病患慢性病個數增加與就醫選擇變化對醫療服務利用與照護結果的影響

The impact of Increased Number of Chronic Conditions and Provider Selection on Health Care Utilization and Outcome

林玥妘(Yueh-Yun Lin)

指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2016年)

https://doi.org/10.6342/NTU201600429

摘要

背景：隨著醫療科技發展，全球人口結構逐年老化與各國平均餘命增加。慢性病與多重慢性病盛行率逐年上升。衛生部門雖然提出強化家庭醫師或是醫院門診的整合性照護，但仍未有一完善的總體規劃，無法滿足國內日益增加之慢性病與多重慢性病患的醫療需求。
目的：本研究主要了解在臺灣特有的自由就醫選擇現象下，慢性病與多重慢性病患選擇到大醫院就醫是否會因為慢性病個數增加而改變，而慢性病與多重慢性病患就醫選擇的改變是否又會影響其醫療利用與照護結果。
方法：使用全民健康保險資料庫選取2006年慢性病患作為研究對象，追蹤其2006年至2011年慢性病增加情形，並以2011年就醫地點醫院占率高中低做為分組，作為就醫選擇變化的替代指標，並使用次序對數迴歸模型、對數線性迴歸模型與負二項迴歸模型進行分析。
結果：研究發現與慢性病個數無變化組相比，慢性病個數增加組的2011年慢性病患大醫院就診比率、門診次數、住院次數與可避免住院次數皆較高。與2011年慢性病患大醫院就診比率低的病患相比，2011年慢性病患大醫院就診比率高的病患的門診次數較低，而住院次數與可避免住院次數則較高。
結論：慢性病個數增加會影響慢性病與多重慢性病患的就醫選擇，而使病患有往大醫院集中的趨勢，但往大醫院就醫之病患門診照護結果未顯示較基層好。可能的原因為往大醫院就醫之病患疾病嚴重度較高。為健全臺灣慢性照護體系的發展，應將民眾慢性病個數增加的趨勢納入未來政策規劃的考量，同時也應再深入研究病患往大醫院就醫的行為。未來研究者對於往大醫院就醫病患的照護結果也應設法取得臨床資料作為疾病嚴重度之校正，並對大醫院與基層之門診照護服務結果進行比較。

關鍵字

多重慢性病 ； 慢性病個數增加 ； 就醫選擇 ； 醫療服務利用 ； 可避免住院

並列摘要

Background: Along with the development of medical technology, the world population structure is aging and the average life expectancy is also increasing. The prevalence of chronic disease and multiple chronic conditions has increased in the past decades. The Health authorities have introduced several models to promote family doctor system or integrated care in hospital outpatient departments. However, the effects seemed to be minimal and more advanced care model should be considered to meet the medical needs of the growing patients with chronic diseases and multiple chronic conditions.
Objective: This study was to understand patients’ ambulatory care choice with a high degree of freedom to access to health care provider in Taiwan. This study aimed to investigate whether the patients’ choice to visit a doctor at a big-hospital would change because of the increased number of chronic disease, and to know whether the increased number of chronic conditions and the changes in patients’ choice would affect the patients’ health care utilization and health care outcome.
Methods: Patients with one of the 4 common chronic conditions in 2006 in the National Health Insurance Research Database was selected as the objects of this study. This study tracked the changes in the number of chronic conditions in 2006-2011, and used the percentage of outpatient visits in big-hospitals as the index for the patients’ choice. This research also managed to transform the percentage into an ordinal variable as high, median and low rates. The analysis model used in this study included ordinal logistic regression model, log-linear model and negative binomial regression model.
Result: The increased number of chronic conditions resulted in a higher probability of big-hospital visits as well as a higher numbers of outpatient visits, hospital admission, and avoidable hospitalization. The higher percentage of big-hospital outpatient visits was associated with fewer outpatient visits more hospital admission and avoidable hospitalization.
Conclusion: The increased number of chronic conditions would lead to a higher probability of visiting doctors at a big-hospital as well as more outpatient visits and hospital admission. The results also showed that patient who visited doctors at a big-hospital did not receive a better outpatient service. The reason might be the lack of information and control on disease severity. In order to implement the referral system in the NHI, and to improve the Taiwan chronic care system, policy maker should take the increased number of chronic conditions into account in the future, and also study more on provider selection. As for the comparison of health care outcome among patients with different provider preference, future researchers should include clinical data to control disease severity.

並列關鍵字

Multiple Chronic Conditions ； Increased Number of Chronic Conditions ； Provider Selection ； Health Care Utilization ； Avoidable Hospitalizations

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