手術預防性抗生素品質指標監測成效評估－以開腹式子宮切除術為例

Assessment on monitoring antibiotic prophylaxis for abdominal hysterectomy

蔡素玲(Su-Ling Tsai)

指導教授 ： 柯承恩

共同指導教授 ： 劉順仁

國立臺灣大學/管理學院/高階公共管理組/碩士(2005年)

https://doi.org/10.6342/NTU.2005.02226

摘要

本研究以開腹式子宮切除術為例，探討民國89年至91年間參加台灣醫療品質指標計畫（TQIP），手術預防性抗生素使用品質指標監測成效。研究概分為三大部分：（1）以描述性方式評估開腹式子宮切除術預防性抗生素使用各細項指標之監測結果；（2）探討開腹式子宮切除術預防性抗生素使用指標趨勢變化與醫療資源耗用之關係；（3）以焦點團體方式討論影響開腹式子宮切除術預防性抗生素使用之介入因素。
　　研究發現，研究期間開腹式子宮切除術使用預防性抗生素國內醫界已有高度共識，達95％，手術感染率亦維持穩定於0.5﹪左右。開腹式子宮切除術預防性抗生素之使用時機，劃刀前2小時使用預防性抗生素比率由44%提高至82%；劃刀前30分鐘使用預防性抗生素比率由民國90年40﹪進步到91年之54﹪，至91年底並已超越國際。至於預防性抗生素使用期間小於等於24小時比率於實施TQIP後已有顯著提升，由17﹪提高至41﹪，但仍有將近60﹪的個案未能符合預防性抗生素使用原則，與國際比較仍有改善空間。各項指標監測敏感度醫學中心高於非醫學中心，公立醫院高於私立醫院。開腹式子宮切除術論病例計酬個案平均藥費於實施TQIP前後大幅下降，其中90%為抗生素費用，平均每個案抗生素費用減少796元，降幅平均達44%，且預防性抗生素使用小於等於24小時達成率愈高，平均每個案抗生素費用愈低。非實驗組醫院該手術抗生素費用亦有下降趨勢。
　　適當的預防性抗生素使用可提升醫療品質，亦同時達醫療費用控制之目的。其指標監測成效，涉及醫院對預防性抗生素使用流程之組織行為改變，與臨床醫師對預防性抗生素處方行為之改變，須應用權變理論，營造有實證基礎之醫院內、外標竿學習環境，亦須內外部政策的介入。TQIP提供有實證基礎之自發性預防性抗生素使用監測機制，並提供國內、外預防性抗生素使用標竿學習機會，經由霍桑效應、學習效應與激勵效應，促進醫療品質之改善。
　　本研究建議醫院應持續監測預防性抗生素使用時機和使用期間，並同時監測手術傷口感染率，及營造促成改變之標竿學習環境；建議有關單位和主管機關擴大評估各項手術預防性抗生素使用成效，並訂定相關指引及管理規範。

關鍵字

開腹式子宮切除術 ； 預防性抗生素 ； 品質指標 ； 成效評估 ； 醫療資源耗用 ； 組織行為

並列摘要

The purpose of this study is to evaluate the effects of monitoring medical care quality through the indicators of antibiotic prophylaxis, using abdominal hysterectomy as an example for the hospitals that were participating in the Taiwan Quality Indicator Project (TQIP) from 2000 to 2002. This study is composed of three parts, (1) to evaluate the outcomes of all sub indicators of antibiotic prophylaxis for abdominal hysterectomy by descriptive analysis, (2) to examine the relationship between the trends of those indicators and the utilization of medical resources, (3) to understand the influential factors for the use of antibiotic prophylaxis for abdominal hysterectomy by the focus-groups method.

The major finds are as the following: (1) the use of antibiotic prophylaxis for abdominal hysterectomy has been highly agreed (i.e., as high as 95%) among the practitioners in Taiwan, the surgical wound infection rate of this operation has been kept steady at 0.5% along the study years, (2) the rate of recriving antibiotic prophylaxis within two hours of incision has been risen from 44% to 82%, the rate of receiving antibiotic prophylaxis within 30 minutes of incision has been risen from 40% to 54% in one year (i.e., from 2000 to 2001) and this rate has exceeded the international level from year 2002, (3) as for the rate of receiving antibiotic prophylaxis for a duration of 24 hours or less has been risen significantly from 17% to 41%, however, there are still 60% participant hospitals do not meet the standard which indicates there is still room for improvement, (4) for all the indicators analyzed, the performance among medical centers are better than other hospitals and public hospitals are better than private hospitals, (5) the drug cost for the case payment of antibiotic prophylaxis for abdominal hysterectomy has been reduced largely, the reduction is mainly from the reduction of antibiotics, on average, the reduction is NT$796 per case which is 44% of the drug cost, and the reduction is larger when the rate of receiving antibiotic prophylaxis for abdominal hysterectomy within 24 hours or less is higher. The non experimental hospitals have a slight reduction in the drug cost during the study period.

Based on the findings of this study, appropriate use of antibiotic prophylaxis can improve the quality of medical care and control medical cost at the same time. The performance of monitoring quality depends on organization behavioral change for the process of administering antibiotics prophylaxis in the hospital, as well as changes of prescribing behavior of the physicians. It is useful to use contingency theory to form evidence based bench marking and the intervention of relevant policies from within and outside the hospital. TQIP has provided this mechanism through voluntary participation and provision of reference information from Taiwan and international bench marking. The hospitals are motivated and learned from each other through Hawthorne effect and incentive effects which lead to improvements in the quality of medical care.

The author suggests hospitals should continue to monitor the timing and duration of administering antibiotic prophylaxis, also, hospitals should monitor the surgical wound infection rate and create environment for improvement and bench marking. Policy makers and authorities should expend the scope of evaluation for the performance of antibiotic prophylaxis, and should establish related guidelines and principals for management of medical care quality.

並列關鍵字

antibiotic prophylaxis for abdominal hysterectomy ； antibiotic prophylaxis ； quality indicator ； assessment of performance ； utilization of medical resources ； organization behavior

參考文獻

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