請用此 Handle URI 來引用此文件:
http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/73292
標題: | 預防保健服務利用軌跡分組與基層醫療服務利用之相關研究 A Study on the Association between Trajectories of Utilization in Preventive Services and Primary Care |
作者: | Ping Tao 陶屏 |
指導教授: | 楊銘欽(Ming-Chin Yang) |
關鍵字: | 預防保健服務,初級照護,基層醫療利用,群組化軌跡模式,Andersen 健康行為模式, preventive health care,primary care,primary care utilization,group-based trajectory modeling,Andersen health behavioral model, |
出版年 : | 2019 |
學位: | 博士 |
摘要: | 研究背景:
基層醫療照護是病人與醫療體系接觸的入口,也是確保現代化分級醫療體系能成功的守門員。如何提升民眾適切的利用醫療初級醫療服務逐漸的取代過去著重提升治療能力、增加醫療服務品質與可近性此類議題。 研究目的: 本研究以Andersen的醫療服務利用理論(Andersen’s health behavioral model)為基礎,透過長期觀察(連續15年)的中央健康保險署全民健康保險(以下簡稱為健保)利用資料,對於民眾個人實際使用健保預防保健服務的軌跡分組及利用Adjust clinical groups(ACG)軟體計算之健康狀態對其基層醫療服務利用及利用的適切程度加以研究之,重新再次確立修正後的Andersen’s health behavioral model是否適合用來解釋基層醫療服務的利用行為。 研究方法: 本研究為一回溯性研究,以1999至2013年全民健康保險學術研究資料庫(百萬抽樣檔)為資料來源,透過群組化軌跡模式先將研究樣本從1999~2013年健保預防保健服務利用結果(每3年計算一次)定義出研究樣本預防保健服務利用率之軌跡分組,再利用Adjust clinical groups(ACG)軟體計算出研究樣本每年Unscaled ACG權重測量其健康狀態,再利用廣義線性方程式分析(1999~2013計15年)修正後Andersen’s health behavioral model對研究樣本基層醫療利用率和適切的程度(適切率)。 研究結果: 本研究結果發現基層醫療利用率與適切率在過去1999~2013年的15年間均呈現下降的趨勢。以本研究修正後的Andersen’s health behavioral model進行更進一步的分析會有兩個重要的發現:1.將健保醫療服務利用的軌跡分組結果納入分析長期基層醫療醫療利用率或適切率會使GEE模式的適配率(配適程度)增加。2.原先Andersen’s health behavioral model中需求因素中的由Adjust clinical groups(ACG)軟體所計算出的健康狀態卻和基層醫療適切程度的模型配適度不佳。 研究結論與建議: 用Andersen’s health behavioral model分析(或是分層分析)個人長期基層醫療利用率與適切率是合適的,但是除非可以改善健保預防保健服務利用率的趨勢,從長期來看健保所推動各項改革(如:調升跨級就醫部分負擔或是目前限制區域以上醫院每年門診量降2%政策等),要達到正確的利用分級醫療(正確利用與適切的基層醫療)或許由提高民眾的「健康素養」會更具成效。 Background: Primary care is fundamentally the patient's first contact with the health care system and the gatekeeper that acertain the successful of modern hierachical medical system. The improving methods of the population’s appropriate use of primary health services has gradually replaced previous issues focusing on improving treatment capacity, increasing the quality of health services and accessibility. Purposes: Based on Andersen’s health behavioral model, this study uses Taiwan's National Health Insurance Research Databases(NHIRD)to conduct a long-term observation, in a total of 15 years. According to the use of preventive health care services, a group-based trajectory model and Adjust clinical groups(ACG)software to calculate health status was conducted in order to investigate the primary care service’s utilization and its adequacy ratio, re-establishing whether the modified Andersen’s health behavioral model is suitable for explaining the utilization of primary care services. Methods: The study is a retrospective study that uses longitudinal data from the national health insurance research database (LHID; 2005) from 1999 to 2013. Using a group-based trajectory modeling for grouping, based on research population’s preventive health care service every three years, calculating unscaled concurrent weighted risk in order to measure research population’s health status. The generalized estimating equation (GEE) model is used to analyze the primary care service’s utilization and the adequacy ratio of modified Andersen’s health behavioral model. Results: Results of this study found that the utilization ratio and adequacy ratio of primary health care showed a downward trend from 1999 to 2013. There are two important findings to highlight from the further analysis of Andersen’s health behavioral model, modified by this study: 1. By incorporating the trajectory grouping results of health care services into the analysis of long-term primary medical care utilization ratio or adequacy ratio, the goodness of fit increases in GEE model. 2. In the original Andersen’s health behavioral model, the health status calculated using the Adjust clinical groups (ACG) software was not well fit with the GEE model of primary care adequacy ratio. Conclusions and suggestions: It is suitable to use the Andersen’s health behavioral model to analyze (or stratified analyze) individual long-term primary care utilization and adequacy ratio. However, unless it can improve the trend of preventive medical utilization in the long term, to effectively implement health care reforms in the long run (such as raising the burden of cross-level medical treatment or currently limiting the number of outpatients in the above-mentioned hospitals by 2%), it maybe more effective by raising people’s high 'health literacy' to achieve proper use of hierarchical medical system (such as correct use and appropriate primary care). |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/73292 |
DOI: | 10.6342/NTU201901026 |
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 |
文件中的檔案:
檔案 | 大小 | 格式 | |
---|---|---|---|
ntu-108-1.pdf 目前未授權公開取用 | 10.88 MB | Adobe PDF |
系統中的文件,除了特別指名其著作權條款之外,均受到著作權保護,並且保留所有的權利。