臺灣健康照護體系病人經常就診醫師指標探索

研究背景：由於臺灣缺乏全面性家庭醫師制度或守門人的角色，加上民眾擁有高度的就醫自由，不須轉診便可至各層級的醫事機構就醫，致使分級醫療無法落實。在家醫計畫成效不如預期、醫療體系朝專科化發展的情況之下，民眾經常選擇專科醫師作為自己的主要基層醫療服務提供者。2016年健保署提出分級醫療政策，欲用實際行動改善無實質分級醫療，鼓勵民眾建立家庭醫師或經常就診醫師之觀念，由固定基層醫師為其健康負起責任。然而臺灣是否存有基層醫療的身影，哪些專科醫師可能受病人選擇為經常就診醫師以擔當基層醫療提供者，值得深入探討。研究目的：利用基層醫療之概念，發展病人經常就診醫師指標測量目前臺灣健康照護體系，哪些醫師較可能受病人選擇為經常就診醫師。研究方法：使用全民健康保險資料庫2007~2011年承保抽樣百萬歸人檔進行研究分析。研究設計分為三部分，第一部分為研究者發展之病人經常就診醫師指標，如：病人之就醫忠誠、病人就診頻率、舊病人占率等指標。第二部分由醫師過去看診初級照護疾病，作為探索病人經常就診醫師指標之效標，以效標關聯效度作為檢定效度的方法。第三部分利用接受者操作特徵曲線(ROC curve)找出指標最佳臨界值作為病人經常就診醫師指標判定依據，並對三項指標進行比較。研究結果：基層診所醫師看診初級照護疾病占率越高，與病人之就醫忠誠指標與舊病人占率指標有正相關性，在排除相關係數無統計顯著相關的專科別後，可以推論民眾可能將基層診所家醫科、內科、小兒科、婦產科醫師作為經常就診醫師；區域醫院層級以上的醫師，其看診初級照護疾病占率越低，在三項指標中一致地呈負相關的結果，表示區域醫院以上就醫的疾病類型可能偏向重症或難症，需要經常回診進行診療。結論：雖然三項指標效度尚可接受，但足以正確區別出病人經常就診醫師為哪些專科別，以及在區域醫院以上層級可一致地發現，非初級照護疾病之病人可成功自我轉診至三級醫療層級就醫。

關鍵字

基層醫療；經常就診醫師；分級醫療；專科化照護；效標關聯效度

並列摘要

Background: Taiwan not only lacks a comprehensive family physician system or a role of “gatekeeper”, but also allows people accessing to any medical care provider without being referred. Therefore, the situation leads to the hierarchization of services cannot be implemented. Along with the effectiveness of Family Physician Integrated Care Program is not as good as expected, and the medical system is developing towards the specialization, people usually chooses specialist as their primary care provider. In 2006, the National Health Insurance Administration strengthen the promotion of the Hierarchically Integrated Healthcare System that encourage people to first seek care at primary-level hospitals or clinics. In addition, it expects that people can have a regular source of care or a family physician to take the responsibility for their health. However, is it still presence of primary care in Taiwan? Which types of specialist could be choosing to be a regular source of care provided primary care practice? Objective: The aims of study are applying the concept of primary care to develop patients’ regular source of care indicators. Methods: The study used National Health Insurance Research Database from 2007 to 2011 for statistics analysis. The study design is divided into three parts. The first part is developing patients’ regular source of care indicators, including: patient loyalty, the frequency of visit and the proportion of old patient. In the second part, tracking the percentages of primary care diseases in outpatient visits, and used Criterion-related validity to validate the validity. The final part used the receiver operating characteristic curve (ROC curve) to find the optimal threshold of the indicator as the basis for the patients’ regular source of care indicator, and compared the indicators. Result: The higher percentages of primary care diseases in clinic outpatient visits, with positive correlation in patient loyalty and the proportion of old patient indicators. After excluding the specialists with non-significant correlation coefficient, it can be inferred that people choose Family Medicine, General Internal, Pediatrics, Obstetricians and Gynecologists as their regular source of care. And the lower percentages of primary care diseases in regional hospital and medical center outpatient visits, with negative correlation in three indicators. It can be inferred that types of diseases sought by the regional hospitals and medical center may be severe or difficult. That result in patients needed to revisit frequently. Conclusion: Although the validity of the three indicators is acceptable, it is enough to correctly distinguish which types of specialist could be choosing to be a regular source of care provided primary care practice. And people would “self-referred” to the tertiary care, when they thought it wasn’t primary care practitioner could help.

並列關鍵字

Primary care ； Regular source of care ； Hierarchization of services ； Specialty care ； Criterion-related validity

參考文獻

Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Q, 83(3), 457-502. doi:10.1111/j.1468-0009.2005.00409.x

江東亮、文羽苹、謝嘉容. (2014). 全民健康保險制度的發展與問題. 台灣醫學, 18(1), 33-42.