- 學位論文
血液透析病人多科別偕同照護模式之初探
Exploration of a multi-speciality coordinated care model in HD patient
摘要
背景：血液透析病患族群有高齡、多重共病症與多重併發症之特徵，在科別診察十分棘手。為了提高照護品質、降低醫療成本，世界各國提出跨科別偕同照護的方法，但臺灣尚未有針對透析病人的跨科別照護模式。 目的：探討臺灣血液透析病人於醫療科別的需求與利用情形，期許能發展臺灣本土化之跨科別協同照護模式。 方法：本研究為橫斷性混合研究，研究對象包括血液透析病人與臨床醫師。質性研究為立意取樣之個人深度訪談，招募有血液透析病人照護經驗醫師共6名，瞭解以醫師觀點的血液透析病人臨床常見狀況、照護所需合作科別及科別偕同照護困難；量性研究使用2015年臺灣全民健保資料庫，研究樣本為持續12個月的血液透析病人，分析變項為血液透析病人的科別使用次數；資料探勘關聯分析採Apriori演算法，資料集之分組基線為月份和是否有糖尿病，分析目標為時間單位每位病患之就醫科別項目集，藉以瞭解以病人為觀點的科別就醫潛在關聯情形。 結果：符合篩選條件共49,995名血液透析病患有24,500(49.0%)名女性、21,097(42.2%)名患有糖尿病、26,281(52.6%)患有高血壓、加權共病症指數中位數(標準差)為4.0 (1.9)。在看診次數一年累計描述性統計結果，內科(17.4%)、腎臟內科(17.0%)、心臟內科(7.6%)、眼科(6.55%)、家醫科(4.72%)使用大於其他科別；關聯分析每三個月的結果下，內科(43.8%)、腎臟內科(42.5%)、心臟內科(28.6%)、眼科(26.1%)、急診(19.4%)、家醫科(16.2%)之關聯規則遠大於其他科別。對醫師訪談結果進行質性分析，獲得以醫師為觀點的照護所需醫療科別為心臟內科(83.3%)、心臟外科(83.3%)、神經科(66.7%)、腸胃內科(50.0%)、骨科(33.3%)、內分泌科(33.3%)、外科(33.3%)；照護所需之非醫療科別為營養師(66.7%)與復健師(66.7%)。在如何達成科別照護模式的訪談部分，目前遇到的困難為基層診所難以經營以及轉診病患資料零散，在照護改善則為機構層級的轉診合作與溝通平台建立。 結論：不論是以病人常見就診觀點或是以醫師的臨床照護觀點，心臟內科、外科系統、全科醫師皆佔有重要的地位。基層醫生在科別轉診上所遇到的困難，可能會間接影響病人的急診使用情形。政府應特別顧及基層透析診所在科別偕同照護模式的建立與需求。
並列摘要
Background: The hemodialysis(HD) patients are characterized by advanced aged, multi-comorbidities and complications, which is hard to care of. In order to improve the care quality and reduce the cost, the multi-disciplines care model has been pronounced around the world, but there are not in Taiwan, especially on ESRD patients. Objective: To explore the needs and utilization of hemodialysis patients, and hope to develop a localized multi-speciality coordinated care model in Taiwan. Methods: This study was a cross-sectional study, using mixed method to explore of hemodialysis patients and physicians. The qualitative research was an individual in-depth interview, included 6 physicians who have caring experience of hemodialysis patients. The quantitative research used the National Health Insurance Database of Taiwan in 2015, the study sample was designed who had been on hemodialysis for 12 months, and the analysis variables were the numbesr of specialities’ visits. The data mining part, adopted association analysis by the Apriori algorithm. The grouping baseline of the data set were month unit and diabetes, and the analysis target was the large itemsets of the specialities’ visits under the time period per patients. Results: The 49,995 hemodialysis patients were enrolled and included 24,500 (49.0%) women, 21,097 (42.2%) had diabetes, 26,281 (52.6%) had hypertension, and the median (SD) weighted CCI was 4.0 (1.9). According to the results of the specialities’ visit a year, the rank was General Medicine (17.4%), Nephrology (17.0%), Cardiology (7.6%), Ophthalmology (6.55%), and Family Medicine (4.72%). The results of association analysis in every three months were Internal Medicine (43.8%), Nephrology (42.5%), Cardiology (28.6%), Ophthalmology (26.1%), Emergency (19.4%), Family Medicine (16.2%). The results of qualitative method, which represents the physicians’ point of view in comprehensive care, were Cardiology (83.3%), Cardiovascular Surgery (83.3%), Neurology (66.7%), Gastroenterology (50.0%), Orthopedics (33.3%), Endocrinology (33.3%), General Surgery (33.3%). Other needed disciplinary were Dietitians (66.7%) and Rehabilitationists (66.7%). In the part of how to achieve the coordinated care model, the current difficulties were “hardly operate the dialysis clinic” and “scattered data of referral patients”; in contrast, the improvement methods refered to “developing hospital-clinic cooperated path” and “established communication platforms with physicians and patients’ caregivers”. Conclusion: Whether the patients’ records or the physicians' opinions, the important departments all refered to Cardiology, Cardiovascular Surgery and Primary care. The problems of referrals in primary-level might indirectly affect the visits of Emergency Medicine in HD patients. To build a better coordinated care model, the government should value demands of dialysis centers of clinics and further analyze the clinical uses in each department.