門診照護連續性和照護協調性測量工具發展與應用-民眾觀點

研究背景與目的：因人口老化和慢性病的增加，世界各國醫療照護體系皆面臨醫療費用快速上漲的壓力。老年人或罹患多重慢性疾病的民眾經常需要在不同的醫療場域，接受多位醫生的照護，加上醫療專科化的持續發展，多數國家的民眾普遍接受到片斷式的照護服務。過去研究希望能以照護連續性和照護協調性的介入來提高民眾照護品質與降低健康照護成本，特別是在初級照護整合上。然而，過去研究對照護結果的評估，因不同研究者對於測量概念所涵蓋面向的定義和內容不同而有所差異和不一致的情形。至今，對於照護連續性和協調性的概念，無一致和明確的概念架構和測量工具。而且針對照護連續性和照護協調性的結果評估多以單一疾病族群或特定區域內病患，或是以行政資料分析為主，在於照護連續性和照護協調性相關因素探討，則是近年來才開始有研究關注此議題，主要以病患自述”有無”照護服務困難來進行結果比較，鮮少針對照護服務面向結果進行研究。因此本研究在驗證照護連續性和照護協調性與照護結果關係之前，會先釐清照護連續性和照護協調性的概念和測量面向和測量工具內容，根據台灣照護特殊性，發展一符合台灣門診照護體系測量使用之工具(目的一)，來探討臺灣照護連續性和照護協調性與照護結果之關係(目的二)，以及瞭解照護連續性和照護協調性的相關因素(目的三)。研究方法：本研究為一橫斷性研究設計。以臺灣地區60歲以上民眾為抽樣母體，進行分層多階段等比例抽樣，以面訪的方式調查民眾過去一年西醫就醫經驗，共計有2144位民眾完成調查(回收率44.13%)。測量工具發展方面，以項目分析、競爭模型比較、驗證性因素分析產生模型和模型分析等四步驟來精簡和驗證門診照護連續性和照護協調性測量工具。接著以卡方檢定、獨立樣本T檢定、單因子變異數分析、二元邏輯斯迴歸和線性複迴歸分析，探討照護連續性和照護協調性與民眾是否經常接受缺乏整合的片斷式醫療服務和醫療照護滿意的關係，以及影響民眾感受照護連續性和照護協調性程度的相關因素。統計軟體採用SAS 9.4和Mplus14.0。研究結果：1729位民眾至少有兩位以上醫師就醫經驗。目的一測量工具發展結果，照護連續性包含三個面向：醫病長期性的關係(2題)、醫病資訊傳遞的情形(3題)、醫病人際互動的關係(4題)；照護協調性包含兩個面向：醫師間的資訊交流(3題)、醫師間的溝通與合作(3題)，共計15題。內容一致性介於0.655~0.795具有不錯信度，經過驗證分析結果顯示，各題項與面向之間以及兩構念之間，具有不錯的收斂效度和區辨效度。目的二研究結果，照護連續性與照護協調性，顯著與民眾感受片斷式照護有正向關係，而滿意度僅與照護連續性有顯著關係，與照護協調性沒有達統計上顯著。「醫病人際互動的關係」和「醫師間的溝通與合作」與民眾感受片斷式照護和滿意度有顯著正向關係。目的三研究結果家戶收入、慢性病個數和門診次數同時為民眾感受到照護連續性和照護協調性程度的相關因素。討論與建議：本研究發展之門診照護連續性與協調性評量問卷是一具有適切的信度與效度的測量工具，可做為未來評估兩構念的工具。透過提高「醫病人際互動的關係」和「醫師間的溝通與合作」來降低病患感受接受片斷式照護和提高照護滿意度。民眾健康狀態是同時是民眾感受到照護連續性和照護協調性程度的重要因素。

關鍵字

門診；照護連續性；照護協調性；測量工具；病患感受照護結果

並列摘要

Background and purpose: Because of the aging population and the increasing prevalence of chronic condition, medical care systems around the world are facing the pressure of rapid increase in medical expenses. The elderly, or the people suffering from multiple chronic condition often need to receive care from multiple doctors in different medical settings, and coupled with the development of medical specialization, these populations are vulnerable to receiving fragmented care services in most countries. Previous studies have used “care continuity” and “care coordination” to demonstration ways to improve care quality and reduce cost, especially in primary care. However, in previous studies, the two terms have been defined and measured inconsistently, leading to inconsistent results. Until now, there has no a been a consistent and clear set of definitions, conceptual frameworks and measurement tools for the concepts of care continuity and care coordination. Moreover, the evaluation of the results of care continuity and care coordination has mostly been based on a single disease group or patients in a specific area, or is based on the secondary analysis of administrative data. The discussion on factors related to care continuity and care coordination has only begun in recent years. Existing studies in this field, mainly compare the results with the patient's self-reported "yes or no" difficulty in obtaining care, and few focuses on care concepts. Before verifying the relationship between care continuity and care coordination and outcome, this study will first clarify the concepts, measurement aspects and content of the measurement tool for care continuity and care coordination. The study’s main objectives are to: (1) develop a tool that meets the needs of the Taiwan outpatient care system; (2) to explore the relationship between care continuity, care coordination and care results in Taiwan, and (3) to understand the related factors of care continuity and care coordination. Method: This study will be conducted is a cross-sectional research design. The target sample of this study is individuals age over 60 years old living in Taiwan. We stratified the sample with multi-stage sampling in equal proportions. Our survey investigated patients’ experience with Western medicine in the past year through face-to-face survey. A total of 2144 people completed the survey (recovery rate of 44.13%). To streamline and verify the measurement tools of care continuity and care coordination measurement tool development, the four steps of project analysis, competitive model comparison, confirmatory factor analysis, and model analysis were used outpatient setting. We used the Chi-square test, independent sample T test, single-factor analysis of variance, binary logistic regression and linear multiple regression analysis to explore the continuity and care coordination of care and to see whether people often receive fragmented medical services and patient satisfaction. We also examined the relationship between care satisfaction and related factors that affect the patient’s perception of care continuity and care coordination. The SAS 9.4 and Mplus14.0 were used to conduct all analyses for this study. Results：The study 1729 participants reported seeing at least two doctors with medical experience. Objective 1: Continuity of care includes three dimensions: the long-term relationship between doctor and patient (2 questions), medical information transmission between doctor and patient (3 questions), and the interpersonal relationship between doctor and patient (4 questions); Coordination of care includes two dimensions: Information exchange between doctors (3 questions), and communication and cooperation between doctors (3 questions), which amounts to a total of 15 questions. The value of Cronbach’s α for each dimension of the care continuity and care coordination ranged from 0.655~0.795 which indicated acceptable reliability. Results of confirmatory factor analysis showed that each item has good convergence validity and discrimination validity between each item and aspect and between two constructs. Objective 2 we found that: Care continuity and care coordination both have a positive relationship with patients’ perception of fragmented care, while satisfaction is only significantly related to care continuity, and is not statistically significant related to care coordination. " Interpersonal relationship between doctor and patient" and "Communication and cooperation between doctors" had a significant positive relationship with patient’s perception of fragmented care and satisfaction. Objective 3: Household income, the number of chronic conditions, and the number of outpatient visits were all significantly related to both care continuity and care coordination. Discussion and suggestions: The Outpatient Care Continuity and Coordination Assessment Questionnaire developed in this research is a comprehensive, reliable and valid measurement tool which can be applied to measure two widely discussed concepts, care continuity and care coordination. Improving the " Interpersonal relationship between doctor and patient" and " communication and cooperation between doctors " can reduce care fragmented care and increase care satisfaction. Individual’s baseline health status is also an important contributor in how patients receive care continuity and care coordination.

並列關鍵字

outpatient setting ； care continuity ； care coordination ； questionnaire ； patient perspective outcome

參考文獻

中央健康保險局. (2019). 全民健康保險家庭醫師整合性照護計畫. Retrieved from https://www.nhi.gov.tw/Content_List.aspx?n=087FF1E97BAC4AC1 topn=1E1039BE19C4DCAC upn=611E631C28979053

Google Scholar

中央健康保險署. (2013). 全民健康保險論人計酬試辦計畫. Retrieved from http://www.nhi.gov.tw/resource/Webdata/22942_4_%E5%85%AB(%E4%BA%8C)%E8%AB%96%E4%BA%BA%E8%A8%88%E9%85%AC%E8%A9%A6%E8%BE%A6%E8%A8%88%E7%95%AB-%E4%BF%AE%E8%A8%82%E7%89%88-%E7%AB%8B%E9%BA%97.pdf

Google Scholar

中央健康保險署. (2019). 醫院以病人為中心門診整合照護計畫 Retrieved from https://www.nhi.gov.tw/resource/Query/%E9%86%AB%E9%99%A2%E4%BB%A5%E7%97%85%E4%BA%BA%E7%82%BA%E4%B8%AD%E5%BF%83%E9%96%80%E8%A8%BA%E6%95%B4%E5%90%88%E7%85%A7%E8%AD%B7%E8%A8%88%E7%95%AB.pdf