醫師特質對急診檢驗檢查利用與照護結果之影響

Impact of Physician Characteristics on the Use of Laboratory Tests and Imaging Studies of Emergency Department

林煒濬(Wei-Chun 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(2020年)

https://doi.org/10.6342/NTU202000733

摘要

研究背景： 在台灣，急診的醫療支出日益上升，安排的檢驗檢查，尤其是高階影像檢查如電腦斷層（Computed Tomography）與核磁共振（Magnetic Resonance Imaging）也逐年上升，這其中部分醫療處置屬於低價值醫療，對於病人只有極少或者甚至沒有幫助。然而過去少有研究，去探討不同因素對於急診病人開立檢驗檢查，或者在費用方面是否有所差異，值得進一步去探討。

研究目的： 本研究透過衛生福利部資料科學中心全民健保資料庫，檢視在急診不同的因素，對於醫師開立檢驗檢查，或者病人預後及費用上是否會有差異。

研究方法： 本研究為橫斷性研究，根據2011~2016年全民健保資料庫進行次級資料分析。研究對象為健保承保20歲以上之人口，並排除外傷的檢傷三級急診病人，從病患臨床過程面 (有無抽血檢驗、開立抽血檢驗醫令數、有無點滴、有無檢查、開立檢查醫令數、有無開立電腦斷層、有無開立核磁共振)、結果面 (有無三日內再急診、有無死亡)與費用面 (醫令費用、總費用) 共選取11個依變項進行探討，使用羅吉斯迴歸控制年份、病患及醫療機構特質後，探討各變項及醫師特質之間的關係。醫師特質包含是否為急診專科醫師、性別、及醫師年齡。

研究結果：從2011年至2016年，排除外傷的急診病人，總計有21,233,836人次。其中67.5%是由急診專科醫師看診，61.2%有執行抽血檢驗，56.8%有安排檢查。排除無該儀器的醫療院所後，8.5%的病人有開立電腦斷層，0.4%的病人有開立核磁共振。排除無再次急診機會的病人後，6.9%有三日內再急診紀錄。所有個案平均醫令費用為288.0 ±2912.5，平均總費用為3395.1 ±5731.4。以檢傷三級病人來分析，醫師特質區分，各層級醫院的急診專科醫師、區域醫院及地區醫院的34歲以下醫師，開立較多檢驗檢查。區域醫院及地區醫院急診專科醫師其病人死亡機率較低，各層級醫院34歲以下醫師其病人死亡機率較低。各層級的女性醫師、醫學中心45-54歲醫師、區域醫院及地區醫院34歲以下醫師造成總醫療費用較高。醫院特質區分，各層級醫院都以公立醫院開立較多檢驗檢查。醫學中心及地區醫院的死亡機率是非公立醫院較高，總醫療費用是公立醫院較高。區域醫院的死亡機率是公立醫院較高，總醫療費用是非公立醫院較高。病患特質區分，各層級醫院都以男性、年齡越大、投保金額低的病人接受較多檢驗檢查，且死亡機率較高，總醫療費用較高。

結論：本研究發現，在急診非外傷的檢傷三級病人，急診專科醫師開立較多檢驗檢查，但是在區域醫院及地區醫院，其病人死亡機率較低。34歲以下醫師開立較多檢驗檢查，其病人死亡機率較低。公立醫院開立較多檢驗檢查。病患為男性、年齡越大、投保金額低，會接受較多檢驗檢查，且死亡機率較高，總醫療費用較高。根據本研究的結果，可以針對產生差異的因素，從政策面及醫師教育面提出改進，改善急診檢驗檢查的過度開立，提升急診照護品質，及減少急診總體醫療支出。

關鍵字

急診 ； 低價值醫療 ； 抽血檢驗 ； 影像檢查 ； 台灣急診五級檢傷分類

並列摘要

Background: Medical expenses in emergency departments have increased in Taiwan. The laboratory tests and imaging studies, especially Computed Tomography (CT) and Magnetic Resonance Imaging (MRI), have also increased year by year. Some of these medical treatments are belong to low-value care, which have little or no help for patients. However, there have been few studies in the past to explore whether different factors may affect the examination amounts for emergency patients, or whether there are differences in costs, which must be further investigated.

Objective: This population-based study obtained data from Taiwan National Health Insurance Database (NHI). The aim is to examine whether different factors in the emergency department may affect the amounts of laboratory tests or imaging studies, and the prognosis and costs.

Methods: This study is a cross-sectional study. The secondary data analysis was performed based on the National Health Insurance Database from 2011 to 2016. The research object is the emergency patients over 20 years of age, excluding trauma patients, and belongs to Taiwan triage and acuity scale (TTAS) Class III. A total of 11 dependent variables were selected, including the clinical process of the patient (the presence or absence of laboratory tests, the number of laboratory tests, the presence of intravenous infusion, the presence of imaging studies, the number of imaging studies, whether to have a CT, and whether to have a MRI), the result of the patient (unplanned emergency department revisits within 72 hours, whether there was death), and the cost (medical order cost, total cost). After controlling the year, patient comorbidity, and the institution factor, multilevel logistic regression was used to identify the relationship between variables and the physician characteristics, patients and medical institution characteristics. Physician characteristics include whether an emergency specialist, gender, and age of the physician.

Results: From 2011 to 2016, there were a total of 21,233,836 cases of emergency patients, excluding trauma patients. Of these, 67.5% were seen by emergency specialists, 61.2% had laboratory tests, and 56.8% had imaging studies. After excluding medical institutions without the instrument, 8.5% of patients had a CT and 0.4% of patients had an MRI. After excluding patients who did not have a chance to revisit emergency department, 6.9% had a record of unplanned emergency department revisits within 72 hours. The average medical order cost was 288.0 ± 2912.5 in all cases, and the average total cost was 3395.1 ± 5731.4. Based on TTAS Class III patient, the characteristics of physicians are: Emergency specialists at all levels of hospitals, physicians under the age of 34 at regional and district hospitals, conduct more laboratory tests and imaging studies. Emergency specialists at regional and district hospitals cause lower mortality rates, and physicians under the age of 34 at all levels of hospitals cause lower mortality rates. Female physicians at all levels of hospitals, 45-54-year-old physicians at medical centers, and physicians under the age of 34 at regional hospitals and district hospitals lead to higher total medical expenses. Hospital characteristics are: physicians of public hospitals in all levels conduct more laboratory tests and imaging studies. The mortality rate of medical centers and district hospitals is higher in non-public hospitals, and the total medical expense is higher in public hospitals. The mortality rate of regional hospitals is higher in public hospitals, and the total medical expense is higher in non-public hospitals. Of all levels of hospitals, patients who are male, the older ages, the lower the National health insured amount would have more laboratory tests and imaging studies. The mortality rate is higher, and the total medical expenses is higher.

Conclusions: This study found that of non-trauma patients who visited emergency department, and classified as TTAS Class III, Physicians of emergency specialist conduct more laboratory tests and imaging studies, but cause lower mortality rates in regional and district hospitals. Physicians under the age of 34 conduct more laboratory tests and imaging studies, but cause lower mortality rates in all levels of hospitals. Physicians of public hospitals would conduct more laboratory tests and imaging studies. Patients who are male, the older ages, the lower the National health insured amount would have more laboratory tests and imaging studies, the mortality rate is higher, and the total medical expenses is higher. According to the results of this study, it is necessary to improve policies and physician education in order to improve the overuse of emergency studies, improving the outcome of emergency patients, and reduce the overall medical expenses of emergency departments.

並列關鍵字

Emergency department ； Low-value care ； Laboratory tests ； Imaging Studies ； Taiwan triage and acuity scale (TTAS)

參考文獻

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