探討新型冠狀病毒肺炎(COVID-19)對不同層級醫療機構服務量的影響

Explore the impact of the Coronavirus Disease 2019 (COVID-19) on the healthcare service volume among different level of provider

張雅惠(Ya-Hui Chung)

指導教授 ： 郭年真

國立臺灣大學/公共衛生學院/公共衛生碩士學位學程/碩士(2021年)

https://doi.org/10.6342/NTU202104103

摘要

研究背景:我國在全民健康保險實施後，醫療機構家數逐年上升，讓民眾就醫更具便利性、快速性。在全民健康保險實施後歷經多次傳染病大流行(如SARS、H1N1等)，並依傳染病疫情嚴重程度也會直接影響民眾就醫意願，進而間接影響醫療機構服務量，像是2002-2004年SARS(嚴重急性呼吸道症候群)流行期間，因SARS病毒傳播途徑主要透過飛沫、空氣等傳播且病毒感染力、致病力強，導致民眾影響民眾外出至醫療機構就醫意願，加上SARS確診個案大多數送至醫學中心、區域醫院接受治療，因此受到各種因素的影響下，事後分析全民健康保險資料庫發現，SARS疫情流行期間醫院的申報件數呈現明顯下降。在本次新型冠狀病毒肺炎(COVID-19)傳染病疫情流行期間，我國的防疫政策已達到超前部署，然仍有出現COVID-19確診個案，因此各醫療機構服務量能仍有受到本次疫情影響。
研究目的:本研究目的為探討本次新型冠狀病毒肺炎(COVID-19)傳染病疫情流行期間，不同層級別之醫療機構服務量疫情受到影響程度，並與SARS(嚴重急性呼吸道症候群)疫情期間進行比較，藉此瞭解兩種不同疫情對我國醫療機構服務量所造成的衝擊。
研究方法:本研究為橫斷性研究，透過分析全民健康保險資料庫，瞭解在 2018-2020年(COVID-19)及2002-2004年(SARS)傳染病疫情流行期間，不同層級別醫院及西醫基層診所醫療服務利用情形之變化。統計軟體是以SAS9.4版及SAS EG進行統計分析，描述性分析包含分析各科別申報平均值、百分比；推論性統計包含兩組變項T檢定、迴歸分析。
研究結果:在2020年COVID-19疫情流行期間，與2019年同期相比後發現2020年3-5月對我國醫療機構衝擊最明顯。SARS疫情期間與疫情前一年(2002年)同期相比，2003年4-8月對我國醫療機構衝擊最明顯，醫院整體門診、住診申報件數均呈現下降，其中醫院門診、住診申報件數均以6月份醫學中心下降最多，分別下降44.38%、42.81%；醫院急診申報件數在醫學中心呈現下降，但區域醫院及地區醫院則呈現上升；西醫基層整體門診申報件數以2003年6月份下降最多(下降20.22%)。
在2020年COVID-19疫情流行期間，小兒科、內科、耳鼻喉科、家醫科是影響最多的科別，且在基層診所申報件數及醫療費用均受疫情影響有呈現明顯下降但醫院部分科別未有明顯減少，但SARS時期醫院的影響居較顯著，與這次COVID-19研究得知的結果相反。
結論:2020年醫院門診、急診、住診與西醫基層診所門診醫療利用情形，與2019年相比，總體來說呈現顯著下降，可以推論COVID-19疫情確實帶來醫療機構服務量能不小的衝擊。雖然疫情流行嚴重程度會影響民眾到醫療機構就醫意願，但以2020整年度觀之，醫院與西醫基層診所整體門診、急診、住診申報件數在3月到5月期間有明顯下降之外，在5月過後其申報件數有回升趨勢，可能是我國防疫政策奏效。
以整體門診申報件數來看，COVID-19疫情期間西醫基層呈現顯著下降，但醫院未有明顯下降；SARS時期則是醫院下降有達統計顯著，西醫基層診所則未受到明顯衝擊，因此COVID-19與SARS兩個疫情流行期間，醫療機構受到衝擊的程度正好相反，推測可能是我國西醫基層診所及執業醫師人數等醫療機構量能逐年增加、2018年起推動分級醫療期望達到壯大基層目的有關。
以就醫科別來看，基層診所整體門診受到衝擊影響最多的科別分別為小兒科、家醫科、內科、耳鼻喉科等，與醫院不同的是，四大科別基層診所門診申報件數及醫療費用在2020年均呈現負成長，且與2019年相比均呈現受到疫情影響有明顯減少，推估可能是截至2020年12月COVID-19疫情尚在流行及COVID-19病毒傳播特性、致病力等，降低民眾就醫意願，間接導致基層四大科別的醫療服務利用情形仍無法恢復。

關鍵字

新型冠狀病毒肺炎 ； 醫療機構服務量 ； 醫療機構層級別 ； 疫情大流行 ； 科別

並列摘要

Background:After the implementation of universal health insurance in Taiwan, the number of medical institutions has increased year by year, making it more convenient and faster for people to seek medical treatment. After the implementation of the National Health Insurance, there have been many infectious disease pandemics (such as SARS, H1N1, etc.), and depending on the severity of the infectious disease epidemic, it will directly affect the people's willingness to seek medical treatment, and indirectly affect the service volume of medical institutions, such as 2002-2004 during the SARS (Severe Acute Respiratory Syndrome) epidemic, the spread of SARS virus is mainly through droplets, air, etc., and the virus is highly infectious and pathogenic, which affects the people's willingness to go out to medical institutions for medical treatment. In addition, the majority of SARS confirmed cases, they were sent to medical centers and regional hospitals for treatment. Therefore, under the influence of various factors, after the pandemic, found that the number of hospital declarations during the SARS epidemic has dropped significantly by analyzing of the National Health Insurance Database. During the epidemic of the Coronavirus Disease 2019 (COVID-19) infectious disease, the epidemic prevention policy in Taiwan has reached advanced deployment, but there are confirmed cases of COVID-19 still happened, so the healthcare service volume among different level of provider are still affected by this epidemic influence.
Objective:The purpose of this study is to investigate the extent to which the healthcare service volume among different levels of provider were affected during the epidemic of Coronavirus Disease 2019 (COVID-19) epidemic, and to compare it with the SARS (Severe Acute Respiratory Syndrome) epidemic period. This is to understand the impact of two different epidemics on healthcare service volume of Taiwan's medical institutions.
Methods:This study is a cross-sectional analysis. Through the analysis of the national health insurance database, we can understand the utilization changes among different levels of hospitals and Primary Western Physician Clinics during the epidemic of infectious diseases in 2018-2020 (COVID-19) and 2002-2004 (SARS). The research used SAS 9.4 version and SAS EG for statistical analysis. Descriptive analysis includes the average and percentage of each department declaration; inferential statistics includes t-tests and regression analysis.
Results:In Taiwan, the COVID-19 pandemic from March to May 2020 was found to have the most prominent impact on healthcare institutions compared with the same period in 2019. For the SARS epidemic, the period from April to August 2003 was the time when Taiwan’s healthcare institutions were most impacted compared with the year before (2002), with both the numbers of outpatient and inpatient cases decreased. Notably, June in the year was the month when the numbers of general outpatient and inpatient cases decreased the most by 44.38% and 42.81%, respectively, while the number of emergency cases decreased in medical centers but rose in regional hospitals and district hospitals. For primary Western physician clinics, the number of outpatients decreased the most was in June 2003 (by 20.22%).
During the COVID-19 pandemic in 2020, the most impacted divisions included Pediatrics, Internal Medicine, Otolaryngology, and Family Medicine. Although the number of cases and healthcare expenses in primary clinics had seen a remarkable reduction, for some divisions in hospitals did not significantly decrease. However, during the SARS epidemic, hospitals were more significantly impacted, which was contrary to the aforesaid result obtained in the COVID-19 study.
Conclusions:Compared with 2019, in general hospital outpatient, emergency, inpatient and primary Western physician clinics outpatient healthcare utilization, showed a significant decline in 2020. It can be inferred that the service volume of healthcare institutions was remarkably impacted by the COVID-19 pandemic. Although the severity of the epidemic affected people's willingness to seek medical treatment in healthcare institutions, the numbers of outpatient, emergency and inpatient cases did not decrease prominently during the whole year except the period from March to May in 2020. The number of declaration cases unexpectedly showed an upward trend after May, which may be attributed to the effectiveness of Taiwan’s national defense policy. Seen from the overall number of outpatient cases, primary Western physician clinics found a significant decline during the COVID-19 pandemic, in contrast to hospitals where no significant decline was found. However, during the SARS epidemic, hospitals were found to have a statistically significant decrease in the number of outpatient cases, but primary Western physician clinics were not prominently impacted. It can be seen that during the two epidemics, different types of healthcare institutions had borne discrepant impacts. This is presumably ascribed to the constantly growing service capacity of healthcare institutions as a result of the increasing numbers of primary Western physician clinics and practicing physicians, as well as the promotion of graded medical treatment since 2018 that was expected to strengthen primary clinics.
In terms of the overall number of outpatients, the most affected healthcare divisions in primary clinics mainly included Pediatrics, Family Medicine, Internal Medicine, and Otolaryngology. Different from hospitals, the four major divisions in primary clinics had seen negative growth in 2020 in terms of the number of outpatient cases and healthcare expenses, but the impact of the pandemic was considerably lessened compared with 2019. This situation should presumably be attributed to the still spread of the COVID-19 pandemic as of December 2020 and the high transmission and strong pathogenicity of the virus, which had discouraged people’s willingness to seek treatment and indirectly resulted in the failed recovery of the utilization of healthcare services in the four major divisions of primary clinics.

並列關鍵字

COVID-19 ； healthcare service volume ； different level of healthcare service provider ； pandemic ； division

參考文獻

Abtahi‐Naeini, B., Saffaei, A. (2020). COVID‐19 and elective cosmetic procedures: Asymptomatic transmission in epidemic area and subsequent burdens. Journal of Cosmetic Dermatology.

Al-Dorzi, H. M., Aldawood, A. S., Khan, R., Baharoon, S., Alchin, J. D., Matroud, A. A., . . . Arabi, Y. M. (2016). The critical care response to a hospital outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: an observational study. Annals of intensive care, 6(1), 1-11.

Birkmeyer, J. D., Barnato, A., Birkmeyer, N., Bessler, R., Skinner, J. (2020). The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States: Study examines trends in US hospital admissions during the COVID-19 pandemic. Health Affairs, 39(11), 2010-2017.

Bolger, J., Kelly, M., Whelan, C., Doyle, A., Frizelle, H., Boyd, W., . . . Conneely, J. (2020). Public‐private partnership: strategies for continuing urgent elective operative care during the COVID‐19 pandemic. The British Journal of Surgery.

Boutis, K., Stephens, D., Lam, K., Ungar, W. J., Schuh, S. (2004). The impact of SARS on a tertiary care pediatric emergency department. Cmaj, 171(11), 1353-1358.