反覆使用急診病患特徵及醫療資源使用之現況

研究背景：根據系統性文獻回顧，急診病患中約有8%為反覆使用急診者，且其就診次數佔全部就診的四分之一。病患反覆使用急診醫療的結果，不僅增加急診資源使用、降低醫療品質與效率之外，另一方面也是病患慢性病復發或持續性照護問題的警訊，目前反覆使用急診者的研究集中於歐美急診醫療的研究，反觀臺灣缺乏對反覆使用急診病患進行探討，因此期能藉由此次的研究了解國內反覆使用急診者之現況。研究目的：探討反覆使用急診病患占全年急診就醫之比例，中重度反覆使用急診者於人口學、疾病屬性、就診特性與醫療資源使用之現況，以及四次急診就醫於就醫主訴、就診後以及急診醫療資源使用之變化。研究方法: 採方便取樣於臺北市某醫學中心急診進行收案，選取2017年1月1日起至2017年12月31日止，所有成年病患皆納入為研究對象。使用醫院醫療整合資料庫，以回溯性暨縱貫性研究設計，採用文獻定義反覆使用急診者為一年內使用急診大於四次者，收集病患人口學屬性、疾病與醫療屬性及急診及其他醫療資源使用現況，以及四次就診的變化。研究結果：一、本研究一年急診成人總人數為61,057人，其總就診次數為85,702，其中被列為反覆使用者有2,191人、佔總人數3.59%，其就診總次數為12,166人次，亦即3.59%的反覆使用急診者，佔總就診次數14.20%。反覆使用者有多重慢性疾病，多數患有糖尿病及高血壓，其中患有癌症高達55.1%、多數持有疾病重大傷病卡。二、以邏輯迴歸模式（Logistic regression）分析，結果發現平均年齡高於65歲的病患成為重度使用急診者的機率為平均年齡低於65歲病患的0.539倍；有食物過敏之病患成為重度使用急診者的機率為沒有食物過敏之病患的1.678倍；低收入戶之病患成為重度使用急診者的機率為非低收入戶之病患的3.387倍；去年使用不同科別門診次數較多者成為重度使用急診者的機率為使用門診次數較少者的1.013倍；過去病史方面，有精神疾患者成為重度使用急診者的機率為沒有精神疾患者的1.885倍；有肝硬化者成為重度使用急診者的機率為無肝硬化的2.292倍；有貧血者成為重度使用急診者的機率為無貧血者的1.666倍。概化估計方程式（Generalized Estimating Equation, GEE）分析發現重度組於四次就診中，有發燒症狀較中度組少，具有顯著差異，機率為0.66倍（β= -0.41, S.E.=0.18, p=0.02）。於四次就診中被列高緊急病患狀況（檢傷為一二級），重度組被列為高緊急病患較中度組少（β= -0.329, S.E.=0.15, p=0.024），機率為0.72倍。無論是中或重度組於四次就診中，隨著就診次數增加，經由救護車運送、疼痛症狀、被列高緊急病患狀況及屬3日內非計劃性回診狀況會越多，而自行步入急診及發燒症狀會越少。研究結論：反覆使用急診者是急診病患中相對較小的族群，但確是急診就診總次數的主要族群。本研究發現反覆使用者主要以老年人（65歲以上）及中年人（40至64歲）病患為主，且老年人居多，超過半數病人患有癌症，常見就診原因皆與疼痛相關。重度組相較於中度組多數為低收入戶者且俱有多重慢性疾病，且在過去病史有精神疾患、貧血及肝硬化者比例較高。此外重度組在使用門診資源、過去一年內曾經住院及持有疾病重大傷病卡等，都相較於中度組之比例高。相較國外文獻僅有8至10%轉住院，本研究後續住院之情況佔27%。根據研究結果需對於反覆使用者以個案管理方式持續追蹤和提供無縫接軌的照護模式，以降低反覆就診急診次數。

關鍵字

反覆使用急診；急診擁塞；急診病人就醫特性；急診醫療資源使用

並列摘要

Background: The rapid growth on the number of emergency medical visits has increased the workload of emergency work day by day and also resulted in huge medical expenses. According to the systematic review study, about 8% of emergency patients are frequent users, and their visit frequency accounts for a quarter of all emergency visits. In previous studies, the improper uses of emergency department (ED) were divided into two categories: (1) Non-emergency severely ill patients who pursue quick and convenient emergency treatments, and (2) hospitalization needed by some patients with recurrence of chronic diseases. Not only do the results of frequent users at ED create more uses of emergency resources and reduce the quality and efficiency of medical care, but also generate a warning issue for patients with recurrence of chronic diseases or need persistent care. Currently, the studies on frequent users of ED are focused on emergency medical care in western countries. In contrast to the situation of a certain medical center in Taiwan with more than 100,000 emergency visits in a year, there is a lack of investigation on repeat patients to the ED. Thus we devoloped this study to analyze the current domestic status of frequent users of ED. Purposes: To explore the proportion of frequent users to the ED against the emergency medical visits throughout the year, and the use status of moderate and highly frequent users of ED based on the aspects of demography, disease attributes, visiting characteristics and medical resources. Methods: A convenience sampling method was conducted at a ED of medical center in Taipei from January 1, 2017 to December 31, 2017, where all adult patients were included in the study. The hospital medical integration database was adopted to perform a retrospective and longitudinal research design, and the literature was used to define the number of frequent users who visit the ED repeatedly more than four times in a year. Furthermore, the patients’ demographic attributes, the diseases and medical need attributes, the use of resources at ED, as well as the information related to electronic medical records such as changes in the four visits, etc. were collected. Finally, an encoding login chart was formulated to access the medical records of each variable. Result: 1. The total number of patients visiting the ED in the study was 61,057 and contributed total number of 85,702 visits. Among them, 2,191 patients (3.37%) were listed as frequent users, contributing 12,166 visits . Otherwise, the frequent users (3.37%) of ED contributed 14.20% of visits. 2. The logistic regression analysis was adopted by this study. It was found that patients of average age above 65 years have become the hightly frequent users of ED, and the probability was 0.539 times higher than patients of average below age 65 years; patients with food allergies have become the hightly frequent users of ED, and the probability was 1.678 times higher than patients without food allergies; patients from low-income households have become the hightly frequent users of ED, and the probability was 3.387 times higher than patients from non-low-income households; and patients visited outpatient departments more frequently in the past year have become the hightly frequent users of ED, and the probability was 1.013 times higher than patients with lower frequency of visiting outpatient departments. In past medical history, patients with psychiatric disease have become the hightly frequent users of ED, and the probability was 1.885 times higher than patients without psychiatric disease; patients with liver cirrhosis have become the hightly frequent users of ED, and the probability was 2.262 times higher than patients without liver cirrhosis; and patients with anemia have become the hightly frequent users of ED, and the probability was 1.666 times higher than patients without anemia. 3. The Generalized Estimating Equation (GEE) analysis was used to compare the differences between the two groups of moderate and highly frequent users of ED with four emergency visits characteristic and the use of emergency resources, respectively. The results indicated that the probability of fever symptom in the four visits by the hightly frequent user group was less than the moderate user group, and its probability of 0.66 times (β= -0.41, S.E.=0.18, p =0.02) showed a significant difference. Among the four visits, patients in the hightly frequent user group who are listed as severe emergency patients status (1st and 2nd degree at triage) was less that patients in the moderate user group (β= -0.329, S.E.=0.15, p =0.024), with a probability of 0.72 times. Conclusion: The frequent users of ED are regarded as a relatively small group of emergency patients, but they contributed high frequency medical visits should be brought into attention. This study found that the frequent users were dominated by the elderly patients (over 65 years old), and the middle-aged patients (40 to 64 years old). More than half of the patients have suffered from cancer. The hightly frequent users of ED from low-income households outnumbered the moderate users of ED, and most of them have suffered from multiple chronic diseases, with a higher proportion of patients with psychiatric disease, anemia and liver cirrhosis in the past history. The causes of frequent ED visits in the moderate and hightly frequent user groups were related to pain. In addition, with regard to the use of outpatient resources in the hightly frequent user group, hospitalization and the possession of a major illness card, etc. over the past year were all higher than those in the moderate user group. All the above data were statistically significant. In terms of patient trends as compared with foreign literature, only 8 to 10% of patients were hospitalized and this accounted for 27% of hospitalization condition in this study. The result of higher hospitalization proportion is speculated that the domestic hightly frequent users of ED were in a severely ill condition when making the visits. Based on this research findings, the systematic tracking and patients management are recommended to use on the hightly frequent users of ED, expecting to reduce the frequency of emergency medical visits.