冠狀動脈疾病病人介入治療後使用遠距照護服務意願之相關因素

Abstract

背景：臺灣超過65歲的老年人口比率快速上升，已成為高度人口依賴的階段，慢性病的發生率及盛行率逐年趨升，其複雜的健康狀況讓就醫照護需求更加多變，國內外近年來對於心臟疾病病人提供遠距照護服務，以生理監測儀器作居家量測，以醫院為後盾將醫療資源串連提供更完善的照護銜接與健康管理，在住院率、急診返診率以及民眾疾病知識或健康行為的改變均獲得良好改善，但目前心臟疾病病人對於遠距照護服務參與率低，如何讓病人接受且願意使用，對於日後推動遠距照護服務是一項考驗。 目的：本研究旨在探討冠狀動脈疾病病人接受介入治療後選擇使用14天免費遠距照護服務之意願及其相關因素。 方法：本研究採橫斷性、相關性研究設計，以量性及半結構式質性問卷進行資料收集，資料收集時間為2014年1月至6月，以北部某醫學中心之冠狀動脈疾病住院病人為對象，研究工具包括基本屬性、疾病特性、使用科技產品相關經驗(包含三部分：1.遠距監測儀器；2.醫療機構特性；3.使用科技產品經驗)、使用電腦自我效能、電腦焦慮、社會支持及半結構式問卷。資料分析以SPSS 20.0統計軟體分析，統計方法包括描述性分析、獨立性t檢定、單因子變數分析、羅吉斯迴歸，質性訪談採內容分析法歸納結果，資料分析與描述以p<0.05為統計之判斷標準。 結果：本研究共140位冠狀動脈疾病病人參與，研究對象平均年齡為61.69歲，以「男性」、「大學以上」與「已婚」居多並以「與配偶同住」，個人月收入以「3萬元以下」為主。關於醫療機構特性在「住院時護理師的建議」、「對醫院提供服務的信任度高」、「遠距照護服務的電話關懷」、「遠距照護服務的個管師陪同門診就醫」及「整體醫療機構特性」於參加14天免費遠距照護服務組顯著較高。但兩組研究對象在使用電腦自我效能、電腦焦慮與社會支持無顯著差異。當研究對象使用14天免費遠距照護服務後對於「有關健康的APP」的使用頻率明顯提高、電腦焦慮程度下降，使用電腦的自我效能則無差異。由單變量二元羅吉斯迴歸分析得知年齡(OR = 1.03，95%C.I. =1.00 ~ 1.07，p<0.05)、居住情形(OR = 5.00，95%C.I. =1.04 ~ 24.03，p<0.05)、醫療機構特性(OR = 1.15，95%C.I. =1.06 ~ 1.24，p<0.001)為使用遠距照護服務之顯著變項，控制其他因素下研究對象的年齡每增加1歲同意使用的勝算比增加3%；與家屬同住者同意使用遠距照護服務是獨居者的5倍；醫療機構特性得分每增加1分，同意使用遠距照護服務的勝算比增加15%，由多變量二元羅吉斯迴歸得知，僅醫療機構特性為顯著預測因子(OR = 1.15，95%C.I. =1.07 ~ 1.25，p<0.001)。最後由半結構式問卷訪談歸納個案不使用遠距照護服務的因素最主要為疾病，再者為儀器、環境及費用等因素。 結論：本研究發現年齡、居住型態、醫療機構特性為個案使用遠距照護服務意願之考量因素，且醫療機構特性為唯一顯著預測因子，但不使用遠距照護服務的主要因素是疾病穩定性及儀器等面向，個案因主觀評估疾病的嚴重程度與儀器是否簡單且易操作而影響使用遠距照護服務意願，但醫療團隊之建議會促進個案使用意願，因此建議醫療團隊瞭解遠距服務內容後共同加入推廣遠距照護服務亦或將病人轉介至遠距照護中心，主動提供相關資訊給潛在需求的病人，協助個案發展對疾病照護認知及管理，此外參加遠距照護服務能藉由個案管理師的陪伴而提供適切的護理指導與關懷，並於返診時陪同就診，讓個案返家後有來自醫院的專業醫護照護與關懷，促使個案與家屬感到安心與滿意而增強使用意願，因此個案管理師應持續提供陪伴與就醫等即時回饋而增加使用意願；再者於推廣服務時實際儀器操作、心得分享與衛教單張等策略，能降低返家電腦焦慮的程度，提升使用電腦自我效能，以促進病人的使用遠距照護服務的意願。

Background: The percentage of Taiwan's population over the age 65 is rapidly increasing, which has been accompanied by rising incidence rates and prevalence of chronic diseases. These complex health problems have multiple care needs; thus health care systems have developed telemedicine services. Hospitals have provided telemedicine services for patients with coronary artery disease (CAD) after being discharged to monitor their physiological condition at home. This combination of technology and care connect hospital services and the patient's home environment. Hospital admission, emergency department (ED) visits, and return visit rates as well as changes in the public's knowledge of illnesses and healthy behavior have since improved, yet current acceptance of telemedicine services by patients with CAD is still low. Therefore, exploration of telemedicine acceptance and influential factors of this system has become an urgent and important issue. Objectives: This study investigated the acceptance of 14-day, free telemedicine services by patients with CAD after coronary intervention, and evaluated telemedicine service acceptance as a predictor for usage compliance. Methods: A cross-sectional survey of patients with CAD after coronary intervention was conducted. Data collection lasted from January to June of 2014. A semi-structured questionnaire, including personal and illness factors, technology use experience (including home health telemonitoring equipment, organizational factors, technology use experience), computer self-efficacy, computer anxiety, and social support, was provided to CAD inpatients at a medical center in northern Taiwan. SPSS 20.0 software was used for data analysis, including descriptive analysis, independent t-tests, one-way ANOVA, and logistic regression. Qualitative interviews used content analysis to categorize results. Statistical significance was set at p<0.05. Results: 140 CAD patients were recruited in this study. The average patient age was 61.69 years old. The majority of patients were married, male college graduates who lived with their spouse and had a monthly income of under NT$30,000. The organizational factors 'nurse suggestions during hospital stays,' 'high confidence in services provided by the hospital,' 'care and concern during telemedicine services,' 'telemedicine case managers' escort to clinic visits,' and 'overall organizational factors ' were more significant in the group of patients who participated in the 14-day, free telemedicine service. However, there was no significant difference between the two groups in terms of computer self-efficancy, computer anxiety, and social support. Use of health-related APPs significantly increased and computer anxiety decreased for participants after the 14 days of telemedicine services. However, there was no change in computer self-efficacy. Univarite binary logistic regression found that age (OR = 1.03, 95% C.I. = 1.00-1.07, p<0.05), living with family (OR = 5.00, 95% C.I. = 1.04-24.03, p<0.05), and organizational factors (OR = 1.15, 95%C.I. = 1.06-1.24, p<0.001) were significantly associated with intent to use telemedicine services. Holding other variables constant showed that a one year increase in age correlated to a 3% increase in the odds ratio for use, patients who lived with family were five times more likely to use telemedicine than those who lived alone, and a one point increase in organizational factors correlated to a 15% increase in the odds ratio for use. Furthermore, multivariate binary logistic regression analysis revealed that organizational factors was the most important predictor (OR = 1.15, 95% C.I. = 1.07-1.25, p<0.001). Lastly, semi-structured questionnaires showed that among reasons contributing to refusal of telemedicine services, the most important were illness, followed by equipment, environment, and fees. Conclusion: This study found that age, living situation, and organizational factors were the key factors that influenced the use of telemedicine services and that organizational factors was the only significant predictor. However, major factors for refusal of telemedicine were disease stability and equipment. Patients' subjective evaluation of illness severity and ease of equipment use influenced their willingness to accept telemedicine services; however, suggestions from the medical team helped increase patient willingness. As such, it is suggested that medical teams collectively promote telemedicine and refer patients to telemedicine centers to provide them with more information on disease care and management. Accompaniment by case managers and provision of appropriate care guidance gave patients professional medical care and concern after discharge which increased feelings of safety and satisfaction as well as user intent. Therefore, case managers should continue to accompany patients in order to increase user willingness. During promotion of telemedicine services, equipment operation, sharing of experiences, and health education pamphlets can reduce computer anxiety and increase computer self-efficacy, thus improving patients' willingness to accept telemedicine services.