兒科專科醫師訓練對兒童氣喘照護品質之影響

Abstract

研究目的：氣喘是兒童常見的慢性疾病，但兒童氣喘的診斷不易。過去的研究發現，醫師對於氣喘的認知與照護方式存在差異，照護品質也因此受到影響。由於兒童的醫療照護服務提供者，並不完全是兒科專科醫師，本研究希望了解，兒科專科醫師在受過完整兒科專業訓練的情形下，對於氣喘診斷品質，與其他專科醫師是否不同。 研究方法：本研究採取次級資料分析，資料來源為向「衛生福利部健康資料加值應用協作中心」所申請之健康資料檔。研究對象為收治過1-11歲兒童的醫師，分析其在2010年間，將因呼吸道相關感染症、炎症、或過敏性病症求診的1-11歲兒童，診斷為氣喘的情形，並比較兒科專科醫師與非兒科專科醫師適當診斷氣喘能力的差異。 研究結果：2010年新診斷為氣喘的兒童，佔研究樣本人數之1.77%。兒科專科醫師對氣喘病人做出適當診斷的比例為0.5127，非兒科專科醫師對氣喘病人做出適當診斷的比例為0.2655，但兒科專科醫師的氣喘診斷偽陽性率比非兒科專科醫師高。兒童的醫療利用愈高，就醫連續性愈低時，就愈不容易被診斷出氣喘，醫師的診斷敏感性降低，偽陽性及偽陰性診斷率都隨之增加。醫師服務量愈高，氣喘病人愈多、加入氣喘給付改善方案且收案並人數愈多時，氣喘診斷的敏感性會上升，偽陽性率也會增加。兒科專科醫師加入氣喘給付改善方案的比例較高，但只要加入方案，兒科專科醫師與非兒科醫師將氣喘病人納入方案的比例無顯著差異，兒科醫師則較傾向將照護連續性高的病人納入氣喘給付改善方案。 結論：即便所受專科訓練不同，影響醫師氣喘診療品質的變項，仍會以不同程度產生影響。兒科專科醫師診斷氣喘的敏感性比非兒科專科醫師高，但較傾向對疑似氣喘病人做出氣喘診斷，因此有較高之診斷偽陽性率。醫師服務量及照護連續性愈高，有助於提高氣喘診斷品質，且加入氣喘給付改善計畫對於兒童氣喘診療品質，有正向的影響。

Aim: Asthma is one of the most common diseases of children, but it is difficult to be diagnosed. Previous researches found that the recognition and care of asthma were different between physicians. The quality of care was affected though. Because some healthcare providers of children are not pediatrics, so we would like to know if the care quality of pediatrics is different with other physicians since they had complete training of pediatrics. Methods: The data was provided by the Ministry of Health and Welfare. We extraced the cliam data of respiratory diseases of children aged 1-11 years in 2010 to compare the differences of diagnosis quality between pediatrics and non-pediatrics. Results: 1.77 percent of children aged 1-11 years were new patients in 2010. The sensitivity of asthma diagnosis of pediatrics was 0.5127, non-pediatrics was 0.2655. Pediatrics had higher false positive rate than non-pediatrics. Asthma was difficult to be diagnosed for children with more healthcare usage and lower continuity of care. Physicians with more outpatient services, more asthma patients, and more patients of pay-for-performance program of asthma, both the sensitivity and fale positive rate of diagnosis of asthma increased. Pediatrics intended to join the pay-for-performance program. The difference of the ratio of enrolled patients of pediatrics and non-deiatrics was not significant. Pediatarics were intended to include the patients with high continuity of care to the pay-for-performance program. Conclusions: The asthma diagnosis quality was influenced by many factors with different level of influences among physicians with different speciality tranings. Pediatrics had higher sensitivity of asthma diagnosis. They intended to make the asthma diagnosis, therefore had higher false positive rate than non-pediatrics. Higher amount of service of physicians was helpful to the asthma diagnosis quality, so did the continuity of care. Physicians joined the program of pay-for-performance had better diagnosis quality.