全民健康保險氣喘論質計酬計劃之效益評估

摘要研究背景與目的根據行政院衛生署的統計顯示氣喘的死亡率在民國91年以前一直都位居於台灣地區每年十大死亡原因之一。中央健康保險局於2001年11月開始推動「全民健康保險氣喘醫療給付改善方案試辦計劃」使醫療院所從過去的「論量計酬」看診方式轉變為「個案追蹤管理」醫療模式。目前國內欠缺就此論質計劃完整性評估，故本研究目的如下：目的一、探討P4P與Non-P4P氣喘個案醫療資源利用情形及其影響因素目的二、探討P4P與Non-P4P氣喘個案臨床指標及其影響因素的影響因素目的三、探討P4P與Non-P4P氣喘個案自我健康照護能力(PACIC)及其影響因素目的四、探討P4P與Non-P4P氣喘個案整體滿意度(PSQ-18)及其影響因素研究方法本研究在目的一為次級資料庫，採回溯性及縱貫性實驗研究設計法，資料取自南部某醫學中心2001年1月至2012年12月氣喘參與論質計酬計劃個案為研究對象，以傾向分數配對法將兩組條件一致共篩選出P4P和Non-P4P兩組分別為247人，以差異中的差異分析醫療資源使用差異。目的二至四為初級資料部份，採為前瞻性的研究設計，了解病患各項臨床指標、自我照護能力及就醫滿意度。收案期間於2013/03/25至2013/05/31止，其中P4P病患50位，Non-P4P病患43位，共93位病患。統計工具為SPSS 19.0統計軟體分析方法有獨立樣本T檢定、成對樣本T檢定、複迴歸分析、對數迴歸分析及以Stata 11.0版進行差異中之差異法分析。研究結果目的一結果，發現氣喘病患P4P組門診次數高於Non-P4P組，收案後門診次數6.1±4.98，顯著高於收案前3.2±4.48(P<0.001)，收案後門診費用2,574±955顯著高於收案前1,476±1314(P<0.001)，收案後有無急診11.1%，顯著低於收案前15.0%(P=0.007)，收案後急診次數0.13次顯著低於收案前0.21次(P=0.002)，平均總醫療費用收案後17,793±23,619顯著高於收案前8,068±12,101(P=0.008)；在P4P組與Non-P4P組前後一年差異中的差異分析中，急診費用為-229(P=0.002)、門診次數為3.55(P<0.001)、門診費用為1,355(P<0.001)、住院費用為1,375(P<0.001)及總醫療費用為9939(P<0.001)；門診次數影響因子為年齡、CCI指數、醫師服務量、有無參加P4P、加入前後及P4P與加入前後交互作用項；門診費用影響因子為年齡、CCI指數、醫師服務量、有無參加P4P、加入前後及P4P與加入前後交互作用項；有無急診影響因子為CCI指數、醫師服務量、有無參加P4P及P4P與加入前後交互作用項；急診次數影響因子為CCI指數、醫師服務量、有無參加P4P；急診費用的影響因子為性別、年齡、CCI指數、醫師服務量、有無加入P4及與P4P與加入前後交互作用項；目的二結果，發現PEF預測值影響因子為年齡、教育程度與BMI；ACT氣喘控制測驗影響因子為性別、過敏史、抽菸史；目的三結果，發現自我照護能力評估(PACIC)影響因子為教育程度、有無參加P4P、就醫滿意度(PSQ-18)；目的四結果，發現就醫滿意度(PSQ-18)影響因子為年齡與自我照護能力評估(PACIC)。討論與建議論質計酬計劃的實施對氣喘病患在有無急診與急診費用上能有效的控制，P4P組對自我照護能力提升。在參加論質計酬的就醫滿意度並無達顯著差異，但與自我照護能力互為其影響因子。可見本研究個案醫院能以視病如親的態度，關懷氣喘病患結果，顯示參加論質計酬方案是具有正向的成效，未來可將此政策擴大到其他慢性疾病照護。

關鍵字

氣喘；醫療資源利用；臨床指標；自我照護能力；就醫滿意度

並列摘要

Abstract Object According to the data from department of health, the death rate of asthma was been on the first place since 2002. Bureau of National Health Insurance had applied several disease management models and pay-for-performance (P4P) programs since 2001, and the hospitals begin to apply the “Pay for Performance” system; but the evaluation of the system is lack of completement. Purpose 1. To investigate the medical resource utilization and the influence fators in the asthma patients with or without the intervention of P4P program. 2. To incestigate the clinical indicators and incluence factors in the asthma patients with or without the intervention of P4P program. 3. To investigate the self-care ability and influence factors in the asthma patients with or without the intervention of P4P program. 4. To investigate the overall satisfaction and influence factors in the asthma patients with or without the intervention of P4P program. Methods This is a both retrospective and prospective study using primary and secondary data analysis. The cases in this study were asthma patients from a south medical center. In the first propose, the study time was dring January 2001to December 2002. The patients in P4P and non-P4P were extracted with propensity score matching (PSM). After matching with the same parameters, 594 patients were enrolled in this study (247 patients for each group). We used difference-in-difference to analyse the difference of medical resource utilization. The second purpose to fourth purpose, the study time was dring March 2013to May 2013. The total cases were 93 patients, 50 patients for P4P group and 43 patients for non-P4P group. The statistical tools in this study were the software SPSS 19.0 using independent t test, paired t test and linear regression; the STATA 11.0 software for difference in difference of generalized linear models (GLM). Results In average, P4P group had higher outpatient consultation (P4P vs. non-P4P: 6.1 vs. 3.2; p<0.001), lower outpatient expense (P4P vs. non-P4P: 2,574 vs. 1,476; p<0.001), higher percent of emergency (P4P vs. non-P4P: 15% vs. 11.1%), lower emergency consultation (P4P vs. non-P4P: 0.13 vs. 0.21 p=0.002), and lower total medical expense than non-P4P (P4P vs. non-P4P:17,793 vs. 8,068; p=0.008). The predictors of outpatient consultation, outpatient expence, emergency expence are age, CCI, physician performance, with or without intervention of P4P program; the predictors of emergency consultation are CCI, physician performance and with or without intervention of P4P program; the predictors of peak expiratory flow (PEF) are age, education and BMI; the predictors of Asthma Control Test (ACT) are age, allergy history and smoking history; the predictors of PACIC medical satisfaction are age and PACIC. Conclusion and Suggestion The emergency consultation and emergency expence were well controlled after intervention of P4P program in asthma patients. There is no different between the medical satisfaction in asthma patients with and without the intervention of P4P program. The disease management and medical resource utilization were well controlled after intervention of P4P program. It can be widely apply on other chronic disease in the future.