氣喘門診照護對可避免住院之影響

Abstract

目的： 氣喘是一國人盛行之慢性疾病，其可因適當的門診照護來降低急診與住院的結果。本研究使用「門診照護靈敏病況（ACSCs）」與「可避免住院」的概念，先以行政區為單位，了解台灣各個行政區在氣喘急性發作人次、住院人次、急診人次的情況。再以個人為單位，深入了解氣喘病人在門診、急診與住院之醫療利用情形，並期望找出門診照護對急診與住院兩照護結果的影響。 方法： 本研究使用89年至91年之全國健保檔，研究對象在門診、急診乃主診斷之國際疾病分類碼(ICD-9-CM)為493、並排除診斷碼兼具491、492，可能為慢性阻塞性肺病的病人，亦排除有進行手術之病人。住院之氣喘病人為符合「可避免」之定義，其篩選則更為嚴格，除了ICD-9-CM為493、排除兼具491、492者、排除兼具其他欄位填寫非呼吸道疾病者、排除進行手術者。統計方法使用羅吉士迴歸與卜瓦松迴歸分析方法。 結果： 在行政區方面，台灣每萬人口氣喘可避免急診率、每萬人口氣喘可避免住院率、每萬人口可避免急性發作率，在89年、90年、91年的表現上，呈現先上升後下降的情況。與美國91年相較，台灣整體在氣喘照護上表現較佳，但各行政區之情況仍有差異。 年齡、性別、疾病嚴重度、低收入戶、固定就醫地點、門診醫療機構權屬別、評鑑等級、健保分局別等，皆對於門診、急診、住院醫療利用有顯著影響。門診次數方面，次數越多的病人，其在急性發作、住院、急診方面，都表現較差。就醫科別適當度對於門診照護結果對嚴重度較大的病人之急性發作與急診次數方面，達顯著保護效果。開立慢性病連續處方箋的病人，其照護結果皆顯著較好。肺功能檢查方面，僅在住院與否及住院次數達到統計上顯著保護結果。過敏檢查方面，在急性發作與急診方面，有作檢查的人有較多的急性發作與急診機會。在住院方面，則有顯著保護效果。在所看醫師之平均門診量方面，服務量越大的醫師，其氣喘照護的成效越佳，雖然照護結果的邊際效益遞減，但仍是正向結果。在開立長效支氣管擴張劑與類固醇方面，無論在急性發作、住院、急診的機會與次數上，全年皆有開立的病人其照護效果顯著較1/3年有開立及2/3年有開立的好。 結論： 在衛生行政主管機關方面，建議引用「可避免住院」之概念，定期監測各區域在門診照護品質與醫療可近性之情況。在病人方面，應教育其自我照護與管理技巧、就醫時機與正確就醫習慣，例如：固定就醫地點與前往低層級就醫，以提供持續性醫療服務。在醫療機構方面，應宣導正確進行檢查及開立慢性病連續處方箋的時機，以及肺功能檢查與過敏檢查完，後續之衛教與處置方案。對於氣喘等慢性疾病管理，有賴病人與醫師共同努力，在持續性及連續性的照護下，不但可以增進病人生活品質與健康狀態，亦可提升醫療資源的有效利用。

Objects： Asthma is the popular chronic disease in Taiwan. Emergency treatment and hospitalization about asthma can be lessened through appropriate ambulatory care. The study apply the concept of “ambulatory care sensitive conditions” and “avoidable hospitalization” to be aware of the quality of caring asthmatic patients. First of all, we want to know the frequency of acute exacerbation, hospitalization, and emergency of asthma in each year in each administration area. Secondly, we try to understand the health service utilization of asthmatic patients in outpatient departments, emergency departments, and hospital departments, and except to find out the impact of appropriate ambulatory care on the utilization of emergency care and hospitalization. Methods： In the article, we use the National Health Insurance database during 2000-2002 to analyze medical resource utilization. The asthmatic patients in the outpatient department and emergency department we are studied are 493 in ICD-9-CM code, and exclude the patients who are undergoing operations and patients whose ICD-9-CM codes are 491 or 492. In order to emphasis the asthmatic patients’ hospitalization are preventable, we identify the asthmatic patients in the hospital department strictly. The hospital asthmatic patients we are studied are 493 in ICD-9-CM code, and exclude the patients who are undergoing operations, whose ICD-9-CM codes are 491 or 492, and whose ICD-9-CM codes are ever not respiratory diseases in the medical record. The data are analyzed by using descriptive statistics, logistic regression and poisson regression analysis. The statistic software is SAS 8.0. Results： In each administration area, the frequency of acute exacerbation, hospitalization, and emergency of asthma in each year during 2000-2002 tend to increase first and then to decrease. Compared with US, the care about asthma in Taiwan is better as a whole. But there are some differences between each administration area. Age, gender, the severity of asthma, low-income family, having a fixed clinic for regular visits, hospital ownership, hospital accreditation status, and each branch of National Health Insurance Bureau are found to have significant influence on the utilization of ambulatory care, emergency care, and hospitalization. The patients who have more times in ambulatory care are more frequency of acute exacerbation, hospitalization, and emergency of asthma. The degree of adequate medical departments in ambulatory care is significant protective influence on the frequency of acute exacerbation and emergency of asthma for serious patients. Taking lung function test regularly is significant protective influence on the frequency of hospitalization only. The patients taking allergen test are more frequency of acute exacerbation and emergency of asthma significantly, but less frequency of hospitalization significantly because of asthma. The patients served by the doctor having the more amounts of outpatient visits have more effect on asthma care. Although the boundary benefit decreases, it is the positive impact. The patients treated with a long-acting beta agonist and steroid in all year have less frequency of acute exacerbation, emergency care and hospitalization because of asthma than one-third or two-thirds year significantly. Conclusions： According to the results of this study, we suggest that public health organizations apply the concept of ‘preventable hospitalization’ to monitor the outpatient care quality and medical acceptability within fixed time in each area. Public health organizations should educate asthmatic patients to manage their diseases, the time when to seek medical advice, and correct habits about taking medical treatment: for instance, having a fixed clinic for regular visits and seeking medical advice in lower-level health care organization. That can help to provide continuity care to asthmatic patients. Besides, public health organizations should educate doctors in health care organization when to test, and when to give chronic-disorder refill prescriptions to patients. After taking lung function test or taking allergen test, doctors should educate patients how to manage their disease and plan the treatment program. Patients and doctors should strive to manage the chronic disease such as asthma continually. That can improve the quality of life of asthmatic patients and increase health service utilization about asthma.