醫療群與非醫療群病人對基層醫療照護品質與家醫計畫之評價---階層線性模式之應用

The Evaluation toward Primary Care Quality and Family Physician Project between Patients in Family Physician Groups and Non-Family Physician Groups-- An Application of Hierarchical Linear Modeling

葉德豐(Te-Feng Yeh)

指導教授 ： 楊銘欽

國立臺灣大學/公共衛生學院/醫療機構管理研究所/博士(2008年)

https://doi.org/10.6342/NTU.2008.02582

摘要

背景：良好的基層醫療照護有助於降低醫療照護成本，並可改善健康狀態以及降低民眾健康的不平等；台灣在實施全民健康保險後，由於民眾不良的就醫習慣與健保給付約束及限制使得基層院所日趨萎縮，整體醫療體系呈現倒金字塔現象。而家醫計畫自2003年實施以來，儘管已有部分研究針對家醫計畫本身的成效進行探討，但是普遍缺乏理論性依據，民眾期待何種的基層醫療照護品質亦未見探討。
目的：探討我國民眾對基層醫療照護品質之期望、實際感受與缺口，以及對目前實施之家醫計畫的評價，並以階層線性模式探討個體層次（病人）與群體層次（醫師）的影響。
方法：本研究以2006年4月中央健康保險局網站上公告之醫療群（294群）以及其他健保特約基層醫療機構為母群體。分別自醫療群與非醫療群診所各抽取50群共4753位病人與100位醫師。以Primary Care Assessment Tool-Adult Edition (PCAT-AE)為藍本、以SRVQUL精神發展一套評估我國基層醫療照護品質的工具，以自填式問卷調查病人對基層醫療照護品質與家醫計畫的評價。由於本研究從一位醫師抽取多位病人，其資料屬於巢狀結構，本研究採用階層線性模式分析，同時探討病人（個體）層次與醫師層次（群體）的影響。
結果：病人對於基層醫師的期望仍傾向傳統的「醫治者」，對於協調轉診、健康諮詢與預防保健則較不重視；醫療群中之家戶會員對基層醫療照護品質以及家醫計畫的評價最高，非醫療群病人則最低；病人基層醫療品質知覺會影響其對家醫計畫的政策評價，進而影響病人參與家戶會員與指定固定就診醫師的意願，但卻是影響病人整體醫療服務滿意度最重要的因素；醫師個人特性與醫師在基層醫療照護品質與家醫計畫評價對其病人之基層醫療照護品質與家醫計畫評價的影響力有限，在複迴歸模式呈現顯著差異之變項在階層線性模式大多呈現不顯著。
結論：病人與醫師對家醫計畫的評價均為正面，因此衛生主管機關應持續推動家醫計畫；並且加強對民眾的教育與誘因，鼓勵民眾尋求固定就診的基層醫師使基層醫師在協調性與周全性的功能有所提升；並給予辦理醫療群成效卓著診所額外的激勵；對基層醫師而言，提升基層醫療照護品質才是增加病人滿意度與提升基層院所競爭力最重要的成功關鍵。

關鍵字

基層醫療照護品質 ； 家庭醫師 ； 家醫計畫 ； SERVQUAL ； 階層線性模式

並列摘要

Background: Excellent primary care can reduce health care expenditure, improve health status, and diminish health inequity. Since the implementation of National Health Insurance, primary care has been going down the slope resulting from inappropriate care-seeking behavior and the restriction of payment systems. Although there were some studies that evaluated the effect of family physician project since its implementation in 2003. However, there still lack of an evaluation tool to understand what type of primary care patients want.
Objective: This study aimed to explore the expectation, perception, and gap of primary care quality, and to evaluate the family physician project. It also examined the influence of individual level and group level simultaneous by using hierarchical linear modeling (HLM).
Methods: This study selected 50 family physician groups and 50 non-family physician groups from the webpage of the Bureau of National Health Insurance (BNHI) as of April, 2006. Totally 4753 patients and 100 physicians were selected for interview. Primary care quality tool was based on Primary Care Assessment Tool-Adult Edition (PCAT-AE) and modified by the concept of SERVQUAL. Self-administrated questionnaire included the evaluation of primary care quality and family physician project. Because of the nested structure of the study sample, hierarchical linear modeling was used.
Results: Patients expected their primary care physicians to be the traditional “healer”, coordinator of care, health consultant, but prevention services were less expected. The perception of primary care quality and the evaluation of family physician project were the highest among the enrollees in family physician groups and the lowest among patients in non-family physician groups. The relationship between the perception of primary care quality and the intent of enroll in and designate the usual care physician was moderated by the policy evaluation of family physician project. But the perception of primary care quality was the most significant factor for patient satisfaction. Physicians’ demographic characteristics and their evaluation of primary care quality and family physician project were less relative to their patients’ evaluation of primary care quality and family physician project. Many of the variables showed significant association in the multiple regression became non-significant in hierarchical linear models.
Conclusion: Both patients and physicians showed positive evaluation for family physician project; the health authority should promote this project continuously. Patients should be educated and give incentive to seek their usual care physician for the coordination and comprehensiveness of care. Well-performed physicians should receive additional incentive. For primary care physicians, enhance the primary care quality is the key success factor for improving patient satisfaction and the competitive competence of primary care.

並列關鍵字

primary care quality ； fmaily physician ； family physician project ； SERVQUAL ； hierarchical linear modeling

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