比較不同權屬別護理之家住民的醫療服務利用情形─全民健保資料庫研究

Abstract

研究背景與目的：機構式照護在人口老化及少子化的衝擊、社會及家庭結構改變下，將是長照議題中不可或缺的一環。近年來，護理之家住民人數持續上升，國內逐漸開始重視護理之家照護品質。台灣地區目前已經有護理之家評鑑，但內容缺少結果層面指標。「機構權屬別」的差異可能帶來照護結果與醫療服務利用的差異，但過去研究較少探討兩者間的相關性。同時過去也因資料規模的限制，較少進行全國性護理之家照護品質結果層面的研究分析。因此，本研究之目的希望藉由分析健保資料庫，除探討機構住民之醫療服務利用情形以外，同時也希望能藉此得知是否有合適之研究方法及研究結果，作為提供未來護理之家評鑑制度進一步建立照護結果指標的參考依據 研究方法：本研究採用次級資料分析進行橫斷式研究。資料來源為健保資料庫2010年百萬承保抽樣歸人檔，篩選2006至2011年入住護理之家達六個月以上的住民做為研究對象，共計579人。護理之家住民依營利別分為公立、法人及私立；依附屬別分為有無醫院附設。研究以兩組樣本T檢定、單因子變異數分析、複迴歸分析及複羅吉斯迴歸分析比較不同權屬別護理之家住民的門診、急診及住院利用情形。 研究結果：研究結果顯示，在控制其他變相的情況下，公立、法人護理之家住民在急診相對風險、住院相對風險、累積急診費用、住院次數、累積住院費用、累積住院日數均大於私立護理之家；醫院附設護理之家住民在急診次數顯著高於非醫院附設護理之家住民，其餘所有醫療服務利用情形則無顯著差異。當住民為男性、年齡越高時，急診、住院的次數及費用會越多。當住民共病症程度越嚴重，門診、急診、住院的次數也會越多。 結論：不同權屬別護理之家的住民，可能因為機構經營型態的差異，而有不同的機構規模，造成不同的醫療服務利用情形。未來若能將機構規模小型化，預期可有效降低機構住民因照護品質不佳而產生不必要的醫療服務利用情形，以維持住民良好的身體功能及生活品質，同時也使機構式照護符合國家在地老化之政策目標。

Background: Taiwan has faced a dramatic demographic change starting from the last couple decades as well as in the next couple decades, such as increasing aged population and low fertility. To fulfill the growing need for long-term care, the quality of institutional care has to be carefully assessed. Nursing home is one of the major types of institutional care services in Taiwan and it provides care for people who need continued nursing care and personal care. Thus, in order to reach a higher quality of care for nursing home in Taiwan, a comprehensive quality assessment should be conducted and reported. Quality assessments in healthcare systems included three important domains, structure, process, and outcome. However, the Nursing Home Accreditations in Taiwan only evaluates the structure and process domains. To evaluate the outcome domain in quality assessment in nursing home, healthcare utilization such as ambulatory care, hospitalization, and emergency department used seem to be common indicators. In addition, previous studied noted that the nursing homes’ funding types, such as whether they are publicly, privately, or legal person owned nursing homes, and nursing home’s management types, such as whether hospital owned or not, might be associated with residents’ healthcare service utilization in nursing home. However, the quality assessment and related factors affecting healthcare utilization in nursing home in Taiwan remained unclear. This research aimed to analyze healthcare utilization among residents living in different nursing home funding types and management types. By using Taiwan National Health Insurance Database, we also hope to provide some evidences for potential outcome indicators for Nursing Home Accreditation in the future. Method: A cross-sectional study was used to examine health service utilization of residents living in different types of nursing homes. Data were extracted from 2010 National Health Insurance Claim Dataset. We examined those subjects who lived in nursing home at least 6 months during 2006-2011 (n=579) and follow-up their healthcare utilization for a year after they were first time admitted to a nursing home. The main outcome variables examined were the use of ambulatory service, emergency service, and hospitalization related services uses. The outcome variables were compared among several nursing homes’ funding types and among nursing homes management type whether the nursing homes were publicly, legal person, privately owned and whether they are hospital-based setting or not, using two sample T-test, ANOVA, multiple logistic regression analysis and multiple linear regression analysis. Result: The regression analysis showed that, after the demographic factors were controlled, people who lived in private nursing home were associated with lower risk of emergency department admission (OR = 0.52, p < 0.0001), lower risk of hospitalization (OR = 0.45, p < 0.0001), fewer emergency expenditure, lower frequency of hospital admission, shorter length of stay in hospital and fewer hospital admission expenditure in a year than residents lived in publicly owned and legal person owned nursing home. Conclusion: The ownerships of nursing home were associated with different healthcare utilization in residents, whereas hospital or non-hospital-based characteristics of nursing home showed non-significant in healthcare utilization. The higher emergency department utilization and hospitalization was found in residents who lived in publicly owned or legal person owned nursing homes, comparing with those lived in privately owned nursing home. The possible explanation might be that the bigger size of nursing home, such as public or legal person one, the more managing, caring problems, and therefore might be associated with higher acute care utilization. Therefore, downsize of nursing home’s scale shall be a good strategy which promoting quality of care in long-term care services as well as fitting better to current long-term care policy—aging in place.