照護連續性與可避免住院之相關性研究

Abstract

前言：全民健保實施以來，確實增加了就醫可近性，然而國內尚未建立完整的轉診制度，doctor-shopping (逛醫師) 的情形嚴重，造成許多醫療資源的浪費。國內在醫療品質的管理上多著重於住院醫療品質的監控，然而影響整體醫療照護品質、效率的根源卻是初級醫療照護，其中「可避免住院」(Hospitalization for Ambulatory Care Sensitivity Conditions；Avoidable Hospitalization)在國際上已廣泛的作為評估初級醫療照護可近性、品質及效率的指標，而照護連續性更是影響醫療照護結果的重要因素。在缺乏完整家庭醫師制度的台灣，病人接受連續之醫療照護，是否可減少不必要的住院，進而降低醫療成本，確值得吾人進一步探討。 研究目的：本研究旨在探討國內照護連續性之相關影響因子，檢視照護連續性與住院醫療利用及可避免住院之相關性，並進一步探討是否照護連續性提高，其可避免之住院能夠減少。 研究方法：本研究採縱向研究法，利用國家衛生研究院全民健康保險學術資料庫，以2004年至2006年抽樣歸人檔為本研究之樣本母群體，取第一組總計約4萬人資料為此研究主要分析樣本。利用所推算的照護連續性指標為自變項，分為高、中、低三組，以住院醫療利用及可避免住院為依變項，檢視其住院及可避免住院之差異。其中控制變項包含年齡、性別、就醫方便性(投保地分局別、投保地醫師密度) 及醫療需求(慢性病指標和門診就醫總次數)等。 研究結果：在34728名研究對象中，2006年未曾住院者31825人，占91.64%。有住院者2903人，占8.36%。有門診照護敏感病況(Ambulatory Care Sensitivity Conditions, ACSC)住院(即可避免住院)者431人，占1.24%。若以醫師為基準，照護連續性指標平均為0.26。其中孩童、老年人、男性、有慢性病者、及高門診次數者，其醫療照護連續性指標較高。多變項邏輯斯迴歸分析顯示，照護連續性低及中間者之住院危險性及ACSC住院危險性，均較照護連續性高者為高，分別為其1.33倍、1.14倍(住院危險性)，及1.96倍和1.44倍(ACSC住院危險性)。而住院、ACSC住院次數方面，經負二項迴歸分析結果亦顯示相同趨勢，且均達到統計學上顯著意義，並具有劑量反應關係。故照護連續性愈高者，其住院、ACSC住院危險性及次數均愈低。 結論：本研究發現照護連續性的高低的確對可避免住院有相當的影響，因此，如何增加國人的醫療照護連續性，改變國人的就醫習性，成為當前重要課題。

Background: The accessibility to health care in our country has improved after the implementation of National Health Insurance. Nevertheless, the doctor-shopping phenomena are still widely seen, which will erode health resource. While our major focus in monitoring the quality of hospitalization, it is the quality of primary care that determines the quality and efficiency of our healthcare system. Hospitalization for ambulatory care sensitivity conditions, the avoidable hospitalization, has been widely accepted as the indicator to evaluate the accessibility, quality and efficiency of primary care. It has been well documented that continuity of care may be an important factor related to the outcome of healthcare. Since the family doctor and patient referral system has not been well established in Taiwan, it is our major concern to interrogate the cost-effectiveness of our health care system through continuity of care and reduction of avoidable hospitalization. Purpose: This study aims to investigate factors related to continuity of care to determine if better continuity of care will cause reduction of avoidable hospitalization. Materials and methods: The longitudinal analysis was employed in this study. The academic database of National Health Insurance in National Health Research Institute was used. From year 2004 to 2006, there were about forty thousand records in section one as our total samples. The putative index of continuity of care (COC) was used as independent variable and divided into three groups. The hospitalization and avoidable hospitalization were the dependent variables. The controlled variables in this study included age, gender, accessibility of health care (location and physician density), and health inquiry (presence of chronic diseases and total ambulatory physician visits). Results: In this study, a total of 34728 patients were recruited. Of which, 31825 patients (91.64%) had not hospitalized, while 2903 patients (8.36%) had hospitalized. There were 431 patients (1.24%) presented with the hospitalizations in ambulatory care sensitivity conditions (ACSC), the avoidable hospitalization. As examined with a single provider, the mean COC index was 0.26. In this cohort, high COCI could be seen in the minority, the elderly, male, patients with chronic diseases, and those of higher ambulatory physician visits. In multiple logistic regression, groups of low and moderate COCI showed higher probability both in hospitalization and ACSC hospitalization than the group of high COCI, with 1.33 and 1.14 folds in hospitalization and 1.96 and 1.44 folds in ACSC hospitalization, respectively. The result of negative-binomial regression analysis also revealed similar trend. The trend for both hospitalization risk and frequency was significant suggesting a dose-response relationship. Higher COC would present with lower risk and frequency in both hospitalization and ACSC hospitalization.

Conclusion: According to this study, the continuity of care plays an important role in hospitalization for ACSC. It is therefore an important issue to facilitate the continuity of healthcare and to promote correct pattern of doctor visit instead of doctor-shopping