急性醫院入院適當性工具AEP於國內應用之初探

An Exploratory Study of AEP on Acute Hospital Admission Appropriateness in Taiwan

溫信財(Hsyien-Chia Wen) ； 陳傑峰(Chieh-Feng Chen) ； 季瑋珠(Wei-Chu Chie) ； 高森永(Sen-Yeong Kao)

《台灣公共衛生雜誌》 24卷2期 (2005/04) Pp. 103-113

https://doi.org/10.6288/TJPH2005-24-02-02

摘要

健保局為持續改善醫療品質，在民國85-92年間，針對不同層級醫院之一般病床給付，逐漸調漲34.4-40.5%，可是醫療機構在醫療審查執行是否適當上，與保險人間仍有相當大的爭議，醫界對未建立共同審查指標迭有抱怨，認為事後醫療審查在無明確基準下，嚴重損害醫院權益，故建議應制訂入院審核標準。
國內有關醫療適當性之研究或報導，多數集中在醫療服務上，但有關醫療場所適當性的研究則不多見。由於Appropriateness Evaluation Protocol(AEP)的信度、效度受到肯定，且具有允許公用(public domain)，不受智慧財產困擾之特性，故常被國際研究做為入院適當性判定工具，因此本文除將之與其他工具比較外，並針對其特性做較詳細的介紹。雖然國際間對AEP多所肯定，但各國之實證研究亦發現：不同國家在採用AEP時均會考慮原基準是否適用於國內，而無論以前瞻或回溯性方式執行住院適當性判定、病歷是否做為審查之唯一依據等問題，均為影響住院適當性判定之相關變項。
全民健保現在雖改變以總額方式來支付醫院，但若無客觀明確之基準做為病人應否住院的依據，在醫院間無一協調機制運作下，醫院為維持原有之醫療收入，仍將多提供醫療服務，今人擔憂其結果將與論量計酬制度相同，因此本文相信發展適用國內之判定工具，將有助於醫療資源的有效運用並減少醫院及保險人間之爭議。

關鍵字

入院適當性 ； 住院適當性評估表 ； 總額支付制度

並列摘要

The Bureau of NHI (BNHI) raised acute bed reimbursement by 34.4-40.5% during 1996-2003 at different levels of hospitals in order to improve quality of care. However, many hospitals were still unsatisfied with the results of the medical review, they complained that the retrospective review which did not include explicit criteria damaged their rights. Therefore, developing admission criteria is of urgent importanct in Taiwan.
Articles or reports regarding medical care appropriateness have focused on medical services. Few have focused on medical setting of Taiwan. An international review criteria ”Appropriateness Evaluation Protocol (AEP)”, which is a reliable, valid and public-domain tool will be introduced in more detail in this paper and compared with other admission instruments. Although AEP has been endorsed by the studies of many other countries, the criteria of the admission is adjusted in the different countries because of physician differing practice styles and available resources. It also needs a further study to find out those variables that will influence the admission decision, such as whether medical records are the only information source, the difference between reviewed by the retrospective and prospective method etc.
Although the global budget payment system was recently adopted by BNHI, there are still no explicit criteria to assess the appropriateness of admission now. If there is no effective mechanism to negotiate between hospitals, over-utilization will be occured in the same way as with previous fee-for-service payment. Therefore, a Taiwanese- version admission criteria needs to be developed in order to provide more efficiently care and resolve the disputes between hospitals and BNHI.

並列關鍵字

Admission appropriateness ； Appropriateness Evaluation Protocol (AEP) ； Global budget

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