可避免住院之研究─以細菌性肺炎為例

Avoidable Hospitalizations of Bacterial Pneumonia Patients in Taiwan

黃馨玉(Shin-Yu Huang)

指導教授 ： 薛亞聖

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2006年)

https://doi.org/10.6342/NTU.2006.00594

摘要

過去國內在醫療品質的管理上多著重於住院醫療品質的監控，然而影響整體醫療照護品質、醫療體系效率表現的根源卻是初級照護品質的優劣。目前可避免住院指標在國際上已廣泛的作為衡量初級照護可近性、初級照護品質的指標。有效提升初級照護的可近性及品質，可減少不必要的住院情形，進而降低醫療成本，達到對成本的控制。

研究目的：藉由次級資料分析來瞭解國內在細菌性肺炎初級照護上的表現，並進一步瞭解國內細菌性肺炎可避免住院的變化趨勢，分析「病人特質」、「醫院特質」、「環境因素」對細菌性肺炎可避免住院之影響、探討不同細菌性肺炎照護結果的門診醫療資源利用情形，以作為國內初級照護服務品質提升之依據。

研究方法：本研究資料來源為民國89、90、91等三年之全民健康保險資料庫的「門診處方及治療明細檔（CD）」、「門診處方醫令明細檔（OO）」與「住院醫療費用清單明細檔（DD）」，以門診細菌性肺炎病患為主要研究對象，並依照護結果將病患分為肺炎有住院（個案組）與肺炎無住院（對照組）二組，為一次級資料分析。

重要研究結果：
ㄧ、整體趨勢：全國細菌性肺炎可避免住院率為上升趨勢。各行政區方面，僅「新竹縣」的細菌性肺炎可避免住院率是下降的趨勢，其他縣市的細菌性肺炎可避免住院率皆為上升的趨勢。
二、病人特質：以男性、1歲以下、1-4歲、65-74歲、75歲以上、有慢性疾病、為低收入戶、無回診者的病患，發生細菌性肺炎住院的機率較高。
三、醫院特質：醫學中心與區域醫院的門診細菌性肺炎病患數佔所有門診細菌性肺炎病患的52-58%，且醫學中心、區域醫院、地區醫院的病患發生細菌性肺炎住院的機率皆較其他等級機構為高。私立醫院的病患發生細菌性肺炎住院的機率較公立機構為高。
四、環境因素：離島地區、台北縣、苗栗縣、南投縣、雲林縣、嘉義縣等行政區的門診細菌性肺炎病患發生細菌性肺炎住院的機率較其他縣市為高。「每萬人口醫師數」方面，三年結果並不一致，89年未達統計上的顯著意義，90及91年結果發現每萬人口醫師數增加，發生細菌性肺炎住院的機率增加。
五、門診醫療利用：結果顯示肺炎無住院者（對照組）在門診次數、給藥天數、抗生素給藥天數、放射線檢查比例、血液培養檢查比例、痰液培養檢查比例上大於肺炎有住院者（個案組）。就醫科別適當比例方面，肺炎無住院者（對照組）大於肺炎有住院者（個案組）之檢定結果未達到統計上的顯著差異。急診次數方面，肺炎無住院者（對照組）小於肺炎有住院者（個案組）之檢定結果未達到統計上的顯著差異。有無使用抗生素與有無因肺炎住院達統計上顯著差異。

綜合以上所述，提出以下幾點建議：
1. 利用「細菌性肺炎可避免住院」作為初級照護品質監控指標。
2. 建立完善的分級醫療制度、家醫制度與轉診制度並推廣預防保健及民眾衛教。
3. 醫療提供者面對高危險群病人時，應提高敏感度與警覺性。
4. 醫療提供者應落實實證醫學的應用與臨床治療指引遵循。

關鍵字

門診照護敏感病況 ； 可避免住院 ； 肺炎 ； 細菌性肺炎 ； 健保資料庫

並列摘要

In the past there were many hospitalized quality monitoring on medical quality management, however affects the overall medical care quality and the medical system efficiency actually is primary care performance. Avoidable hospitalization is an outcome indicator used to evaluate access to primary care and primary care quality. A reduction in unnecessary hospitalization would affect quality and access. The potential cost savings associated with reducing potentially avoidable hospitalizations are substantial.
The main purposes of this research are to : (1) understand the performance of bacterial pneumonia primary care in Taiwan ; (2) describe bacterial pneumonia admission rate trends ; (3) evaluate the impact of " patient characteristic ", " hospital characteristic" and " environmental factor " on avoidable hospitalizations of bacterial pneumonia ; and (4) evaluate the different outcome of bacterial pneumonia on primary medical utilization.
Research design: this study used claim data of National Health Insurance and Department of Health from 2000 to 2002 for analysis. This study observed the outpatients of bacteria pneumonia. It was a secondary and case-control study. The study group was the outpatients of bacterial pneumonia who were hospitalized due to bacterial pneumonia and the control group was the outpatients of bacterial pneumonia who were not hospitalized due to bacterial pneumonia.

Main findings :
1. Trends :
During 2000-2002, the national admission rate of bacterial pneumonia were increased, only " Hsin Chu County " were decreased.
2. Patient characteristic :
Rate of bacterial pneumonia admission were higher for male, the person age fewer than 4 and upper 65, the patients who have chronic disease, low income, and lack compliance.

3. Hospital characteristic :
Different hospital type and hospital ownership were impact the bacterial pneumonia admission rate. Rate of bacterial pneumonia admission were higher for hospital type in medical center and regional hospital and hospital ownership in private.
4. Environmental factor :
Rate of bacterial pneumonia admission were higher in isolated island, Taipei County, Miaoli County, Nantou County, Yunlin County, and Chiayi County. About physician supply, the results were not consistent. In 2000, the physician supply had a non-significant association with avoidable hospitalizations, but in 2001 and 2002, the physician supply had a significant association with bacterial pneumonia admission rates.
5. Ambulatory medical utilization :
The control group on ambulatory care visits, drug days, antibiotic drug days, and the proportion of radiographic examination, blood examination, and sputum examination were higher than case group. The statistical result of the proportion of appropriate medical departments and emergency visits are non-significant. About the antibiotic used is significant association with bacterial pneumonia hospitalizations.
Base on above findings, this study suggests :
1. The authority can use avoidable hospitalizations of bacterial pneumonia as an indicator to evaluate primary care quality.
2. The authority should establish a good rating of hospital, family physician system, and the system of diagnose-shifting.
3. When health care providers faced high risk groups, they should be sensitive and raise awareness.
4. Health care providers should use evidence-based medicine and follow clinical guideline.

並列關鍵字

Ambulatory care sensitive conditions ； Avoidable hospitalizations ； Pneumonia ； Bacterial pneumonia ； NHI claim data

參考文獻

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