以病患觀點探討影響醫師轉診行為之相關因素

Abstract

背景：目前台灣的家庭醫師並沒有如同西方國家家庭醫師能夠提供全科初級照護服務及擔任醫療守門人的功能，以致民眾容易產生越級就醫、重複就醫、接受到片段式醫療服務等現象，更是分級醫療、轉診制度長期以來無法有效落實的主要原因之一。然而，我國正面臨人口高齡化的挑戰，醫療資源利用能否更有效率被利用成為醫療體系永續發展的關鍵之一。因此，轉診制度的運行慨念有被重新釐清的需要。 目的：瞭解台灣民眾擁有習慣就醫場所情形、對於與習慣就醫場所的醫師之間醫病關係的經驗評價以及這些民眾的特性，並且探討習慣就醫場所、醫病關係與醫師轉診行為間的關係，以瞭解在沒有實質家庭醫師之下，民眾是否有可能透過與習慣就醫場所建立長期良好醫病關係而使醫師願意積極協助病人轉診。 研究方法：使用「民眾就醫經驗調查」面訪問卷資料，調查期間2018年11月至2019年1月，屬一橫斷性研究。研究對象針對具有我國國籍以及在台灣本島設有戶籍的60歲以上民眾，瞭解民眾在過去12個月內的西醫就醫經驗感受。研究分析方面，使用符合研究目的之問卷題項，並檢視各變項間的相關性，主要研究變相包括習慣就醫場所、醫病關係、醫師轉診行為。 研究結果：本研究發現，台灣60歲以上的民眾有89.53%擁有習慣就醫場所，且整體民眾自評與醫師醫病關係程度平均總分為17.68分(滿分為21分)，另外22.13%民眾表示過去12個月內曾經接受過醫師的轉診行為。經過分析結果發現，有無習慣就醫場所與是否醫師轉診行為之間沒有顯著相關，不過，民眾與醫師的醫病關係與是否接受醫師轉診行為有顯著正相關。 結論：眾多具有家庭醫師制度的西方國家限制民眾就醫時必須優先至一名固定的家庭醫師看診，並由該醫師視病人病情需要進行轉診，而此單一家庭醫師制度的概念並不適用於台灣醫療體制。因此，本研究建議，以民眾為核心，並從民眾之多個習慣就醫場所介入，鼓勵民眾與習慣就醫場所建立長期良好的醫病關係，也許能夠促使醫師提高替民眾把關醫療資源利用的積極程度。

Background: Compare to the western countries, Taiwan does not have a family doctor’s role that can provide general medicine and gate-keeping service. Therefore, not only does it make patients seek health care at any level easily but also contribute to the phenomenon of self-referral, readmission and so on. Moreover, this is one of the reasons why the referral system in Taiwan has not been effectively implemented for a long time. However, when Taiwan is facing the challenge of the aging crisis, the utilization of healthcare resources becomes an important factor in the development of the healthcare system in the future. As a result, the concept of referral in Taiwan needs to be confirmed again. Objective: First, this study was to understand whether Taiwanese have usual source of care, how well is the relationship between patient and doctor, and the characteristics of these people. Then, we will explore whether having usual source of care or great doctor-patient relationship is related to the referral behavior from the doctor. Last, the purpose of this study was to investigate that without a family physician system in Taiwan, whether it is possible to the doctor willing to make a referral decision for patients through having a solid long-term relationship with patients. Methods: Using the nationwide face-to-face survey data obtained from the “Patient Health Care Experience Survey” from November 2018 to January 2019. The research was aim at understanding the experience of a patient who has visited a western medicine in the past 12 months, and the research subjects are people 60 years of age or older who have the nationality of Tawan and household registration on the shore of Taiwan as well(N=2144). In terms of research analysis, this study used some items of the questionnaire that meet the purpose of the research and examining the correlation between those variables including major research variables usual source of care, doctor-patient relationship, physician referral behavior, and the rest control variables. Results: We found that 89.53% of the population over 60 years old in Taiwan has usual places of care, and the overall self-rated doctor-patient relationship score was 17.68 on average (total score was 21). We also found there were 22.13% of patients indicate a referral experience in usual places of care in the past twelve months. After the statistical analysis, this study found that there was no significant correlation between whether people have usual places of care and doctor referral decision, and there was a significant positive correlation between doctor-patient relationship and doctor referral decision. Conclusion: In many western countries, the concept of the family medicine requires to seek their family doctor before being referred to the specialists may not fit for the healthcare system in Taiwan. As a result, this study suggests that encouraging people to build a good long-term relationship with usual source of care may be a feasible strategy to increase doctor’s willingness to make a referral decision for patients.