從研究結果中獲致的資訊，探討此類資料是否足以作為未來推廣論質計酬給付制度的理論基礎。 本研究資料是利用國家衛生研究院發行之全民健康保險資料庫，選取2006年全民健康保險資料庫中診斷為慢性中耳炎之住院病患，總計5,327人，分析其醫療資源利用、手術預後及併發症、臨床治療指引遵從度之情況。採用SAS 9.1及SPSS 16.0統計套裝軟體進行資料分析，統計方法包括卡方檢定、獨立t檢定、變異數分析、複迴歸及羅吉斯迴歸分析等。 2006年慢性中耳炎的盛行率為31.6每十萬人口，總住院醫療費用為226,561,682元，平均住院天數為4.4±2.6天。在「醫療資源利用」的部份，慢性中耳炎的疾病型態、術式、年齡、合併症、醫院屬性、醫院層級、地理區域及醫院服務量是重要之影響因素；在「預後及併發症」的部份，慢性中耳炎的疾病型態及合併症是重要之影響因素，醫院的服務量並無顯著影響；在「臨床治療指引遵從度」的部份，術式及地理區域是重要的影響因素。 醫療品質是醫療機構經營最重要的績效，本研究發現，以慢性中耳炎的治療為例，地理區域、疾病型態及術式是影響疾病治療品質的重要因素。本研究發現分析以疾病為基礎的全民健康保險資料可以知道醫療提供者對於臨床指引的遵從情況，醫療資源使用及併發症等資訊，從而間接得知醫療品質狀況，但申報資料無法取得主觀的病患經驗。未來醫療產業必須要提升醫療服務的附加價值，政府機構要能利用這些積效數據來提供適當的誘因，讓醫療院所願意投資在醫療品質促進上。

The performance of a healthcare provider can be evaluated from financial, service process, customer satisfaction, employee career development, or institutional reputation dimensions. Nevertheless, in summary, the synchronized performance output can be broadly defined as the healthcare quality a hospital delivers. It is a public concern to link healthcare quality with the hospital and care giver’s individual performance. The performance-based payment system is becoming a popular issue lately owing to the findings that suggest hospital performances are highly associated with healthcare reimbursement. Some has advocated in adopting the so called pay-for-performance payment system. Taiwan’s National Healthcare Insurance is a nation-wide, single-payer system that is able to provide valuable national healthcare information from its claim database. In this case study, we use the National health insurance data to investigate the healthcare quality and outcomes confounders of chronic otitis media surgery. Aim of this study is to explore the feasibility of pay-for-performance system based on the information found by our analyses. In this study, we study 5,327 surgical admissions for chronic otitis media from 2006 National Healthcare Insurance Research Database (NHIRD, provided by the Taiwan’s National Healthcare Research Institute with permission). We analyze the medical resource utilization, surgical outcomes, complication, and clinical guideline provider adherence. We use the SAS 9.1 and SPSS 16.0 statistics softwares to conduct Chi-square, independent t-test, variance analysis, multiple, and logistic regressions. The 2006 incidents of chronic otitis media was 31.6 per 100,000 population, with total healthcare expenditure of NTD$ 226,561,682 and average hospitalization days of 4.4±2.6. The disease pattern, surgical type, age, complication, hospital type, hospital level, geographic area, and service volume are significant “medical resources utilization” predictors. The disease pattern and comorbidity, rather than service volume, are significant “outcomes” and “complication” predictors. Surgical type and geographic area are significant predictors for “clinical provider adherence”. Healthcare quality is the most important performance of healthcare provider; we found geographic area, disease pattern, and surgical type are significant predictors for chronic otitis media surgery quality. The disease-based NHIRD provides indirect quality information such as clinical provider adherence, medical resource utilization, and complication. However, the claim data is not able to demonstrate the patient experiences to the healthcare services they received. Our study suggests that healthcare providers should dedicate to improve the value of healthcare; at the mean time, the government should provide sufficient incentive to encourage healthcare providers for quality investment.