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Title: | 探討不同就醫層級的初級照護品質—以三種慢性病為例 The Association between Levels of Healthcare Providers and Quality of Primary Care on three chronic diseases |
Authors: | Guan-Ling Lin 林冠伶 |
Advisor: | 郭年真(Raymond N. Kuo) |
Keyword: | 初級照護品質,分級醫療,忠誠病人,可避免住院,可避免急診, primary care,quality,avoidable hospitalization,avoidable emergency visits, |
Publication Year : | 2022 |
Degree: | 碩士 |
Abstract: | 研究背景:區域以上醫院門診減量措施希望藉由醫療服務提供者視病況將輕症民眾導引至基層就醫,進而落實分級醫療。然而民眾有至大醫院就醫之偏好,與政策認為基層院所應能提供完善的初級照護之宗旨產生矛盾。過往在不同層級與照護品質之研究,受限於初級照護定義及探討的品質構面、衡量標準不同,尚無一致結論,使得就醫層級對於初級照護品質的影響仍有待研究補足知識缺口。 研究目的:本研究以糖尿病、高血壓、氣喘三種慢性病為例,探討不同就醫層級對於照護結果的影響,以此評估層級的初級照護品質。 研究方法:以全民健康保險資料庫進行分析,針對符合初級照護診斷之新病人進行研究。先以傾向分數配對法找出各層級特性相似的忠誠病患,利用群集存活分析,探討不同就醫層級對於病患發生可避免住院、可避免急診之風險差異。此外,為更精確掌握病患嚴重度,將以糖尿病樣本為例,加入研究期間的用藥情形為控制變項進行分析。 研究結果:在大型醫院(醫學中心、區域醫院)就醫之糖尿病(HR=3.4)、高血壓(HR=6.2)及氣喘(HR=4.6)病患,相較於基層院所(地區醫院、診所)發生可避免急診風險較高,在發生可避免住院風險則皆未有顯著差異(糖尿病HR=1.3;高血壓HR=1.7;氣喘HR=1.6)。而高齡、機構位於低都市化地區、住院次數越高,發生可避免急診風險也越高。 結論:不同就醫層級發生可避免住院風險無顯著差異,以可避免急診為指標則顯示基層院所的初級照護品質較佳。建議鼓勵民眾在基層院所接受初級照護,由基層醫師視病況進行轉診,並讓各層級醫療院所能依其目標適性發展。 Background: Based on the suggestions of medical professionals, the policy of reducing outpatient visits at medical centers and regional hospitals aims to improve the efficiency of healthcare by educating patients on their choices of healthcare providers. However, the public's preference for large hospitals contradicts the policy objective of providing comprehensive primary care at community hospitals and physician clinics. Previous studies on the differences in the quality of care between healthcare providers are limited by the inconsistent definitions of primary care, dimensions, or measurement, which has left a research gap on the impact of healthcare providers on the quality of primary care. Objective: This study aims to explore the impact of different levels of healthcare providers on the quality of primary care for diabetes, hypertension, and asthma. Methods: The study utilized the National Health Insurance database to analyze new patients with a diagnosis code of primary care. Propensity score matching was used to identify loyal patients with similar characteristics at each level of the healthcare provider, and cluster survival analysis was then conducted to explore the differences in the risk of avoidable hospitalization and emergency avoidance. Analysis of the diabetes patients was also performed by adding medications aimed at controlling the severity of the disease more precisely as a covariate in regression models. Results: Patients with diabetes (HR=3.4), hypertension (HR=6.2), and asthma (HR=4.6) treated in large hospitals had a higher risk of avoidable emergency visits; however, the risk of avoidable hospitalization was not significant among these patients (HR=1.3 for diabetes; HR=1.7 for hypertension; HR=1.6 for asthma). Older patients, healthcare providers located in less urbanized areas, and patients with more hospitalizations before the index year were associated with a greater risk of avoidable emergency visits. Conclusions: There were no significant differences in the risk of avoidable hospitalization among patients at different levels of healthcare providers. The quality of primary care in primary institutions was better, as measured by avoidable emergency visits. Recommendations include encouraging people to receive primary care in community hospitals and physician clinics with referrals made by their primary physicians so that patients can receive care at the appropriate level of healthcare providers according to their medical condition. Thus, all providers can develop according to their own goals. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/86603 |
DOI: | 10.6342/NTU202202010 |
Fulltext Rights: | 同意授權(全球公開) |
metadata.dc.date.embargo-lift: | 2024-08-27 |
Appears in Collections: | 健康政策與管理研究所 |
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U0001-0308202214571700.pdf | 3.58 MB | Adobe PDF | View/Open |
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