醫療專業人員與一般民眾在就醫機構層級選擇上的差異 ─以七種手術處置為例

The type of medical care institution selection of the case of seven surgeries among medical staffs and general adults

林雨亭(Yu-Ting Lin)

指導教授 ： 郭年真

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2018年)

https://doi.org/10.6342/NTU201800109

摘要

研究背景：醫療機構必須根據專業分工，才能讓整體的醫療資源利用更有效率。臺灣目前將醫療體系分為醫學中心、區域醫院、地區（社區）醫院及基層院所等四個層級，但在全民健保制度下並未限制患者的就醫地點，故病患可能前往各個不同層級的院所接受醫療照護，導致分級醫療難以落實。過去文獻指出醫療供給面及需求面特性皆會影響民眾的就醫選擇，而醫事人員身為健康照護體系中的知情消費者 (informed consumer) ，其醫療利用及就醫選擇亦與一般民眾的型態不同。但是，究竟醫療專業知識背景的差異是否會影響接受一般手術之患者在就醫院所層級別的選擇與背後的原因為何？目前尚未有學者以國家級資料針對此類議題做探討，故本研究希望能藉此了解臺灣目前不同病患族群的醫療選擇現況以及探討可能之醫療品質因素。

研究目的：本研究以七項臨床上常見之手術處置為例，探討不同身分別患者與一般民眾在接受手術處置之院所層級別，以及醫療選擇與照護品質結果的關係，最後是執業地點與就醫選擇院所層級別的關係。

研究方法：本研究採回溯型研究法，以全民健保資料庫中的承保檔、醫事人員檔與健保門、住診申報資料，分析並比較醫護人員及其眷屬在生產 (labor) 、闌尾炎切除術 (Appendectomy) 、痔瘡手術 (Hemorrhoids surgery) 、疝氣手術 (Hernia surgery) 、白內障手術 (Cataract surgery) 、(股)膝關節置換術 (THR,TKR) 及尿路結石體外震波碎石術 (Extracorporeal shock wave lithotripsy, ESWL) 等七項門、住診常見手術處置就醫選擇的差異，以及探討不同就醫院所層級與離院後3日、14日內發生再急診或再住院之情形是否相關。

研究結果：本研究共納入217,514筆案件進行分析，結果發現病患本身或其眷屬為醫療專業人員的個案，擇醫學中心就醫的比例最高 （33.3% ~72.0%） ，約為一般民眾的1.78~5.66倍。出院後發生3日、14日內再急診或再住院的機率則無顯著差異。最後，本研究也發現病患本身或眷屬為醫療專業人員，多選擇與自己執業之機構層級相同或更高之醫事機構就醫。
結論與建議：綜上而言，病患本身為或眷屬為醫療專業人員，對高層級別的醫事機構選擇有較大的偏好，且在不同的手術處置類別有些許的差異，而瞭解醫療專業人員與一般民眾偏好至大型醫療機構的原因，有助於改善分級醫療推動的困難。

關鍵字

知情消費者 ； 影響就醫選擇因素 ； 醫事機構特約類別 ； 醫療品質 ； 執業地點

並列摘要

Background: The medical care institution depends on a hierarchical division of labor to allow for an efficient utilization of medical resources. Taiwan’s medical care institutions are currently categorized and ranked into four levels: medical centers, regional hospitals, community hospitals, and physician clinics. However, the current National Health Insurance system does not restrict patients to any one type of medical institution for the care they seek. Patients are thus able to go to any one of these four types of medical institutions to receive medical care. This has inhibited the hierarchical structure of the medical care institution from realizing its intended purpose. Research literature has pointed out that both the supply for and demand of medical treatment affect how patients choose where they receive medical treatment. Medical professionals are considered to be “informed consumers” in the medical care system and approach medical care differently from members of the general public. This study investigates whether being more “informed” about medical care affects how patients, specifically general surgery patients, choose medical care institutions, and looks into the reasons driving that choice. Currently, no scholars in Taiwan have utilized national registry data to investigate this issue. Thus, this study aims to use such data to better understand how patients in Taiwan decide where to receive medical care, and also delve into the quality of care as a possible factor affecting such a decision.
Objectives: This study looks at seven clinical common surgeries to investigate the surgery patient’s identity and the type of medical care institution in the hierarchy that is chosen for the surgical procedure to be done. The study also investigates the relationship between the type of medical care institution chosen by the patient and the resulting quality of care. Lastly, the study investigates the relationship between the surgery patient’s place of work and the type of medical care institution chosen by the patient.
Methods: This is a retrospective study that utilizes the registry of NHI beneficiaries, the registry of medical professionals, and data from medical insurance claims filed by patients to analyze and compare the type of medical care institution chosen by medical professionals, who are patients themselves, or their relatives to receive care for the following seven procedures: labor, appendectomy, hemorrhoids surgery, hernia surgery, cataract surgery, THR, TKR and extracorporeal shock wave lithotripsy (ESWL). The researcher has also tracked emergency department revisits and hospital readmissions that have occurred in 3 or 14 days after the patient has been discharged from the hospital, and investigated whether these revisits and readmissions are related to the type of hospital chosen.
Results: This researcher collected and analyzed a total of 217,514 files. The results of the analysis showed that patients who chose medical centers are highest among medical professionals or their relatives (33.3% to 72.0%). This percentage is 1.78 to 5.66 times higher than patients who are not themselves nor relatives of medical professionals. Instances of revisits to the emergency department occurring in 3 days and hospital readmissions after being discharged in 14 days showed no significance differences between these two groups. Lastly, the analysis showed that medical professionals or their relatives tended to choose medical care institutions that were equal to or above the level of the medical care institution at which they worked.
Conclusion and recommendations: The results of the study showed a preference for higher level medical care institutions among medical professionals as patients or their relatives. Depending on the type of surgical procedure being performed, the type of medical care institution chosen may also have differed. All in all, understanding the reasons behind why patients who are medical professionals and general patients have a preferential bias for larger medical institutions will contribute to improving the effectiveness of a hierarchical division of hospitals.

並列關鍵字

informed consumer ； factors affecting choice of medical care ； contracted medical care ； quality of medical treatment ； place of work

參考文獻

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