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標題: | 多重慢性病在DRGs對醫療資源耗用與照護結果影響中所扮演的角色 The role of multiple chronic conditions in the impact of DRGs on health care resources usage and outcome |
作者: | Lan Lin 林蘭 |
指導教授: | 鄭守夏(Shou-Hsia Cheng) |
關鍵字: | 住院診斷關聯群,多重慢性病,差異法之差異法之差異法(Difference-in-difference-in-differences ,DDD),醫療資源利用,照護結果, Diagnosis related groups,Multiple chronic conditions,Difference-in-difference-in-differences,Medical resources usage,Health care outcome, |
出版年 : | 2018 |
學位: | 碩士 |
摘要: | 研究背景:為有效提升管理效率與合理分配醫療資源,使民眾能獲得更完善的醫療照護,中央健康保險署於2010年起分階段導入臺灣住院診斷關聯群(Tw-DRGs)支付制度。該項支付制度屬於前瞻式支付方式,以住院病患之診斷、手術或處置及其他條件分成不同的群組,以達到醫療資源耗用相似的分類,再參考過去之醫療費用訂定預先支付醫院之費用標準。然而多重慢性病患的醫療資源耗用通常較高,醫事機構是否會為了有效控制成本,而在醫療處置上有所改變,進而影響多重慢性病病患之住院醫療利用情形及照護結果,鮮有研究加以探討。
研究目的:本研究以Tw-DRGs實施前後,比較心導管診斷與治療之病人有無多重慢性病,探討其住院醫療利用及照護品質之影響。 研究方法:研究資料使用「全民健康保險資料庫」原始檔,降低樣本代表性之限制及增加樣本數擷取,並以「審核結果DRG」之欄位擷取申報正確之案件作為研究樣本,降低資料因錯誤分組而導致的偏誤。本研究以MDC5為研究對象,介入組為第一階段導入Tw-DRGs接受心導管診斷與治療之病患,對照組為未納入第一階段Tw-DRGs之同類MDC5,使用傾向分數配對法增加導入Tw-DRGs前後之可比較性,並以廣義估計方程式(GEE)統計方法,進行差異法之差異法之差異法(Difference-in-difference-in-differences ,DDD)探討Tw-DRGs實施前後多重慢性病在醫療利用與照護結果的影響。 研究結果:Tw-DRGs實施對於多重慢性病之病人在住院總醫療費用、住院天數、住院前一週門診醫療費用、藥費占率、醫令數等醫療利用皆無顯著差異;照護結果亦顯示30日內死亡率、30日內再入院率及3日再急診率無顯著差異。若以整體政策效應分析,Tw-DRGs實施,相較於對照組,介入組住院總醫療費用、住院天數及住院前一週門診醫療費用、處置醫令皆有顯著差異。照護結果的部分,30日內死亡率無顯著差異、30日內再入院率顯著增加及3日再急診率無顯著差異。 結論與建議:本研究中進行心導管處置之病人,在Tw-DRGs實施後並不會影響多重慢性病人之醫療利用與照護結果,建議未來的研究設計,可以利用敏感度分析,將多重慢性病個數以不同切點進行分析,做為政策建議之參考。 Background: In order to effectively enhance the quality and efficiency of care, Taiwan’s version of diagnosis related groups (Tw-DRGs) launched in 2010. Under the prospective system, patients within each category are clinically similar and are expected to use the same level of medical resources and health care costs. However, patients with multiple chronic conditions usually needed more medical resources. Tw-DRGs was implemented eight years ago, many studies have examined whether Tw-DRGs contributes to reduced resource usage, as does its effects on healthcare quality. Few studies have been conducted to investigate the impact of Tw-DRGs payment system on patients with multiple chronic conditions. Objectives: The purpose of this study was to determine the impact of the Taiwan Diagnosis Related Groups (Tw-DRGs) payment system treating patients with Cardiac Catheterization and examine medical expenses and quality of care for patients with multiple chronic conditions. Methods: Patient-related data were obtained from the National Health Insurance data warehouse during the study period (2008-2011). To eliminated sample bias and misclassification, we select the representative sample from population and patients are assigned to DRG with EXM_RESULT_DRG in claim data. Patients who underwent Cardiac Catheterization as the intervention group and the comparsion group who underwent MDC5 intervention which were not phased in study period. Propensity score matching (PSM) was used to divide the subjects into DRG and non-DRG groups. The difference-in-difference-in-difference approach and the generalized estimating equation (GEE) model were used to compare the DRG and non-DRG groups with multiple chronic conditions on their medical usage and health outcome. Results: After Tw-DRGs were implemented, we found no significant difference between patients with multiple chronic conditions and patients without multiple chronic conditions in medical usage and health outcome. However, after Tw-DRGs was initiated, the DRG group had lower medical expenses, lower length of stay, higher medical expense shifting outpatient and lower number of orders for diagnosis or treatment. The mortality rate within 30 days after discharge and ED visits within 3 days after discharge compared to the non-DRG group were not significant. In contrast, after Tw-DRGs were implemented, the DRG group had a higher readmission rate within 30 days after discharge compared to the non-DRG group. Conclusions: After implementing the Tw-DRGs payment system, the medical usage and health outcome did not lead to the difference in patients with multiple chronic conditions and patients without multiple chronic conditions. We suggest that a sensitivity analysis used to determine how different values of an independent variable impact dependent variables under a given set of MCC assumptions. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/69936 |
DOI: | 10.6342/NTU201800485 |
全文授權: | 有償授權 |
顯示於系所單位: | 健康政策與管理研究所 |
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