在不同照護場域接受居家照護病患之醫療利用情形與照護結果

背景與目的：居家照護為長照體系重要且不可或缺的一環，在高齡化社會來臨之際，居家照護更是醫療體系中的重要服務項目。高齡化社會使人口與家庭結構改變，人口老化延伸照護需求，從醫院到社區，病患可能留在家中療養或進入護理之家甚或安養護機構。因此，本研究以在不同照護場域接受居家照護的病患，探討其醫療利用情形與照護結果的影響。方法：本研究為回溯性世代研究，採用全民健康保險研究資料庫2010年百萬承保歸人檔進行次級資料分析，篩選出2012年有使用居家照護服務者，依健保申報案件類別區分不同照護場域，分別為居家、護理之家、安養護機構之居家照護病患共1556名。使用二部模型，第一階段以複羅吉斯迴歸分析及第二階段以廣義線性模型分析，比較在不同照護場域接受居家照護病患一年內之門診、急診、住院、居家護理、醫師訪視等醫療利用情形，並以可避免住院做為照護結果指標進行比較。結果：在醫療利用情形方面 (1)門診利用：門診次數，護理之家及安養護機構分別較居家高出44%及13%(p<.001)；門診費用，護理之家較居家高出14% (p<.01)、安養護機構較居家少14%(p<.001)。(2)急診利用：相較於居家病患有無急診，護理之家及安養護機構發生急診機會分別為0.72倍(p<.05)及0.63倍(p<.001)；急診次數，護理之家及安養護機構分別較居家少35%及43% (p<.001)，但急診費用未達顯著差異。(3)住院利用：住院次數未達顯著差異；住院天數，護理之家及安養護機構分別較居家少14%及24%(p<.001)；住院費用，護理之家及安養護機構均較居家少17%(0.83倍)(p<.05)。(4)居家護理利用：居家照護次數，護理之家及安養護病患均較居家高出5%(p<.05)；居家照護費用，安養護機構較居家高出12%(p<.01)。(5)醫師訪視利用：相較於居家有無醫師訪視，護理之家及安養護機構醫師訪視機會分別為1.95倍及1.99倍(p<.01)；醫師訪視次數，護理之家及安養護病患分別較居家高出28%及21%(p<.001)；醫師訪視費用，護理之家較居家高出17%(p<.001)。在照護結果方面：可避免住院次數未達顯著差異；可避免住院天數，護理之家及安養護機構病患分別較居家少29%及32% (p<.001)；可避免住院費用，護理之家及安養護機構病患分別較居家少35%及33% (p<.001)。在總醫療費用方面：整體總醫療費用及醫療利用總費用(門急住)，安養護機構均顯著少於居家；然而於居家照護利用總費用(居家護理及醫師訪視)，安養護機構則顯著高於居家。結論：整體而言，在醫療利用情形的部份，接受居家照護者，在居家有較高的急診次數利用；護理之家有較高的門診次數利用與費用，以及較高的居家護理利用及醫師訪視利用，安養護機構次之；而安養護機構則在急診次數利用最低，其他方面大多介於護理之家與居家之間；另住院次數在不同照場域未達顯著差異，但住院天數與費用均以居家較高。在照護結果的部份，居家在可避免住院天數及費用均高於護理之家與安養護機構，可避免住院預防性品質指標(PQIs)主要病因為尿路感染、細菌性肺炎、慢性阻塞性肺病。顯見居家因無常駐護理人員而未能滿足病患之照護需求，以致急診利用較高；而護理之家呈現門診及居家照護利用較高情形，但在急診利用相對較低，亦即機構與醫院間基層照護合作關係有助於維持病況，惟仍建議應進一步檢視機構對病患照護安排的合宜性。

關鍵字

居家照護；護理之家；安養護機構；醫療利用；可避免住院

並列摘要

Background: Home care is an essential part of the long-term care system, and it also plays an important role in the medical system in an aging society. An aging society may cause changes in population and family structure, and increase the demand for care in the hospital and community. Patients may choose to receive care at home, nursing home or residential care home. This study aims to explore the expenditure and outcome of care delivered at different sites. Method: This study is a secondary data analysis of retrospective cohort studies. We used data for the year of 2010 from the National Health Insurance Research Database and collected data from patients receiving home care service in 2012. In this study, data from1,556 patients was collected and the patients were categorized into 3 groups: patients receiving care at home (HC), at nursing home (NH) and at residential care homes (RCH). Two-part model was used in this study. The first-stage multiple logistic regression analysis and second-stage generalized linear model analysis were conducted to verify the patients’ usages of outpatient department, emergency department, hospitalization, home care, and physician visits within one year after receiving home care, and make comparison between medical utilization and avoidable hospitalization. Results: Concerning medical utilization, in terms of (1) out-patient departments: patients utilizing nursing homes and residential care homes led to more outpatient visits than those utilizing home care by 44% and 13% (p<.001); and the outpatient expenses were higher among patients at nursing homes (14%, p<.01), and lower among patients at residential care homes (14%, p<.001) than among patients at home. (2) emergency room: patients utilizing nursing homes and residential care homes led to less emergency utilization than patients utilizing home care by 0.72 times (p<.05) and 0.63 times (p<.001); emergency visit: patients utilizing nursing homes and residential care homes led to less emergency visits than patients utilizing home care by 0.35 times and 0.43 times (p<.001) ; and the difference in emergency department expenses among different sites was not significant. (3) hospitalization: the difference in admission at different sites was not significant; patients utilizing nursing homes and residential care homes made fewer days of stay than those utilizing home care by 14% and 24% (p<.001); patients utilizing nursing homes and residential care homes made fewer expense than those utilizing home care by 17% (p<.05). (4) home care: patients utilizing nursing homes and residential care homes utilized more home care services than those utilizing home care by 5% (p<.05); patents utilizing residential care homes got more expense of home care services than those utilizing home care by 12% (p<.01). (5) utilization of physician visit: patients utilizing nursing homes and residential care homes made more utilization of physician visits than those utilizing home care by 1.95 times and 1.99 times (p<.01); physician visit: patients utilizing nursing homes and residential care homes made more physician visits than those utilizing home care by 28% and 21% (p<.01); and the expense for patients utilizing nursing home was higher than those utilizing home care by 17% (p<.001). Concerning care outcomes, no significant difference was found in visits of avoidable hospitalization; patients utilizing nursing homes and residential care homes made fewer days of avoidable hospitalization than those utilizing home care by 29% and 32% (p<.001); patients utilizing nursing homes and residential care homes made fewer expense of avoidable hospitalization than those utilizing home care by 35% and 33% (p<.001). While the total expense of home care services is lower for patients receiving home care at home, the total expense of medical use for them is much higher than those who received their home care service in residential care homes. Conclusions: Overall, among home care recipients, those who received home care at home made more emergency visits; but those who received home care at nursing home made most outpatient visits, outpatient expenses, home care utilization and physician visits, followed by those who received home care at residential care homes. Parameters of residential care homes are usually between nursing homes and homes, except patients utilizing residential care homes made least emergency visits. There was no difference among hospitalization visits among the three groups, but those who received home care at home made most days of stay and emergency department expenses. Concerning the care outcome, those who received home care at home made most days of stay and expenses of avoidable hospitalization, which is mainly caused by infection in urinary tract, bacterial pneumonia, and chronic obstructive pulmonary disease. It is obvious that nursing needs of the patients receiving home care at home cannot be satisfied owing to the lack of regular nursing staff, which demands more emergency use. The outcome demonstrated that patients utilizing nursing home made more outpatient and home care utilization but less emergency use. Despite the outcome may indicate decent collaborations among institutes and hospitals, further examination may still be needed to verify if there are adequate home care applied in institutes.