台灣地區急診利用與重返急診病患資源耗用分析

Abstract

重返急診病患會增加醫療資源耗用與醫療照護成本，也是病患照護問題的警訊。隨著台灣地區急診醫療的進步以及全民健保的實施，醫院急診的服務量呈現逐年成長的趨勢，2002年台灣地區急診服務量為6,600,872人次，急診醫療支出費用高達88億元，相較於1995年全民健保開辦初期急診人次成長42.05%。基於促使醫療資源合理分配、提升醫療品質、促進國民健康、及確保全民健保永續經營為考量，則有賴於落實醫療品質指標監控。藉由分析重返急診案件則可降低醫療成本、促進急診醫療品質、促使急診部門資源有效利用、提供病患更好的服務與急診更高的醫療品質。 目標：探討台灣地區2002年急診醫療資源利用情形、分析三日內重返急診案件之病患特質與醫院特質、以及探討不同重返急診型態的醫療費用利用情形。 方法：本研究方法為橫斷性研究，研究材料採用2002年健保資料庫之「門診處方及治療明細檔（CD）」、「住院醫療費用清單明細檔（DD）」、及衛生署2002年「醫療機構現況檔」進行分析。 結果：研究結果顯示（1）2002年急診次數20次以內急診病患共有5,431,414案件，醫療費用共計9,157,936,407元，三日內重返急診率為6.56％。（2）急診病患男性（52.94％）比女性（45.95％）多，且男性急診利用率與重返急診率較女性高。（3）年齡方面以15~65歲佔59.32％比例最高，而65歲以上者急診利用率與重返急診率最高，其次為0∼14歲族群。（4）疾病主診斷最多前四項為：「損傷及中毒」、「呼吸系統疾病」、「病徵及診斷欠明各種病態」、「消化系統疾病」；重返率最高前三項為：「腫瘤」、「精神疾患」、「循環系統疾病」。（5）在重返急診資源利用分析比較不同重返急診型態發現：「重返至較高層級醫院」急診費用最高，其次為「重返至同層級醫院」、「重返至較低層級醫院」，而「重返急診至同醫院」急診費用最低。 結論：針對本研究結果主要建議衛生當局必須持續監控急診醫療品質、落實分級醫療、建立完善的轉診制度，對於重返率最高前三項之「腫瘤」、「精神疾患」、「循環系統疾病」病人，衛生當局應提供足夠且適當的持續照護機構，以減少急診病患在各醫院間重返急診。衛生當局可利用健保IC卡監控病患在各醫院間重返急診情形，於健保IC卡中儲存相關的檢查報告（如：數位X光片、CT檢查結果、生化檢查結果等）以減少重複的檢驗檢查。醫院急診部門對於男性、65歲以上、疾病診斷為「腫瘤」、「精神疾患」、「循環系統疾病」的病患需更加留意，可考慮提供較長時間的留院觀察或是改由較為資深的醫師進行診療，並提供合適的後續治療計畫，可以採用電話聯絡等方式持續追蹤，如此可以讓病患及家屬放心，也可以降低病患重返急診的機率。最後衛生當局必須建立分級醫療與落實家庭醫師制度，提供民眾完整的醫療照護，如此才能減少醫療資源浪費且促進醫療品質。

Emergency department revisits will increase medical costs, and it is the warning of medical quality, too. As a result of developing emergency medicine and practicing National Health Insurance (NHI), the emergency service volume is growing up year by year in Taiwan. In 2002, emergency service volume is 6,600,872 visits, and emergency medical expenditures are 880 million. It relies on monitoring medical quality index practically on purpose to distribute medical resources fairly, improve medical quality and public health, and insure National Health Insurance sustainable operation. Analysis of revisits to the emergency department can induce medical costs and improve the quality of emergency medicine. Purpose: The objectives of this study were to evaluate the ‘emergency medical resources utilization’, ‘the characters of patient and hospitals with three days revisits’, and ‘emergency medical expenditures of different revisiting types’ in Taiwan during 2002. Method: A cross-sectional study was conducted by using claim data of NHI and Department of Health (DOH) in 2002. Result: The result of study finds (1) there are 5,431,414 visits of emergency department within 20 times in 2002, the medical expenditures are 9,157,936,407 dollars (NT), and the rate of return to the emergency department in three days is 6.56%. (2) There are more emergency men (52.94%) than women (45.95%), and the men’s rate of emergency utilization and revisit are higher than women’s. (3) In age, the 15 to 65 years old are 59.32% of the proportions. The over 65 years elder’s rate of emergency utilization and revisit are highest, secondly it is 0 to 14 years old. (4) The first four items of primary diagnosed are ‘injury and poisoning’, ‘diseases of the respiratory system’, ‘symptoms, signs, and ill-defined conditions’, ‘diseases of the digestive system’. The highest first three items of emergency revisits are ‘neoplasms’, ‘mental disorders’, ’diseases of the circulatory system’. (5) Analyzing the different types of emergency department revisits find that the emergency medical costs of revisiting to higher level hospitals are highest, the next is the emergency medical costs of revisiting to the same level hospitals, the next is the emergency medical costs of revisiting to lower level hospitals, and the emergency medical costs of revisiting to the same hospital are lowest. Conclusion: Based on the result, we suggest that the government departments should monitor emergency medical quality index continually, implement classified medicine, and establish emergency transfer system. To the first three of the revisit diseases are neoplasms, mental disorders, and diseases of the circulatory system, we should provide enough and appropriate hospitalization in order to reduce emergency revisits. The government departments could monitor patient who revisits between hospitals by IC cards and save medical reports in IC cards. Emergency departments should look out the patients who are men, over 65 years old, and diagnosed by tumors, psychological disorders, and circulatory system diseases. At last, the government departments should implement family doctor systems for reducing medical resources wasted and improving medical quality.