中風出院病人後續醫療照護之研究

Abstract

腦血管疾病（中風）是台灣第二大死因，也是導致成人身體功能障礙的重要病因，不但需要急性住院治療，更導致出院後續醫療照護的大量需求。因此探討其服務使用和費用為長期照護領域重要的研究課題，而過去研究侷限於少數醫院的立意取樣樣本，或小地區，並非以全人口層面之研究，若能從宏觀角度來進一步釐清影響中老年人出院後續照護的相關因素，對我國全民健康保險和長期照護政策的中介規劃應有重要的參考價值。 本研究目的主要有四：一、了解全民健保中風病人出院後續六個月內醫療照護的使用和費用情況；二、分析中風失能者出院後續醫療服務的利用和費用結構；三、探討影響中風失能者後續照護醫療使用和費用的主要相關因素。四、探討全民健保的支付政策的改變，對出院後續照護服務的可能影響和啟示。 本研究係採用橫斷研究法，以「全國長期照護需要評估」調查中的50歲以上中風住院病人為總樣本；該調查中的失能中風者為失能者樣本，進行描述性分析、雙變項分析、邏輯斯迴歸分析及複迴歸模式分析。本研究的總樣本共計4,700人，其中有4,385人來自社區，315人來自照護機構。本研究的失能者樣本共計1,567人，其中323人採用機構照顧，1244人為社區個案。 研究結果顯示中風失能者出院後六個月內再住院、急診、居家照護、門診、復健服務等各項後續服務的使用率（46.5%、38.0%、12.2%、98.1%、32.3%），皆高於一般中風病人的各項使用率（41.9%、35.1%、6.2%、95.1%、27.0%）。特別是居家照護使用率幾乎加倍，而復健的使用率有兩成的差距。此外，中風失能者各項後續服務的平均總醫療費用為91,924元，一般中風病人則為82,507元，高出11%。 4700位病人的出院後六個月內醫療總費用，以5-6項ADL失能者、有健保重大傷病證明者、有殘障手冊者、出血型中風患者、住機構個案、指標住院有復健者等最高。另外中風失能者樣本中，以減免部分負擔者（有全民健保重大傷病證明者、有殘障手冊者）、有配偶者、居住於院轄市者、合併罹患慢性病三類以上者、完全依賴者、住機構個案，其平均每人後續醫療總費用最高。 本研究發現對後續醫療服務使用，有顯著影響的前傾因素：中風病人以50-64歲為參考組時，75-84歲個案的再住院勝算比為1.26（95﹪CI=1.07-1.49），85歲以上個案的復健勝算比0.52（95﹪CI=0.38-0.71）；中風失能者年齡越高復健使用的勝算比為0.98（95﹪CI=0.96-0.99）；「中學程度以上者」相較於「未受教育者」復健使用的勝算比為2.08（95﹪CI=1.38-3.15）。 有顯著影響的使能因素：中風病人以「需部分負擔者」為參考組，具「減免部分負擔身分者」的再住院的勝算比為1.82（95﹪CI=1.59-2.08）、急診為1.43（95﹪CI=1.25-1.63）、居家照護為1.89（95﹪CI=1.40-2.56）、復健的勝算比為1.60（95﹪CI=1.37-1.87）。住省轄市者居家照護使用顯著高於住鄉鎮者，勝算比為1.51（95﹪CI=1.08-2.13）。中風失能者中，減免部分負擔者使用復健的勝算比為1.46（95﹪CI=1.10-1.94）；住院轄市者使用復健的機率顯著高於居住於鄉鎮者，勝算比為2.30（95﹪CI=1.49-3.54）。 需要方面的顯著影響因素：以功能正常者為參考組，「5-6項ADL困難者」的再住院的勝算比為2.32（95﹪CI=1.97-2.74）、急診的勝算比為1.68（95﹪CI=1.42-1.98）、使用復健的勝算比為1.98（95﹪CI=1.64-2.39）。失能者的巴氏量表分數越高，其再住院勝算比為0.73（95﹪CI=0.65-0.82）、其急診機率的勝算比為0.78（95﹪CI=0.69-0.88）、其居家照護的勝算比為0.22（95﹪CI=0.15-0.32）。失能者樣本以無合併症者為參考組，合併三類以上的慢性病者的再住院勝算比為1.86（95﹪CI=1.33-2.61），使用復健的勝算比為0.61（95﹪CI=0.42-0.91）。 中風病人居住於「機構者」的急診顯著低於「居住於家中者」，勝算比為0.58（95﹪CI=0.44-0.75），但再住院天數、門診、復健服務等的使用都較高。以「居家未聘看護者」為參考組，中風失能者「居住於機構者」的復健使用勝算比為2.49（95﹪CI=1.75-3.54），「居家聘看護者」的復健使用勝算比為1.87（95﹪CI=1.38-2.53）；「居家聘看護者」的急診勝算比為1.35（95﹪CI=1.04-1.76），「住機構者」的急診勝算比只為0.58（95﹪CI=0.42-0.81）。中風病人指標住院時於地區醫院者，其再住院使用較高；中風失能者指標住院時於地區醫院者，其門診、急診的使用較高，居家照護使用較低。 從本研究結果顯示台灣中風失能者出院後續全民健保醫療使用或費用，因失能越嚴重、合併症越多、重大傷病患者所需要的費用越高，在訂定健保資源配置的基準時，應納為全民健保後續照護支付政策重要考慮因素。對於機構照護者等的復健利用偏高現象，也應適度探討資源的利用的管理，以提升資源使用效率。城鄉差距現象提醒應留意地理的可近性是否平等。此外，在即將推動醫院前瞻式論病例支付制度時，建議宜(1)同時研議出院後續照護的範圍、支付方式和部分負擔設計，且避免費用過度轉成民眾自付；以及(2)思考如何將急性醫療與出院後續照護加以配套，以求服務連續完整，並設計客觀的成果評估方式。

Stroke is the second leading cause of death in Taiwan; they are also a major cause of disability of adults. Patients not only require acute care, their demands for post-hospital care are also considerable. Along with the aging of society and the increase in medical care costs, an understanding of the use and costs of long-term care is an important issue. Past studies have focused primarily on some non-random samples of hospitals in small areas; they are not targeted at the entire population. A population-based study to clarify some relevant factors that affect the post-hospital care of the elderly should be of important reference to health policies. The objectives of the present study are four: 1) to understand the use of medical care and their costs of stroke patients under the National Health Insurance（NHI） in the six months after discharge from hospitals; 2) to analyze the use and cost of medical care of disabled stroke patients after discharge; 3) to understand the major factors that affect the use and their costs of post-hospital care of disabled stroke patients ; and 4) to pre-examine the impact of the changes in the payment policies of the National Health Insurance on post-hospital care services. The study employed the cross-sectional design, using data collected in the first phase survey and the second phase survey of the “Long-Term Care Need Assessment in Taiwan” in 2002. The diagnosis and utilization data is from NHI claim data. The study performed descriptive, bivariate, logistic regression, and multiple regression analyses. A national representative sample of 4,700 stroke patients and another national representative sample of 1567 disabled stroke individuals aged over 50 were studied. Results of the study show that the use rates of disabled stroke patients of various post-hospital care services such as readmission, emergency care, home nursing care, clinic care, rehabilitation services (46.5%, 38.0%, 12.2%, 98.1%, 32.3% respectively) were higher than those of the general stroke patients (41.9%, 35.1%, 6.2%, 95.1%, 27.0%). The use rate for home nursing care in particular almost doubled. There was a 20% difference in the use rates of rehabilitation services. The average medical costs for post-hospital care for the disabled stroke patients were NT$ 91,924; whereas those of the general stroke patients were NT$ 82,507, an 11% difference. Of the 4,700 stroke patients, higher total post-hospital care costs were found in those who are with 5-6 items of ADL disabilities, with certificates of severe illnesses under NHI, with hemorrhagic stroke, cared in institutions. Of the disabled stroke sample, higher costs were found in those who are waived of NHI co-payments (patients with certificates of severe illnesses under NHI, with disability certificates), married, patients living in municipalities, suffering from three and more chronic diseases, completely dependent, and cared in institutions. Logistic regression analyses showed that, enabling factors including the waiving of co-payment, marital status, living in municipalities were significantly associated with post-hospital care utilization. Demand factors such as the number of complications, degree of disability were significantly associated with post-hospital care utilization. The study also found that there were significant predisposing factors affecting the use of post-hospital care: more outpatient visits for women; longer length of re-hospitalization for men; more rehabilitation visits for disabled stroke women; the use of outpatient clinics and rehabilitation service declines with age; the use of re-hospitalization, emergency care and home nursing care of stroke patients increases with age; more rehabilitation visits and outpatient visits for higher educational level cases. There are significant need factors: patients with 5-6 items of ADL difficulty, completely dependent (0-20 on the Barthel Index score) had higher use of re-hospitalization, emergency care, home nursing care and rehabilitation; though, the completely dependent patients had fewer outpatient visits. Disabled patients with more chronic diseases had longer re-hospital stay and more outpatient visits, though their use of rehabilitation was less. Patients provided with rehabilitation during their index admission continued to accept outpatient rehabilitation after discharge. Results of the study suggest that the use and cost of post-hospital care were higher when the patients were more severely disabled, with more complications. In allocating health insurance resources, these factors should be taken into consideration in policies for post-hospital care. The management of resource use should be properly reviewed to improve efficiency. Differences in urban and rural areas suggest that the equality in geographic access should be considered. The NHI benifits, payment and co-payment for post-hospital care should be studied at the same time, and excess out-of-pocket by the public should be avoided. The integration of acute care with post-hospital care should be considered to assure the continuity and comprehensiveness of services.