本土失智症機構照護收容模式成本效果分析

Abstract

台灣與許多已開發國家相同，人口結構已走入高齡化社會；平均餘命延長的同時，需要注意的便是如慢性病等老年疾病所帶來的威脅。失智症即是一項隨著年齡越高、罹患機率與嚴重程度皆會持續上升的老年疾病，由於病患缺乏自行照顧能力的疾病特性，經常造成照顧者之心理與生理負擔；在家庭或社區無法支持的情形下，未來對於失智症機構式照護的需求務必會增加。綜觀現今失智症收容機構，大部份的民間單位投入專業型與區隔型機構數較少，而以混合型(同區域中同時照顧失智與非失智症住民)居多，但何種機構收容模式可兼顧病患照護效果與經營成本，仍尚無相關研究與定論。 本研究為一前瞻性研究，以立意取樣方式，利用開放性問卷進行北、中、南三種收容模式共十九家機構之橫斷面成本資料調查，並利用病歷審查方式回溯性收集住民效果資料。除比較三種模式之失智症住民每人月照護成本外，並利用複迴歸控制住民基本屬性及功能程度後，求出預測一年後住民分數改變值，以俾進行此三種機構照護收容模式之一年前後效果改變人數比率之比較；並利用成本效果分析(cost-effectiveness analysis)找出本土最適失智症機構照護收容模式。 結果發現，失智症住民平均每人月照護成本最高者為專業型，其次為混合型，最低者為區隔型，但模式間未達統計上顯著差異。一年後住民無論是認知功能或日常活動功能上，分數平均而言皆呈退步情形，且模式內之住民前後功能分數改變皆達統計上顯著差異。若以不同模式之住民功能退化分數來看，MMSE平均退化分數由低至高排序為專業型、混合型、區隔型；巴氏量表分數平均退化分數由低至高排序為混合型、區隔型、專業型，但統計上僅有專業型於巴氏量表分數平均退化分數上顯著高於混合型。若以預測之一年後住民功能程度來看，住民認知功能進步與維持之人數比率，專業型最高、混合型最低；住民日常活動功能進步與維持之人數比率則以區隔型最高、專業型最低，但此現象與專業型入住功能較佳之住民人數較多，一年後自然病程退化分數亦較高有關。就成本效果分析之結果而言，區隔型無論於住民認知功能及日常活動功能皆佔成本優勢，且透過敏感度分析，發現當佔總成本最大宗之人力成本增減時，其成本效果優勢不變；本研究結果具穩定性。 因此就成本效果分析結果而言，區隔型機構收容模式屬本土較適之失智症機構收容照護模式。但認知功能屬於輕度與中度之失智症患者，考量其可能發生問題行為干擾其他住民，較不適合入住區隔型或混合型機構；專業型機構收容模式仍有其存在之必要性。 本研究所進行之成本與效果分析結果，或許在收集資料時仍有不足之處，但應可做為未來政府相關單位分配資源、扶植長照產業與民間單位規劃經營時投入之參考。

Background Same as many developed countries, the population construction of Taiwan shows an aging societal trend. As the life expectancy becomes longer, we should pay attention to the threats of elder diseases such as chronic diseases. Dementia is a kind of elder diseases. As the elders’ age, the prevalence and severity will keep rising; patients lack the abilities of caring themselves, and caregivers often experience mental or physical burdens. When the family and society cannot find the solution to these problems, the demands of dementia institutional care will sure rise. Nowadays, most of the non-governmental circles practices the “Specialized type” and “Segmented type” institutional care models, but less of the “Mixed type” institutional care models. There are still no relative studies and conclusions found in institutional care models in dementia with both better effectiveness and costs of caring. Method and Objectives This study is a prospective study. Applying the methods of purposive sampling and opened-questionnaire to collect north, central and south of Taiwan, 3 models and 19 institutions’ cross-sectional cost data were collected. Dementia residents’ retrospective effectiveness data were collected by chart reviewed. In addition to comparing the average per resident/month care costs of three models, multiple regression was also applied to control residents’ basic characters and degrees of cognitive function and ADL, to predict residents’ changes of scores after one year. Then, the count rate of residents effectiveness changed of these three models were compared, and cost-effectiveness analysis was applied to find out the best Taiwan institutional care models in dementia. Results “Specialized type” model is the highest in each resident’s per month care costs in average, “Mixed type” model is the next highest, and the “Segmented type” is the lowest; but there is no statistically significant difference among the three models. No matter what residents’ cognitive function or ADL are, all changes of scores presents the situation of retrogressing in average after one year, and there is statistically significant difference in all models. Comparing the residents’ functional degenerated scores among three different models and to arrange the average degenerated MMSE scores from the lowest to the highest are “Specialized type”, “Mixed type” and “Segmented type” models; to arrange the average degenerated Barthel Index scores from the lowest to the highest are “Mixed type”, “Segmented type” and “Specialized type” models. But there is only statistically significant difference in the average degenerated Barthel Index scores that in “Specialized type” model is higher than in “Mixed type” model. Comparing the predicted residents’ functional degrees one year later, the rate of residents whose degrees of cognitive function gained and kept, the “Specialized type” is the highest, and the “Mixed type” is the lowest; the rate of residents whose degrees of ADL gained and kept that “Segmented type” model is the highest, and the “Specialized type” model is lowest. But this phenomenon is relative to that there are more residents with better ADL in “Specialized type” model, the degenerated scores are also relatively higher because of the natural courses of disease degenerated one year later. In the results of cost-effectiveness analysis, no matter it is on cognitive function or ADL, “Segmented type” model takes the advantage in the cost-effectiveness; through the sensitivity analysis, we find that no matter how manpower costs which takes the largest part of total costs increase or decrease, the results does not change, therefore, the results of this study are stable.

Conclusions According to the results of cost-effectiveness analysis, “Segmented type” is the better institutional care model in dementia for Taiwan. But when residents’ cognitive functions are mild and moderate, their problematic behaviors might disturb others. Those who lived into the “Segmented type” or “Mixed type” care models were not appropriate; “Specialized type” institutional care model still have its necessity in existing. Perhaps the costs and effectiveness analytic outcomes in the study are inadequate because of insufficiency of data collection. However, it still should be enough for relative government sections’ reference in distributing resources, and helping long-term care industries and non-governmental circles’ operators to manage themselves appropriately.