使用不同類型長期照顧服務之失智長者的醫療服務利用之比較

Abstract

研究背景與目的： 全球人口老化的同時，失智人口大幅上升，影響的不僅是失智者本身的生活，也連帶影響失智者的周遭親友及照顧者。由於現階段尚無得以治癒失智者的藥物，因此藉由長期照顧服務來維持失智者的身心功能是目前照顧者的首要目標。由於失智人口預計會持續大量增加，不但會增加照顧體系的負擔，也會增加醫療體系的負擔，因此不同長期照顧服務對於醫療體系的影響值得進一步探討。本研究旨在比較使用不同類型的長期照顧服務，對於失智者後續之醫療服務利用情形的差異。 研究方法： 本研究串聯衛生福利部之衛生福利資料科學中心資料及照顧服務管理資訊平臺，篩選2010年至2013年間曾予核定長期照顧服務之24,969位失智長者，依照其使用之長期照顧服務類型分為三組失智者，分別為居家社區組（21,772人)、機構組（511人)及其它輔助組（2,686人)。本研究以安德森行為模式理論（Andersen’s Behavioral Model）作為研究變項挑選之依據，其中傾向因素包括性別、年齡、是否獨居、是否有配偶及是否為原住民，使能因素包括是否有主要照顧者及福利身份別，需要因素包括共病症指數、憂鬱情況總分、是否有聽力損傷、行為問題分數、失智程度、失能程度、BADL分數及IADL分數。最後，本研究以羅吉斯迴歸及複迴歸分析其核定服務後一年內門診、急診與住院使用情形，及醫療服務總費用。 研究結果： 整體而言，控制社會人口學變項後，相較於使用其它輔助類長期照顧服務的失智長者，使用居家或社區式長期照顧服務的失智長者，其後續的門診使用次數（= -2.511, p <.0001）及累積門診費用（= -6,940.985, p <.0001）較低，在統計上達顯著水準；相較於使用其它輔助類長期照顧服務的失智長者，使用機構式長期照顧服務的失智長者，其後續的急診（OR=1.492, p <.0001）及住院（OR= 2.218, p <.0001）風險較高，且每次急診費用（= 639.145, p < 0.01）、住院使用次數（= 0.592, p <.0001）、每次住院費用（= 22446, p <.0001）、每次住院天數（= 2.675, p <.0001）及累積住院天數（= 7.069, p <.0001）較高，在統計上達顯著水準。 結論與建議： 本研究發現，相較於使用其它輔助類型長期照顧服務，使用居家式或社區式長期照顧服務的失智長者，其後續使用較少的門診服務，代表使用居家式或社區式長期照顧服務，對於失智長者後續的醫療服務利用情形有正面的影響，未來研究可以針對居家式或社區式長期照顧服務的項目、頻率與次數，探討對於社區中失智長者有最佳效益的服務組合。使用機構式長期照顧服務的失智長者，其後續使用較多的急診及住院服務，代表機構式長期照顧服務似乎不能滿足我國失智長者的照護需求，或是在照護過程中沒有注意到機構內失智長者的照護需求，導致其後續的醫療服務利用情形較高，未來政策應針對機構式長期照顧服務進行改善，而未來研究可以針對機構內失智長者，探討其照護需求及未滿足需求。

Background As population aging, dementia population is simultaneously rising. Dementia has an impact not only on patients themselves, but also on their caregivers and family. Since there is no cure for dementia, it is crutial to develop long-term care systems for maintaining physical and mental health of patients with dementia. Demented population is expected to fast increase in the next couple decades, which may not only add burden to the social care system but also to the medical care systems. Whether different social care serivces may be associated with different health care service usage and costs merited further examination. This study aims to compare the difference of medical services usage of older adults with dementia using different types of long-term care services offered by the Ten-Year Long-Term Care Program (TLTCP). Methods Data was extracted from National Health Insurance Program (NHIP) Database and Long-Term Care Service Management System, which was derived from the TLTCP. Individuals who were approved services in Long-Term Care Service Management System between 2010 and 2013 were included in this study (N=24,969). Participants were divided into three groups, home/community group (n=21,772), supplementary group (n=2,686), and facility group (n=511). The previous two groups were based on their first service prescription records in the TLTCP, and the last group was based on their status of institutional care serivces use in NHIP database. Andersen’s Health Behavioral Model served as a guild for variable selection. For predisposing factors, the current study included gender, age, living situation, marriage status, and race; for enableing factors, included with or without main carer, and economic status; for need factors, included comorbidity, depression, hearing impairment, behavioral problems, dementia severity, disability, BADL, and IADL. Logistic regression and multiple linear regression were conducted to examine participants’ 12-month healthcare utilization of outpatient, emgenrcy, and hospitalization, and total medical expenditure. Results With predisposing, enabling, and need factors controled, compared with older adults who used supplementary long-term care services, those using home care or community-based long term care services have statistically significant lower outpatient visits (= -2.511, p <.0001) and fees (= -6,940.985, p <.0001). Compared with older adults who used supplementary long-term care services, those using long-term care facility have statistically significant higher risks of emergency (OR=1.492, p<.0001) and hospitalizztion (OR= 2.218, p<.0001) usage, and statistically significant higher per emergemcy fees (= 639.145, p < 0.01), hospitalization visits (= 0.592, p <.0001), per hospitalization fees (= 22446, p <.0001), per hospitalization days (= 2.675, p <.0001), and hospitalization days (= 7.069, p <.0001). Conclusion The present study showed that older adults with dementia used home care or community-based long-term care services has less medical services usage, whereas those using institutional care services have more health care serivce use and costs. Although institutional care included regular physicain visits every month, the institutional care group did not only show more emergency room and hospitalization visits, but also more health care fees. Our findings indicated the importance of promoting institutional care to better meet dementia older adults’ care needs. Future research could focus on the frequency, items, and combination of home care and community-based long-term care services for older adults with dementia.