可預防住院之研究-以闌尾炎破裂或穿孔為例

Abstract

近年來我國對照護的品質已朝「預防勝於治療」和「以病人為中心」的概念發展，但健保局現行的指標並沒有相對應反映預防保健成效的門診照護相關指標。而對於門診照護適當的指標，國際上的研究多從可避免住院的角度切入。本研究主要的目的是在了解我國在門診的照護上是否適當，採用橫斷式(Cross-section)事後回溯研究(Ex post facto research)次級資料分析，以89-91年三年「全民健康保險申報資料」中，因闌尾炎發生破裂或穿孔的病人作為主要的研究對象。 從89-91年三年的資料了解闌尾破裂/穿孔率的變化趨勢。進一步了解發生闌尾炎與闌尾破裂/穿孔情況病人的特性。並且以發生闌尾破裂/穿孔情況病人其住院前一個星期的就醫情況、個人醫療的充足性和就醫醫療提供者特性，比較三年來這些因素對發生闌尾破裂/穿孔情況病人的影響。 以下為本研究之主要結果： 1.整體趨勢：闌尾炎發生破裂或穿孔的比率，以不同進入醫院途徑者來說自89年到91年皆有下降的趨勢，但以各分局的發生比率來看，除了台北分局有上升的趨勢，其他分局皆呈現下降的趨勢。 2.病人的特性：男性、年齡小於18歲和大於50歲者和有其他疾病者發生破裂或穿孔的比例較高。 3.醫療的充足性：以部份負擔類別為重大傷病者和低收入者發生破裂或穿孔的比例偏高，而病人居住地區醫療資源較高者和偏遠地區者較低。 4.醫療的即時性：以之前沒有相關門診和急診就醫記錄者較多，若以門診或急診有使用抗生素者來說，則其發生的比率較高。 5.醫療提供者特性：醫院權屬別為私立者其發生破裂或穿孔的比例較低，醫院等級為醫學中心發生破裂或穿孔的比例較高。 綜合以上所述，則有以下建議： 一、給予民眾相關衛教 二、可將闌尾炎發生破裂或穿孔的情況作為品質監控的指標。 三、政策制定者應輔導醫療院所參加醫院評鑑。 四、醫院可對其內部管理(如手術室排程等)進行改善。 五、醫院可加強急診醫師相關訓練

Recently,「Prevention」 and 「Patient Centered Care」are the important topic in health care delivery system. In order to assure medical care quality, Bureau of National Health Insurance (NHI) has established many quality indicators for hospital. But those quality indicators can’t evaluate the quality of ambulatory care. Therefore, this study used the perforated appendix admission rate of prevention quality indicator (PQI) to evaluate the quality of ambulatory care in Taiwan. The study observed Appendix patient aimed to describe perforated appendix admission rate during 2000 to 2001 and to understand what factor will impact the Appendix patient’s medical outcome. This study used claim data of National Health Insurance and Department of Health from 2000 to 2001 for analysis. The main findings of this study were concluded as below: 1. Trend: During 2000 to 2001, the perforated appendix admission rate in Patient, get into hospital in different way, and Different locations were significant decrease. 2. Patients characteristics: Rate of perforated appendix admission were higher for male and the person age under18 and upper50. 3. Efficiency: Rate of perforated appendix admission were higher for patient who type of co-payment is catastrophic illness and low income. Rate of perforated appendix admission was lower for patient type of co-payment was remote area. 4. Timely: Rate of perforated appendix admission were lower for patient who have emergency treatment or outpatient services before hospitalization. 5. Hospital Characteristics: Different hospital type and hospital ownership were impact the perforated appendix admission rate. Rate of perforated appendix admission were higher for hospital type in medical center and hospital ownership in private. Base on above finding, this study suggests: 1. The authority can give population education about how to seek appropriate care. 2. The authority can use perforated appendix admission rate to be quality assurance indicator. 3. The authority guidance and assistance hospital to joint hospital accreditation. 4. The hospital management can strengthen the turnover time in operating room. 5. The hospital management can strengthen the medical education in resident physicians.