中醫資源可近性對於中醫門診利用之影響

The effect of the resource accessibility on the utilization of Traditional Chinese Medicine

林宜瑾(Yi-Chin 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(2019年)

https://doi.org/10.6342/NTU201901044

摘要

研究背景：中醫門診為健保給付的醫療服務之一，但台灣不同地區的中醫資源分布與中醫門診利用情形差異甚大，且中醫醫療資源主要集中於中部地區。在資源有限的環境下，使醫療資源有效率的配置是目前當務之急，而釐清中醫資源變化對於民眾中醫門診利用之影響，有利於未來中醫資源分配之規劃。
研究目的：本研究主要探討當民眾中醫資源可近性改變時，對於中醫門診利用行為之影響。
研究方法：利用全民健保全人口資料，研究期間為2011年至2013年，以每年所公告巡迴醫療施行區域與各年度的每萬人口中醫師數作為可近性之測量指標。本研究共分為兩個子研究樣本：可近性增加組與可近性降低組，各子樣本又再區分為個案組與對照組。個案組為2011年至2012年中醫可近性有改變的民眾，對照組則為可近性無改變的民眾。經配對後，以廣義估計方程式(GEE)進行差異中的差異法，搭配使用二部模型(Two-part model)進行分析。
研究結果：本研究經配對後，可近性增加組共納入個案組42,109人與對照組84,218人，可近性降低組則為個案組37,785人及對照組75,570人。在中醫資源可近性增加後，可近性增加組的個案其中醫門診利用皆顯著增加，利用機率、次數與費用之差異為對照組的1.094倍、1.022倍與1.128倍。而在中醫資源可近性降低後，對於可近性降低組的個案而言，其中醫門診利用皆顯著減少，利用機率、次數與費用之差異為對照組的0.823倍、0.940倍與0.763倍。中醫資源可近性對於前測無中醫門診利用者而言，與後測利用行為無相關；但對於前測高度中醫門診利用者來講，可近性降低後，其中醫門診利用機率顯著較低(OR=0.785)。
結論：中醫資源對於中醫門診利用會造成影響，然而對於無中醫利用習慣者而言，中醫資源與其利用行為無相關，但當中醫資源可近性降低時，高度中醫利用者利用率會降低。故建議主關機關能持續保障醫療資源缺乏地區民眾的之中醫就醫權益，並且須擬定相關政策以改善當前不同地區中醫利用差異之問題，以落實全民健保精神。

關鍵字

中醫資源不足地區 ； 中醫資源可近性 ； 中醫門診利用 ； 差異中之差異法

並列摘要

Background: Traditional Chinese medicine (TCM) is one of the medical services provided by the National Health Insurance (NHI) in Taiwan; however, researchers have determined that the utilization of TCM is concentrated in the central region of the country. In an environment with limited medical resources, efficiency in the allocation of resources is crucial; thus, it is important to understand the means by which access to TCM resources affects utilization.
Objective: This study evaluated the means by which changes in the availability of TCM resources affect their utilization.
Methods: Data between 2011 and 2013 were obtained from the claims database at the Health and Welfare Data Science Center, Taiwan. TCM mobile health care coverage and the number of TCM physicians per 10,000 were used to define accessibility. Individuals who faced changes in access to TCM resources were adopted as the case group, and individuals with unchanged access to TCM resources were adopted as the control group. The case group was further divided into two groups based on 1) an increase in accessibility and 2) a decrease in accessibility. After matching the case group and the control group, difference-in-difference analysis was used in conjunction with the generalized estimating equation (GEE) to estimate the effects of access to TCM resources on utilization, and the same two-part model was used to identify the association between TCM resources and utilization by different classes of TCM users.
Results: After parameter matching, the accessibility-increase group included 42,109 individuals in the case group and 84,218 individuals in the control group, whereas the accessibility-decrease group included 37,785 individuals in the case group and 75,570 individuals in the control group. Individuals who were provided greater access to TCM increased their utilization of TCM, compared to the control group, as follows: probability (+1.094 x), frequency (+1.022 x), and cost (+1.128 x). In contrast, individuals with reduced access to TCM decreased their utilization of TCM, compared to the control group, as follows: probability (-0.823 x), frequency (-0.940 x), and cost (-0.763 x). Among individuals who were provided greater access to TCM, there was no association between the availability of TCM resources and utilization among those that reported no ambulatory TCM utilization in the pretest. In the accessibility-decrease group, we found that among individuals who reported high TCM utilization in the pretest, the case group was less likely to have the ambulatory care utilization of TCM in the posttest (OR=0.785).
Conclusions: Our results indicate that access to TCM resources affects the ambulatory utilization of TCM among all individuals except those who are unaccustomed to using TCM. In cases where access to TCM decreased, individuals who were previously accustomed to using TCM were likely to reduce utilization. We therefore recommend that efforts be made to improve access to TCM in areas where TCM resources are scarce and that the government develops policies aimed at narrowing the differences in the utilization of TCM.

並列關鍵字

areas deficient in TCM resources ； accessibility of TCM resources ； ambulatory care utilization of TCM ； difference-in-difference

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