探討組合分數應用於臺灣急性心肌梗塞品質報告卡

Abstract

研究背景：本研究旨在探討不同組合分數方法在臺灣急性心肌梗塞(AMI)醫療品質報告卡的應用。急性心肌梗塞為臺灣重要死亡原因，2022年死亡人數近6,000人，為重大公共衛生事件。為提升急性心肌梗塞患者的照護品質，政府推動包括醫院評估、緊急醫療能力分級制度(EMSSP)及品質報告卡等策略。然而，目前的公開品質指標，在便於理解便於使用的角度，對醫療使用者都存在一定難度，無法直觀地反應出醫院好壞或是否有提升。 研究目的： 探討組合分數應用與品質公開網的成效，以「緊急醫療能力分級評定」與醫院「心肌梗塞品質報告卡」照護品質之相關性為例。 研究方法：本研究採回溯性世代研究(retrospective cohort study)，利用2015、2019及2023年「全民健康保險醫療品質公開網」資料，比較有無通過評定醫院在4年後照護品質的差異。比較範圍包括過程面、結果面單一品質指標外，也比較過程面組合分數、結果面組合分數與總體組合分數在三種計算方式(等權重、基於機會的權重及基於分子的權重)下的差異。研究控制醫療區域別之差異，雙變項使用獨立t檢定及ANOVA並進行事後精確檢定探討組合分數與自變項之關聯；多變項使用線性迴歸(Linear Regression)。 研究結果：EMSSP評定結果對品質指標之驅動效應隨時間推移而顯著強化。在2015-2019年期，僅LDL檢查執行比率（單一指標）及過程面與總體之等權重、基於機會組合分數達顯著相關。至2019-2023年期，單一過程指標中之Aspirin給藥、ADP受體拮抗劑給藥及LDL檢查均轉為顯著；組合分數方面，等權重與基於機會模型均呈現強顯著影響（p<0.01），且模型解釋力大幅提升（調整後R² =0.079–0.082），其中以等權重組合分數表現最佳。然而，在兩個分析期間內，結果面指標（14日內非計畫性再住院及3日內急診返診）無論是單一指標或組合分數，與EMSSP評定結果未達統計顯著相關。 討論及結論：緊急醫療能力分級評定對醫療機構急性心肌梗塞之過程面品質，具有顯著且具累積性的指引作用。針對醫院層級的「心肌梗塞品質報告卡」照護品質所應用的三種組合分數，能夠有效反映單一指標的整體變化趨勢。

Background: This study aims to explore the application of different composite scoring methods in Taiwan's Acute Myocardial Infarction (AMI) medical quality report card. Acute myocardial infarction is a major cause of death in Taiwan, with nearly 6,000 deaths in 2022, representing a significant public health issue. To improve the quality of care for AMI patients, the government has implemented strategies including hospital assessment, Emergency Medical Service Capability Grading (EMSSP), and quality report cards. However, current public quality indicators present certain difficulties for healthcare users in terms of comprehensibility and usability, failing to intuitively reflect hospital performance or improvement. Objectives: Investigating the effectiveness of composite score application in public quality disclosure: A case study on the correlation between ' Hospital emergency capacity accreditation by level (EMSSP) ' and care quality in hospital 'Acute Myocardial Infarction (AMI) Quality Report Cards'. Methods: This study adopts a retrospective cohort study design, utilizing data from the ' National Health Insurance Quality Indicator' for the years 2015, 2019, and 2023 to compare differences in care quality four years post-accreditation between hospitals that passed the assessment and those that did not. The scope of comparison includes individual process and outcome quality indicators, as well as process, outcome, and total composite scores calculated under three different methods: equal weighting, opportunity-based weighting, and numerator-based weighting. The study controls for differences across medical regions. Bivariate analysis utilizes independent t-tests and ANOVA with post-hoc tests to explore the associations between composite scores and the independent variables, while multivariate analysis is conducted using linear regression. Results: The results indicate that the driving effect of EMSSP accreditation results on quality indicators strengthened significantly over time. During the 2015–2019 period, only the LDL testing rate (as a single indicator) and the equal-weighted and opportunity-based composite scores for both the process and total dimensions reached statistical significance. By the 2019–2023 period, individual process indicators including Aspirin administration, ADP receptor antagonist administration, and LDL testing all became significant. Regarding composite scores, both equal-weighted and opportunity-based models demonstrated highly significant impacts (p < 0.01), and the model's explanatory power improved substantially (Adjusted R² = 0.079–0.082), with the equal-weighted composite score performing the best. However, across both analysis periods, outcome indicators (14-day unplanned readmission and 3-day emergency department return) showed no statistically significant correlation with EMSSP accreditation results, whether analyzed as single indicators or as composite scores. Discussion and Conclusion: The Emergency Medical Service Capability Accreditation provides a significant and cumulative guiding effect on the process-of-care quality for acute myocardial infarction in healthcare institutions. The three composite scores applied to hospital-level 'Myocardial Infarction Quality Report Cards' can effectively reflect the overall trends of individual quality indicators.