探討骨科醫師對醫療品質資訊公開之看法與影響醫療行為意向改變之研究-以人工膝關節置換手術品質報告卡為例

Abstract

背景與目的：由於醫療具有高度專業特殊性，故醫療服務提供者與醫療服務接受者之間向來存有專業資訊不對等之問題，而過去被歐美國家健康照護體系所採用已有十年以上的歷史的品質報告卡政策，即為希望藉此提供民眾有能力選擇與瞭解醫療服務提供者的相關訊息，並同時促進醫療服務提供者改善其醫療照護之品質；但品質報告卡的公開後對醫療照護提供者或消費者所造成的影響研究，至今仍呈現不一致現象，甚至有相關研究指出，反而導致潛在非預期與負面的結果產生。而行政院衛生署於2008年4月25日公佈國內人工膝關節置換手術品質報告卡，因此本研究目的為瞭解骨科醫師對此項政策的看法，以及認為品質報告卡可提昇醫療照護行為意向之原因，以冀研究結果能減低非預期效益行為之發生。 方法：本研究採用調查研究法，以郵寄結構式問卷方式蒐集所需之資料。並藉由發送正式公文方式徵詢於97上半年度人工膝關節置換手術品質報告卡內之醫療院所的參與意願後，選擇同意施測醫院之骨科醫師為本研究對象。研究期間為2009年4月29日至6月29日止，共寄出66家醫院，373份，回收有效問卷60家醫院，176份，回收率為47.2%。 結果：低於50%以下之骨科醫師在施測前已知道、已看過、或已瞭解品質報告卡之內容，並顯著存在於工作層級較高之醫院、且能決定醫院整體醫療決策者；於品質報告卡內之數值結果表現較差的醫院，越顯著表示數值是錯誤的；52%醫師贊成公佈此項資訊；67%認為所公佈的三項指標可評估人工膝關節置換手術之照護品質，但應再納入其他更重要的指標用以全面性評估醫療照護情況；58%會因為品質報告卡而導致盡量避免替高風險病患進行手術，以及69%擔心各家醫院之醫師會為了讓數據好看而操弄數據。經利用結構方程模式分析發現，若要使醫師會因為品質報告卡而提昇對病患的醫療照護行為意向，必須先使醫師內心產生會因為品質報告卡而改變醫療照護行為的傾向態度，但要使其行為傾向態度提昇，首要條件為公佈醫師認為可用以評估醫療照護品質的指標。 結論：受訪醫師大多不知道品質報告卡政策已推行，衛生主管機關應加強政策之宣導頻率，並重新考量指標數值計算的公平性，以及與骨科醫師協商可全面評估人工膝關節置換手術照護品質之指標。如此不但可使醫師提昇使用品質報告卡的頻率，並可增加醫師會因為品質報告卡而提昇醫療照護行為之傾向態度，進而實際提昇整體醫療照護之品質。

Background and Objectives: Report cards have been adopted by the US health care system for more than 10 years. The publication of report cards is intended to inform consumer’s choice on providers and to improve quality of medical care delivered by providers. Despite these plausible mechanisms of quality improvement, the value of publicly reporting quality information is largely undemonstrated and public reporting may have unintended and negative consequences on health care. In Taiwan, the total knee replacement (TKR) report card has been disclosed by Department of Health on April 25, 2008. The purpose of this study was to explore factors of the opinions on TKR report card and its behavioral intention influence by orthopedic surgeons. Methods: This study used survey research and structured questionnaire were mailed out to collect data during April 29 ~ June 29, 2009. A total of 176 questionnaires were returned, yielding was 47.2% response rate. Result: Less than 50% of the orthopedic surgeons were aware of the TKR report card, and obviously existed in the people who have played medical decision role in hospital. The performance in the report card were worse, the more significant express this data were incorrect.52% of orthopedic surgeons were willing to publish this information, 67% thought these three indicators could be used to evaluate TKR health care quality, 58% reported that they were less willing to operate surgery on high risk patients, and 69% worried that other physicians might improve TKR report card’s performance by gaming technique. The structural equation modeling analysis showed that indicators which are approved to evaluate TKR health care quality by orthopedic surgeons would improve health care attitude toward behavior, and induce to improve health care behavioral intention. Conclusions: Fewer orthopedic surgeons were aware of the TKR report card policy has been published, we suggest that the health authority might strengthen frequency of policy guidance. To rethink risk adjustment method might inadequate to compare surgery fairly, and to enhance the usefulness of the reports, indicators which approved to evaluate TKR health care quality by orthopedic surgeons should be added.