醫院出院準備表現與其影響因素:病人觀點的分析

研究背景與目的：國內無論是在出院準備服務還是病人經驗調查的發展和推進都相對國外緩慢許多，然而隨著台灣社會的超高齡化，以及全球健康照護體系的轉型，重視並完善國內的出院準備服務，同時增加關於國內住院病人本身的出院準備服務經驗的關注，是當前極需被深入了解的議題，從病人觀點發現的於照護過渡期間會面臨的照護銜接問題，能提供健康照護政策制訂者一個契機與切入口，以改善整體健康照護體系，增進國人醫院和社區間照護的連續性。因此本研究的研究目的是以具有良好信效度的本土化病人經驗調查工具，進行跨院的全國住院病人經驗調查，以獲得台灣住院病人出院準備服務經驗之全景，並且再進一步探討哪些病人因素和醫院因素會影響國內住院病人的出院準備服務經驗評分。研究方法：本研究採橫斷性研究設計，使用次級資料分析，資料來源為衛福部健保署委託鄭守夏教授的107年度計畫–「住院病人就醫經驗調查運作模式之先驅研究」。以全國與健保特約且提供住院服務之醫院為收案院所，針對年齡大於20歲以上、於107~108年間有住院經驗的病人為收案對象，研究工具為量性的、自填式問卷，問卷調查方式有臨櫃發放、郵寄發放、電腦輔助電話訪問，以及網路填答四種。結果變項為出院前的準備服務綜合經驗評分。原始回收樣本數為11,793份資料，經過資料除錯、處理和插補後，最後剩餘11,000筆資料納入分析。以描述性統計方法說明資料的分布情形；推論性統計方法，包括雙變項分析和多變項分析。雙變項分析以獨立樣本t檢定和GLM為主要分析方式，並附上皮爾森相關性分析；多變項分析以混和線性多階層分析為主，探討哪些病人階層與醫院階層的變項會影響住院病人最後的出院準備服務經驗評分。研究結果：整體而言國內住院病人的出院準備服務經驗良好，僅有不超過11%的病人對於出院前的衛教內容表示不理解，平均得分為3.17分(總分為4分)；然而在「是否參與出院準備計劃的制訂」問題上，仍有36%的病人回覆沒能參與，並且在平均得分上，有參與組病人比起未參與組病人高出0.48分。其中，高齡病人雖比一般病人高出4.61%有參與出院準備計畫的制訂，於出院準備服務構面中各指標的平均得分卻普遍較一般病人低。另外也發現，產婦、地區醫院和私立醫院都有較好的出院準備服務經驗表現。在影響因素方面，病人因素中：男性、高齡、產婦、住院期間有親友陪病、住院天數越長、病人於住院期間感受到的醫師照護與護理照護經驗越佳等，都與國內住院病人的高出院準備服務經驗評分相關；而醫院因素中，權屬別為私立的醫院則與高出院準備服務表現相關。最後，由於問卷調查方式會顯著影響病人的給分，因此需謹慎處理。本研究另外發現，產婦和高齡病人的出院準備服務經驗評分幾乎不受任何病人因素和醫院因素影響，以及證實需將手術病人與非手術病人、高齡病人與非高齡病人分開看待等研究結果。結論與建議：國內的住院病人經驗調查尚未普及，目前也缺乏新修的、全國一致的本土化病人經驗調查工具，因此各醫院在評估自身的照護服務表現時均選擇各自習慣的調查方式，導致評估結果在信效度上令人存疑，並且難以進行跨機構的比較。本研究突破上述限制，使用最新發展的具有良好信效度的病人經驗調查工具，將受測對象擴及全國，以便對國內住院病人的出院準備服務經驗有更全面的了解。本研究結果將有助於未來研究者或政策制訂者更深入探討甚或發展台灣出院準備服務相關政策討論。

關鍵字

病人住院經驗；出院準備服務；病人因素；醫院因素；多階層分析

並列摘要

Background Objectives: The development and advancement of discharge planning and patient experience surveys in Taiwan are slower than those of foreign countries. However, with the rapid aging of Taiwanese society and the transformation of the global health care system, we must now better understand patients’ experience of inpatient care, such as discharge planning after hospitalization. Exploring care transition issues from the patients’ perspective can provide health care policy makers with an opportunity to improve the overall health care system and enhance the continuity of care between hospitals and communities. Therefore, the purpose of this study is to conduct a nation-wide inpatient experience survey to obtain a panoramic view of inpatients’ experience with discharge planning in Taiwan, and examine which patient and hospital factors will affect this experience. Method: This was a secondary data analysis using existing data from a cross-sectional survey conducted in 2018. This study was supported by the National Health Insurance Department of the Ministry of Health and Welfare and conducted by National Taiwan University’s Graduate Institute of Health Policy and Management. Patients who were older than 20 years old and had hospitalization experience between 2018 and 2019 were randomly selected for the survey. The survey was a quantitatively measured, self-reported questionnaire, and was conducted in four modes: 1) manually at the discharge counter, 2) by postal mail, 3) by computer-assisted telephone interviews, and 4) electronically using an online survey link. The outcome variable was the aggregate scores of inpatients’ experience with discharge planning. Of 11793 total participants, we included 11000 after excluding data that were illogical or incomplete. Descriptive statistics were obtained to illustrate the distribution of data. Bivariate analyses were carried out using independent sample t-test and GLM process. Finally, variables were further subjected to multilevel analysis to explore which patient and hospital factors have an influence on patients’ experience with discharge planning after being hospitalized. Results: In general, respondents rated their experience with discharge planning positively. The average score was 3.17 out of 4. Only 11% of patients did not understand their discharge instructions. However, there were 36% of patients not involved in the formulation of their discharge plan. Those who were involved in their discharge planning process rated their experience 0.48 points higher than those in the non-participating group. Although elderly patients who participated in the formulation of the discharge plan were 4.61% higher than those of the non-elderly patients, the average scores were generally lower than those of the non-elderly patients. It was also found that respondents from regional hospitals and private hospitals reported better discharge instruction experience. Patient level factors positively influencing discharge planning experience included being male, elderly, pregnant, having relatives and friends during hospitalization, length of stay, and experience with their inpatient clinicians. Private ownership was the only hospital-level factor that was positively related to patient experience scores with discharge planning. Finally, because the survey mode could significantly affect the patients’ evaluation of health care services, it needed to be addressed with caution. Our results show that pregnant and elderly patients’ experience with discharge planning were minimally affected by any patient factors and hospital factors. From the results, we also concluded that surgical versus non-surgical patients and elderly patients versus non-elderly patients needed to be treated separately. Conclusion: Inpatient experience surveys have not yet been widely disseminated in Taiwan, and currently there is a lack of recently updated survey questionnaires applicable to inpatient care. Therefore, each hospital uses different standards when evaluating their own health care service performance. As the survey was not externally validated, it is difficult to make cross-institutional comparisons. This study overcomes these limitations and uses the newly developed patient experience survey tool with good reliability and internal validity and hopes to expand the survey to the whole country in order to have a more comprehensive understanding of the inpatients’ experience with discharge planning in Taiwan. The results of this study will help future researchers and policy makers to further discuss and develop relevant policies about discharge planning in Taiwan.

並列關鍵字

Inpatient experience survey ； Discharge plan ； Patient factor ； Hospital factor ； Multilevel analysis

參考文獻

吳孟嬪, 馮容莊, 施至遠, 徐愫萱, 鄒淑萍, 朱怡蓁, 黃勝堅. (2019). 從醫院到社區的全人照護－建構完善的出院準備服務. [Holistic Care from Hospital to Community-Building a Comprehensive Discharge Planning Service]. 北市醫學雜誌, 16, 10-24. doi:10.6200/tcmj.201910/sp_16.0002

Google Scholar

李芳菁, 蘇子舜, 陶阿倫. (2018). HCAHPS病人住院經驗調查結果初探. [Preliminary Findings of HCAHPS Inpatient Experience Survey]. 彰化護理, 25(2), 35-41. doi:10.6647/cn.201806_25(2).0006