週日門診開診狀況與忠誠病人急診利用之相關性探討

Abstract

研究背景：急診部門面臨著服務需求日益增加，擁擠的急診除了使患者無法獲得適切的照護外，也造成臨床醫護人員工作上的負擔，並降低急診醫療品質。在醫療資源有限的情況下，如何確保急診醫療費用有效利用，是當今各國都相當重視的課題。若能瞭解民眾假日就醫需求及影響假日急診就醫的因素，將有助於提升整體醫療服務的品質 研究目的：本研究旨在了解週日使用西醫醫療資源的患者特質並探討病人特性、醫療利用、醫事機構特徵及院所週日門診開診狀況對忠誠病人急診利用之影響。 研究方法：本研究採次級資料分析，利用中央健康保險署全民健康保險資料庫2016年1月1日至2018年12月31日週日就醫之急診、門診及週一早上8點前的急診就醫療資料進行分析，變項分析以「門診就醫或急診就醫」類別變項為依變項，使用羅吉斯迴歸分析在控制病人特性(性別、年齡、是否為低收入戶、共病症、身心科就醫史、重大傷病)、醫療利用(就醫年度、門診就醫次數、有無住院、就醫時段、就醫科別)、醫事機構特徵(忠誠院所特約類別、就醫院所都市化程度、忠誠院所都市化程度、區域醫療院所開診率)等變項後，探討院所於週日開診狀況，對忠誠病人選擇門診或急診醫療之影響。 研究結果：民眾固定就醫的忠誠院所週日未開診則其患者至急診的風險顯著高於有開診的院所(OR=12.72，95%CI:12.56-12.87)，在病人特性方面：男性、65歲以上的老人、低收入戶、有共病症、有重大傷病、身心科就醫病史者，其急診就醫的風險較高，醫療利用方面，門診就醫次數低、有住院的紀錄、就醫刷卡時間越晚、就醫科別為外科、兒科更容易至急診就醫，忠誠院所特約層級別越高、就醫院所位於高度都市化市鎮者、忠誠院所位於低度都市化市鎮者、開診率較低的醫療區急診就醫的風險越高。 結論：研究顯示院所週日開診與否與其忠誠病人急診利用相關，建議衛生主管機關除提供誘因鼓勵假日開診外，強化基層醫療照護系統、宣導民眾應用資訊科技，提升資料查詢便利性及正確性，使西醫基層醫療照護的可及性及可近性提高，促進醫療資源有效利用，以減少假日急診壅塞情形。

BACKGROUND: The emergency departments of hospitals have been facing increasing demands for services. In situations of limited medical resources, ensuring the effective use of emergency medical expenses is an issue to which all countries attach great importance. OBJECTIVE: Barriers to timely access to usual sources of medical care lead patients to use the emergency department as a ready alternative. This study aims to determine (1) the characteristics of patients who use medical resources on Sundays and (2) the relationship between emergency department visits and barriers to receiving usual sources of care in a timely manner for loyal patients. METHODS: This was a secondary analysis from a cross-sectional study. Data from 2016 to 2018 were obtained from Taiwan’s National Health Insurance Research Database, and the study estimated of medical care utilization in the past year. Patients were classified as having a usual source of care if they made 80% or more of their total ambulatory visits to the same clinic. Descriptive statistics and logistic regression analyses were used to determine relationships between the medical service provided on Sundays and the use of the emergency department by loyal patients. RESULTS: This study included a medical care utilization of 2,995,305 on Sundays from 2016 to 2018 from 1,477,131 loyal patients. Patients who had a higher risk of emergency visits had the following characteristics: male, over 65 years of age, low-income, co-morbidities, major injuries, poor physical health, or poor mental health. In terms of medical use, the following was also associated with a higher risk of emergency visits by patients: low outpatient visits, having a record of hospitalization in the past year, after-hours visits, medical needs for surgery, or pediatrics. The positive associations between barriers to receiving usual source of care in a timely manner and emergency department usage persisted even in multiple logistic regressions that adjusted for patient characteristics, medical use, and characteristics of medical institutions. The risk of emergency department visits was significantly higher among loyal patients whose usual clinics did not provide medical services that met their needs than among patients whose usual clinics did meet their needs (OR=12.72, 95%CI:12.56-12.87). CONCLUSIONS: The results indicate that loyal patients who have barriers to their usual source of medical care are more likely to utilize the emergency department. Improving the availability and accessibility of primary medical care on Sundays may help reduce rates of emergency department use and resolve current situations of unmet medical needs.