病患自控式止痛行為之研究與對醫療行政之建議

背景與動機：全民健康保險制度之實施是全台灣人民的福祉，造福了無數病患，但同時也帶給醫院經營管理的困難！全民健康保險制度以先前勞工保險支付制度為架構來進行制定，在這架構不理想的影響之下，加上後來經費不足，開始實施總額預算、點值折扣核刪，與檢討藥價差，醫院已是步入艱難時期。為了全民健康保險制度之永續經營，並維護醫療機構之合理經營與醫療品質，醫療機構管理者於全民健康保險制度外的自費市場亦應重視，已期求得經營的平衡。研究目的：病患自控式止痛是自費醫療服務，須利用機器與耗材，因新舊產品世代交替，衍生成本增加，在提高病患自控式止痛定價是否影響業績量的考量，藉此探討病患自控式止痛醫療行為模式，期對醫療行政有所建議，繼續提供更優良的醫療服務品質。研究對象與方法：本次研究對象選取北部某區域教學醫院之病患，有效樣本共66位病患接受本次問卷調查，病患自控式止痛方式選用靜脈注射途徑，調查對象選取第一或第二等級的病患來做研究，調查內容包括：性別、有無商業保險、居住地、收入、身高體重、手術類別、是否公務人員等，在麻醉前諮詢時隨機調查訪問，病患於當日手術後回病房後，無論是否接受病患自控式止痛之醫療，全部接受疼痛指數評估，隔日再做一次疼痛指數評估。研究結果：問卷之線性回歸等統計結果，使用病患自控式止痛會降低疼痛指數，驗證病患自控式止痛在手術後止痛有臨床上的意義；關節置換、開胸等手術之病患採用病患自控式止痛比例相對較高，應可鼓勵此類病患多加利用病患自控式止痛；性別、公務員、年齡層、保險種類、月收入、居住地卡方檢定結果與使用PCA與否無關。建議：因病患自控式止痛成本增加，在提高售價後一年內，並無影響病患自控式止痛總業績量，策略上應可繼續維持目前定價；統計分析結果，PCA對開胸手術呈正相關，對重症病患之術後止痛服務加強，應對醫院發展重症醫療應有正面之意義；鼓勵發展關節置換手術，提高其病患自控式止痛服務比例，讓術後病患減少疼痛，不再恐懼關節置換手術帶來之疼痛，甚至害怕接受手術，應可造成雙贏的局面；對於病患自控式止痛自費項目，應適時檢討其醫療與成本之關聯性，合理調整定價，期能提高醫療品質，畢竟好的醫療服務品質才是最佳的醫療成本控制。

關鍵字

病患自控式止痛；手術後疼痛；醫療行政

並列摘要

Background: The national health insurance is a blessing for the people of Taiwan! However, it challenges the management of the medical administration. The national health insurance is based on the structure of the foregoing labor insurance system which is a history now. Under the previous system, the bureau began to manage the total budget of national health insurance with discount of the point value and decreasing the discrepancy of the drug’s price. The running of a regional hospital becomes much more difficult! In our opinion, searching for the medical market of self-expense is important for the lasting of national health insurance system and the quality of medical institution. Purpose: Patient controlled analgesia (PCA) is a self-expense medical service in Taiwan. PCA should utilize a specific machine and intravenous set bundled with. New machine of PCA increases the cost of the PCA system. By working on this issue, we have marked up the price of PCA service to maintain to profit. In this study, we would like to investigate the market share and probe into the behavior of the patient for the PCA system. By providing better medical service, we hope that we can have some discovery in this study. Methods: We have sampled 66 patients from a regional teaching hospital in northern Taiwan. The method of PCA is by intravenous route. All the patients are ASA class I or class II. The items of census include gender, insurance, residency, income, body weight, body height, surgery and functionary. The census is completed at pre-anesthetic consultation except visual analogue score (VAS). The VAS is evaluated at day 0 and day 1 after the surgical operation. Results: According to the results of the linear regression, PCA has strong relations with the decreasing VAS. It interprets that PCA is effective on postoperative pain control. The operations of joint replacement and thoracotomy have higher ratio of applying PCA than others. We conclude that patients received these operations should have a PCA service. Chi-Square shows no significance about gender, functionary, age, insurance, incomes and residency. Strategy: After mark-up of PCA service, we find that the number of service keeps the pace as usual. A strategy for the medical administration might be the following: Ongoing the current pricing strategy is possible. Statistically, thoracotomy is highly related with PCA. Enforce the PCA service for the patient receiving major operation should have the positive meaning for developing the intensive medicine. Strategically, the developing of intensive medicine should be encouraged by the promotion of PCA service. By promotion of PCA, we encourage the surgery of joint replacement. The patient will not be afraid of post-operative pain to reject the operation. It will be a win-win situation. We should discuss the cost of PCA to adjust the pricing respectively and hope to provide better medical service. After all, the best control of cost is higher quality of medical service.

並列關鍵字

Patient controlled analgesia ； Postoperative pain ； Medical administration

參考文獻

2. Waldman, Steven D. Physical Diagnosis of Pain, An Atlas of Signs and Symptoms Saunders, Elsevier 2010

3. Levine, Wilton C. Clinical Anesthesia Procedures of the Massachusetts General Hospital Woofers Kluwer

4. Miller, Ronald D. Anesthesia Churchill Livingstone, Elservier 2010

5. Wall and Melzack. Text of Pain 5th Edition Churchill Livingstone, Elsevier 2006

6. Bready, Noorily and Dillman. Decision Making in Anesthesiology 4th Edition Mosby, Elsevier 2005

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病患自控式止痛行為之研究與對醫療行政之建議

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