失智症與非失智症家庭照顧者的醫療服務利用之比較

Abstract

研究背景與目的：隨著人口老化加速、失智人口大幅上升、家庭照顧人力減少，再加上失智症患者有較多行為問題使得照顧負荷更大，失智症照顧者的支持服務顯得愈發重要。過去研究已發現失智症照顧者，較非失智症照顧者，有更大的照顧衝擊、較差的身心健康，甚至影響到醫療服務利用。不同於國外已就失智症照顧者的門診、急診與住院面向進行深入研究，臺灣目前尚未探究失智症照顧者的醫療服務利用情形。因此，本研究根據國內外研究缺口，來比較使用臺灣長期照顧十年計畫的成員中，失智症與非失智症照顧者的醫療服務利用情形、長期照顧服務介入對兩者醫療利用情形的影響，以及醫療服務利用可能影響因子，以作為臺灣規劃家庭照顧者支持服務、失智照顧的重要考量。研究方法：本研究採用次級資料分析進行縱貫式研究。資料來源為串聯衛生福利部下，照顧服務管理資訊平台及衛生福利資料科學中心之資料庫，篩選2008至2013年期間，提供非正式照顧給使用長期照顧十年計畫之65歲以上長者的主要照顧者，共計10,771人。依據被照顧者是否有失智情況，將主要照顧者劃分成失智症組5,610人與非失智症組5,161人。本研究使用多變項羅吉斯迴歸分析與多變項複迴歸分析，比較失智症與非失智症照顧者自初次核定使用長照服務日期開始，一年內所使用的門診、急診、住院、醫療總費用等醫療服務利用情形；再以分層分析進一步探究初次核定使用多項長照服務與否，對失智症與非失智症家庭照顧者醫療服務利用所帶來的影響。研究結果：整體而言，失智症較非失智症照顧者，有門診次數較高、門診費用較低、急診相對風險、次數與費用皆較高、住院相對風險、次數與費用較高，但住院天數及醫療總費用較低的傾向，但未達統計顯著差異；在被照顧者輕度失能時，失智症較非失智症照顧者有較高的累積急診費用，且達統計顯著差異(β = 2507.83, p < 0.01)；在被照顧者重度失能時，失智症較非失智症照顧者有較多的住院使用次數，且達統計顯著差異(β = 0.22, p < 0.05)。同時，在使用一項長照服務情況下，失智症照顧者有較高的急診使用次數(β = 0.82, p < 0.05)與累積急診費用(β = 1590.09, p < 0.05)；但當使用多項長照服務，失智症照顧者有較低的累積門診費用(β = -3180.14, p < 0.05)與較低的每次住院費用(β = -9796.04, p < 0.05)，可能代表失智症照顧者在使用多元長照服務時，其醫療服務利用改善效果，較非失智症照顧者更明顯。此外，本研究特別發現男性照顧者的急性醫療利用更高，其需求值得繼續探究。結論：失智症照顧者，特別是輕度失智症照顧者，仍可能在照顧過程中較忽略自身健康，最終傾向尋求急性醫療資源協助；同時，多元長照服務的介入，對失智症照顧者的效果可能更明顯。本研究期盼未來政策透過提供照顧者喘息相關服務的加強，給予失智症照顧者時間滿足其自身初級醫療服務需求；本研究發現也呼應長照2.0計畫納入輕度失智症者，並發展失智症照顧者多元長照服務。此外，失智症與非失智症的長期醫療服務利用軌跡，及多元服務的搭配方式，值得進一步研究，以提供照顧者更全面的需求描繪。

Background: Due to population ageing, long-term care, the rise of dementia older adults, and the care burden due to behavior problems, services that support dementia caregivers have become more and more important. Past studies have proved that dementia caregivers have greater care impact, poorer physical and mental health, and it even affects their healthcare utilization. Foreign studies have conducted researches on dementia caregivers' health care service utilization, but Taiwan hasn’t yet explored the healthcare utilization of dementia caregivers. Therefore, based on research gaps at home and abroad, this study aims to compare the healthcare utilization between the primary caregivers of elderly adults with or without dementia who were in Ten-year Long Term Care Project (TLTCP) of Taiwan. Also, it demonstrates the healthcare utilization effect of long-term care services, and the possible associated variables of healthcare utilization. Methods: Data were extracted from the population-based datasets of the Long-Term Care Service Management System and National Health Insurance of Taiwan. Individuals who acted as the primary caregivers of elderly adults aged 65 or above in the TLTCP from the period of 2008 to 2013 were included in the study (N = 10,771). This study included 5,610 caregivers of elderly adults with dementia and 5,161 caregivers of elderly adults without dementia. Starting from the first long-term care needs assessment, we compared the one-year healthcare utilization of outpatients, emergency department uses and hospitalizations between caregivers of dementia and nondementia older adults. Furthermore, it examined the healthcare utilization impact of long-term care services through stratification based on single or multiple service use. This study applied multiple logistic regression analysis and multiple linear regression analysis. Result: Dementia patients’ caregivers had higher tendency of outpatient visits, lower tendency of outpatient fees, higher tendency of emergency visits and fees, higher tendency of hospitalization visits and fees, but lower tendency of hospitalization days and total fees without significantly difference from nondementia patients’ caregivers. When the care recipients are at the stage of light disability, dementia caregivers had higher emergency fees (β = 2507.83, p < 0.01). When the care recipients are at the stage of severe disability, dementia caregivers had higher hospitalization visits (β = 0.22, p < 0.05). Compared with nondementia caregivers, dementia caregivers had higher emergency visits (β = 0.82, p < 0.05) and higher fees (β = 1590.09, p < 0.05) when they used only single service; but dementia caregivers had lower outpatient fees (β = -3180.14, p < 0.05) and lower per hospitalization fees (β = -9796.04, p < 0.05) when they used multiple services. This result shows that the effects of multiple services on dementia caregivers may be more obvious than nondementia caregivers. We have also found the acute care healthcare utilization of male caregivers is higher, and the reason is needed to be examined in future research. Conclusion: Dementia caregivers, especially caregivers of mild dementia, are more likely to neglect their own health in the caring process, and resulted in more use of acute care health resources eventually. The intervention of multiple services might have greater effect on dementia caregivers than nondementia caregivers. Our study suggests that policymakers should provide additional respite care services to allow caregivers time to seek primary healthcare resources and to improve their self-care. In addition, the findings support future policies that promote the multiple service use pattern among caregivers, particularly among the caregivers of elderly adults with dementia. Future research can focus on the long-term change in healthcare utilization between different types of caregivers, the moderator effect of long-term care services, and the combination of multiple services for the caregivers of elderly adults with dementia.