醫院整合醫學照護對住院病人照護結果之影響：單一社區醫院之回溯性世代研究

Abstract

研究背景與目的： 隨著人口快速高齡化，多重慢性病住院病人日益增加，傳統分科照護面臨協調與效率瓶頸。醫院整合醫學科（Hospitalist）模式藉由專責醫師整合住院照護，被報告可縮短住院天數並降低醫療費用，但其對長期功能維持之效益在臺灣尚未釐清。本研究以臺北市立聯合醫院中興院區為例，檢視整合醫學科病房對臨床結果與出院後再住院追蹤到的變化之影響。 研究方法： 採回溯性世代研究，比較2018 年1月至2022 年12月首度住院於整合醫學科病房（3,629 人）與相似診斷之感染／胸腔急性病房（2,291 人）的臨床表現。透過電子病歷擷取人口學、共病指數（CCI）、BMI、入院ADL與跌倒風險等協變項。最終採完整樣本多變項迴歸，包含功能結果評估出院後一年內「ADL下降≥10分」事件。 研究結果： 調整年齡、性別、CCI、BMI、基礎 ADL、跌倒風險與教育程度後，整合醫學科病房組之院內死亡風險較對照組降低 52 % (整合組4.5%，對照組11.1%，調整後勝算比 aOR 0.48；95 % CI 0.37‑0.63)，且平均住院日數縮短 5.5 天 (β = ‑5.54；95 % CI ‑6.15~‑4.92；p < 0.001)。30 天再住院 (aOR 0.92；p = 0.59)、1 年再住院 (aOR 1.01；p = 0.94) 與 1 年死亡 (aOR 1.01；p = 0.94) 皆未達顯著差異。整合醫學科照護對「一年內 ADL 顯著衰退事件」之風險無統計影響 （次分佈危險比 sub-HR 1.14；95 % CI 0.85–1.54）。ADL 衰退的主要決定因子為年齡 ≥ 80 歲、CCI ≥ 2 及入院跌倒高風險和基礎ADL依賴。 結論： 本研究證實，採雙主治輪班與固定床數之 Hospitalist 模式可在社區醫院顯著降低院內死亡率（-52 %）並縮短住院時間（-5.5 天），呼應「救急不就窮」的核心理念，展現急性期跨科協調與病安管理的韌性效益。然而，出院後再住院率、一年生存及 ADL 功能維持並未顯著改善，顯示僅靠住院期間的專責醫師管理，以及有轉銜制度化支持，仍不足以確保長期健康結果。但整體結果仍說明以輪班論時之薪資誘因留住核心人力，展示於急性指標，是醫院整合醫學對韌性照護模式對臺灣醫療體系的顯著價值。

Background and Objectives： Population ageing in Taiwan has led to a surge of inpatients with multiple chronic conditions, highlighting coordination and efficiency limits of traditional specialty-based care. The hospitalist model—characterised by full-time physicians who coordinate all aspects of inpatient management—has been reported to shorten length of stay and reduce costs, yet its impact on long-term functional outcomes in Taiwan remains unclear. Using Taipei City Hospital Zhong-Xing Branch as a case study, we evaluated the effect of hospitalist wards on in-hospital outcomes and post-discharge trajectories, including readmission and functional decline. Methods： We conducted a retrospective cohort study comparing adult patients admitted for the first time between January 2018 and December 2022 to either hospitalist wards (n = 3,629) or diagnosis-matched infectious-disease / pulmonology acute wards (n = 2,291). Electronic medical records provided demographics, Charlson Comorbidity Index (CCI), body-mass index (BMI), admission Activities of Daily Living (ADL), and fall-risk scores. Multivariable regressions on the full sample assessed clinical outcomes; functional outcome was defined as a ≥10-point decline in Barthel Index within one year after discharge. Results： After adjusting for age, sex, CCI, BMI, baseline ADL, fall risk, and education level, hospitalist care reduced in-hospital mortality by 52 % (hospitalist 4.5 % vs. control 11.1 %; adjusted odds ratio [aOR] 0.48, 95 % CI 0.37–0.63) and shortened mean length of stay by 5.5 days (β = −5.54, 95 % CI −6.15 to −4.92; p < 0.001). No significant differences were found in 30-day readmission (aOR 0.92; p = 0.59), 1-year readmission (aOR 1.01; p = 0.94), or 1-year mortality (aOR 1.01; p = 0.94). Hospitalist care did not significantly affect the risk of marked ADL decline within one year (sub-distribution hazard ratio [sub-HR] 1.14; 95 % CI 0.85–1.54). Key determinants of ADL decline were age ≥ 80 years, CCI ≥ 2, high fall risk at admission, and baseline ADL dependence. Conclusions： A dual-attending, fixed-bed hospitalist model in a community hospital significantly lowers in-hospital mortality (−52 %) and shortens length of stay (−5.5 days), underscoring its resilience in acute-phase coordination and patient-safety management—an embodiment of delivering urgent care without pushing patients into financial hardship. However, unchanged post-discharge readmission, one-year survival, and functional maintenance indicate that inpatient-only hospitalist management, even with transitional support, is insufficient to secure long-term outcomes. Nonetheless, the findings demonstrate that scheduling-based remuneration that retains core staff and delivers measurable acute-care benefits represents substantial value of hospitalist medicine to Taiwan’s healthcare resilience.