醫療照護連續性與急診醫療利用之相關性探討

Abstract

急診是醫療體系中不可或缺的重要部門。就急診部門的運作而言，急診就醫次數的上升會導致急診過度擁擠的情形，甚至排擠真正急重症病患所需要的醫療資源，嚴重影響到醫療的品質。影響急診醫療利用的原因相當多。醫療體系與醫療照護連續性是一個重要因素，然而，不同的研究似乎呈現不一致的結果，其作用仍有待釐清。值得關心急診醫療的人士進一步研究。 本研究目的首先在了解國內民眾急診就醫狀況，探討不同年齡、性別、居住地，及就醫習慣族群之民眾的急診醫療利用狀況。其次，檢視醫療照護長期性是否對急診醫療利用有所影響。 本資料取材於國家衛生研究院之全民健康保險學術資料庫。並以第一組抽樣歸人檔2001，2002，及2003 年之門診處方及治療明細檔( CD 檔 )以及醫事機構基本資料檔(HOSB 檔)為研究資料來源。研究中以非外傷之急診就醫為依變項，利用2001，2002 年所推算的照護連續指標作為自變項，檢視其對於2003 年急診利用的影響。本研究控制變項包含有年齡，性別，居住地點，以及醫療需求等。其中醫療需求部分，包括既有疾病和門診就醫總次數等。 研究結果顯示，在36510 名研究對象中，曾於研究期間看過急診者有4597人，佔12.59%。未看過急診者有31913 人，佔87.41%。照護連續指標平均值為0.33，標準差0.22。最小值為0，最大值1。平均急診次數0.19 次，標準差0.66，最小值為0，最大值24。 邏吉斯迴歸研究結果顯示，在控制相關變項後，照護連續指標為1 者和照護連續指標為0 者相比，急診醫療利用可能較低 (OR, 0.65; 95% CI 0.56 , 0.76)。負II二項迴歸分析研究結果顯示，在控制相關變項後，照護連續指標為1 者和照護連續指標為0 者相比，急診醫療利用次數較低 (RR, 0.70; 95% CI 0.60 , 0.81)。 有鑑於此，為舒緩急診擁擠及避免急診擁擠的狀況惡化，政策的規劃與設計應朝向加強醫療照護連續性著手。

Emergency department is an indispensable part of the health care delivery system.Increased emergency department utilization may contribute to emergency department overcrowding, and may divert the scarce emergency health care resource away from those who really need them. The health care quality may therefore be jeopardized. The reasons involved with emergency department overcrowding are multi-factorial. The continuity of care among health care system has important effect on the emergency department utilization, yet the results remained controversial in the relevant literatures. The purpose of the study was to explore the effect of continuity of care on emergency department utilization. The ambulatory visit file of the first 50000-person cohort database from the National Health Research Database in year 2001, 2002, and 2003 were analyzed. Those with at least 4 ambulatory visits in year 2001 and 2002 were included in the study. The dependent variable was non-traumatic emergency visit frequency in year 2003. Continuity of care score derived from year 2001 and 2002 ambulatory visits was used as independent variable. Control variable included age, sex, residency location, and health care need. The health care need factor were represented by comorbidity and total ambulatory visits in year 2001 and 2002. Negative binomial regression was used in the analysis. The analysis was repeated by applying logistic regression when the dependent variable was dichotomized as whether use emergency department or not. In 36510 people who met the inclusion criteria, 4597(12.59%) people ever visited emergency department in year 2003. The average emergency department visits was 0.19 (SD 0.66, Max 24, Min 0). The average continuity of care score was 0.33(SD 0.22, Max 1, Min 0). The result of negative binomial regression revealed that more emergency department visits was associated with lower continuity of care score (RR, 0.70; 95% CI 0.60, 0.81). When logistic regression was applied, the Odd Ratio of aving at least one emergency department for those with the highest continuity of care score was 0.65 (95% CI 0.56, 0.76), when those with the lowest continuity of score were compared with. The results of the study may provide insights for health policy makers and health care facility administrators when dealing with emergency overcrowding. Methods facilitating the continuity of care may improve emergency overcrowding.