初級照護品質與可避免急診之探討

Abstract

研究背景：急診壅塞的問題是台灣醫療體系中廣受關注的議題，而國外研究也指出，急診壅塞導致醫療照護品質與病人安全下降、造成醫療成本的增加。目前可避免急診指標在國際上已被運用作為衡量初級照護品質、初級照護可近性的指標，若能有效提昇初級照護品質，將能減少可避免急診的發生，進而提昇醫療品質、降低成本。 研究目的：藉由次級資料分析來了解國內在可避免急診的發生情形，並進一步探討可避免急診與初級照護品質的關係，以期能找到紓緩部分急診壅塞的方向。 研究方法：本研究資料來源為國家衛生研究院2010年承保抽樣歸人檔，採用2010年至2013年之健保申報資料進行分析，以各年度發生可避免急診之病患作為研究對象，與同年未發生可避免急診之門診患者進行配對。本研究以「照護連續性」作為測量初級照護品質的指標，分析「病患特性」、「照護連續性」、「門診主要就醫機構層級」對於發生可避免急診的影響。可避免急診採用美國CMS 2015年公布之門診敏感性病症(ACSC)測量。 研究結果：在2010至2013年間，相較於投保金額最低的組別，投保金額最高的兩組發生可避免急診的機率越低（OR=0.635~0.763）。多變量分析結果發現，照護連續性越低的組別，發生可避免急診機率越高（OR=1.925~3.225）。相較於診所層級，區域醫院（OR=3.544）、醫學中心（OR=2.924）與地區醫院（OR=2.149）發生可避免急診機率較高。 結論：本研究發現門診的照護連續性高則可避免急診之發生機率較低。因此建議應提昇民眾的照護連續性，尤其是診所的照護品質。此外建議可將「可避免急診」作為門診照護品質之監控指標。而醫療提供者面對高危險群病人，應提高敏感與警覺性。

Background: Overcrowding in emergency departments (EDs) decreases the quality of care and increases hospital costs. This is currently a matter of concern in Taiwan's health care system. Avoidable emergency department visits often indicate that the quality of primary care is subpar. Improving the quality and availability of primary care should reduce avoidable ED visits, thereby improving the quality of care and reducing costs.

Objective: This research aims to explore the relationship between avoidable ED visits and the quality of primary care in Taiwan through the analysis of secondary data. A better understanding of this relationship could help inform strategies that seek to alleviate overcrowding in emergency departments.

Methods: This study analyzed secondary claims data from the National Health Research Institutes for the period covering 2010 to 2013 using a case-control matching design. In so doing, we focused on ED visits for ambulatory care sensitive conditions (ACSC). The study group comprised patients that had been admitted to the ED for ACSC, and the control group comprised outpatients who had not been admitted to the ED for ACSC during the same year. The continuity of care index (COCI) was used as an indicator to measure the quality of primary care. Specifically, we were interested in how avoidable ED visits are impacted by patient characteristics, the continuity of care, and the level of the outpatient medical institution. Data pertaining to avoidable ED visits for ACSC were obtained from the CMS published in 2015.

Results: Between 2010 and 2013, the rate of ED visits for ACSC was lower for patients who were insured at a level higher than NT$22800 (OR = 0.635 ~ 0.763). Multivariate analysis further revealed that the rate of ED visits for ACSC was higher for patients with lower continuity of care (OR = 1.925 to 3.225) and for regional hospitals (OR = 3.544) and medical centers (OR = 2.924).

Conclusions: Higher continuity of care was found to significantly lower the risk of avoidable ED visits. Health policy stakeholders are therefore encouraged to improve continuity of care, especially as it pertains to clinics. Avoidable ED visits may also be useful monitoring indicators for the quality of primary care.