於衛生所就醫之慢性病患者回診行為與COVID-19疫情之關聯性

研究背景： COVID-19大流行自2020年初於全球開始快速蔓延，截至2022年7月31日全球已累積超過5億確診案例，對於民眾的生活、健康和醫療服務使用都造成極大的衝擊，尤其是有慢性病患者表示在疫情期間更有可能放棄醫療保健之服務，甚至有醫療服務中斷之現象發生，然而慢性病患者需長期服藥控制病情，理應不該因疫情而影響回診，因此本研究欲探討於社區基層醫療機構就診之慢性病患者其回診行為是否會受到疫情影響。研究目的： (1)透過衛生所之就醫紀錄，描述2018至2021年彰化縣二水鄉衛生所門診量在COVID-19疫情全球大流行前後之變化；(2)透過衛生所之就醫紀錄，分析2018年至2021年慢性病患者的回診行為與國內COVID-19疫情變化之關聯性；(3)針對藥物到期日遇到疫情事件日之持有長期處方籤的慢性病患者，分析其長期處方籤回診狀況與疫情事件日之關係。材料與方法：本研究為回溯性之次級資料分析，採用彰化縣二水鄉衛生所之2018至2021共四年之就醫紀錄，人次檔共270,629筆，人日檔共24,444筆，歸人後共9328人。選定糖尿病、高血壓及腎臟病主要探討之慢性病，並界定與彰化縣相關之疫情事件日有二：其一為彰化白牌計程車司機事件日(為2020年2月19日至2020年2月28日)，其二為彰化水果商傳播鏈+升三級警戒事件日(為2021年5月13日至2021年7月26日)。長期處方籤之持有係以人日檔之歸人認定為有開長期處方籤之依據，長期處方籤回診狀況係先計算就診間隔(下次就診日期減處方籤到期日)，並分為正常(與處方籤到期日間隔7天前～3天後)與延遲(與處方籤到期日間隔4天～30天後)兩類。使用卡方檢定、適合度檢定、ANOVA檢定、獨立t檢定、Wilcoxon rank sum test及邏輯斯回歸等統計方法進行分析。結果： (1)衛生所門診總量於2021年顯著低於2018-2020年之門診總量 (P<.0001)；(2)每日門診總量、一般醫療門診量、預防保健門診量、其他門診量的平均就診人數在彰化水果商傳播鏈+三級警戒事件日時顯著低於非疫情事件日 (P<.0001、P<.0002、P<.009、P<.002)；(3)針對持長期處方籤之糖尿病或高血壓或腎臟病之患者，在疾病組合(單純只有腎臟病、有糖尿病+高血壓、有糖尿病+腎臟病及有糖尿病+高血壓+腎臟病)及居住地在其他地區的人比單純只有高血壓及居住在彰化縣二水鄉的人，其延遲回診的機會分別是2.45倍、0.81倍、0.79倍及0.75倍，但與疫情事件日、性別及年齡無統計顯著相關；(4)針對持長期處方籤之糖尿病或高血壓或腎臟病患者在非疫情事件日曾經有延遲紀錄的人比未曾有延遲紀錄的人，在疫情事件日有延遲紀錄的機會是5.37倍，與社會人口學特徵無統計顯著相關。結論：本研究發現，彰化縣二水鄉衛生所雖然門診總量及每日門診人數在COVID-19大流行後有顯著低於大流行之前，但是慢性病長期處方籤患者之門診量並沒有顯著差異。至於持長期處方籤之慢性病患者是否延遲回診也與COVID-19在台灣的疫情事件日無關。研究限制及重要建議：研究限制：本研究資料為單一鄉鎮及基層醫療機構(衛生所)之就醫紀錄，可能無法推估至其他縣市與其他層級之醫療機構。重要建議：建議可擴大研究範圍至(1)同一縣市所有衛生所的門診資料、(2)同一縣市不同層級之醫療機構、(3)台灣地區不同地區(北中南)、都市化或疫情流行程度，或可擴大分析之時期(如2022年5月台灣爆發社區大流行)，並使用不同的研究方法(如質性研究)，以分析不同狀況下的門診量與就醫行為之差異。

關鍵字

COVID-19 ；慢性病；就醫行為；衛生所

並列摘要

Background： The COVID-19 pandemic has spread rapidly around the world since the beginning of 2020. As of July 31, 2022, there have been more than 500 million confirmed cases in the world, which has caused a huge impact on people's life, the utilization of health and medical service, especially those with chronic diseases indicated that they were more likely to give up medical care services during the epidemic, and even the phenomenon of medical service interruption occurred. However, patients with chronic diseases need to take long-term medication to control their conditions, and should not be affected by the epidemic. Therefore, this study intends to explore whether the return visit behavior of patients with chronic diseases in community-based primary medical institutions will be affected by the epidemic. Objectives: (1) Through the medical records of the health center, describe the changes in the outpatient volume of the Ershui Township Health Center in Changhua County from 2018 to 2021 before and after the COVID-19 pandemic. (2)Analyze the correlation between the return visit behavior of chronic disease patients and the changes of the COVID-19 epidemic in Taiwan from 2018 to 2021 through the medical records of the health centers. (3) For chronic disease patients with long-term prescription whose rescription expiration date was during the epidemic event , analyze the correlation between their long-term prescription return visit status and the epidemic event. Methods: This study is a retrospective secondary data analysis, using the four-year medical records of Ershui Township Health Center in Changhua County from 2018 to 2021, with a total of 270,629 records per person, 24,444 records per person per day, and a total of 9328 people. Diabetes, hypertension, and chronic kidney disease are selected as the main chronic diseases to be discussed, and two epidemic events related to Changhua county are defined: one is the Changhua taxi driver event (from February 19, 2020 to February 28, 2020), the second is the chain of Changhua Fruit Merchant infection and the Nationwide level 3 alert event (from May 13, 2021 to July 26, 2021). Those who has a long-term prescription is based on the return of the person-day file as the basis for the issuance of a long-term prescription. The long-term prescription return visit status is based on visit interval (the date of the next visit minus the expiry date of the prescription) , and divided into two categories: normal (7 days before to 3 days after the expiration date of the prescription) and delayed (4 days to 30 days after the expiration date of the prescription). Statistical methods such as chi-square test, fitness test, ANOVA test, independent t test, Wilcoxon rank sum test and logistic regression were used for analysis. Results: (1) The total number of outpatient volume in health center in 2021 was significantly lower than the total number of outpatient volume in 2018-2020 (P<.0001); (2) The average number of daily outpatient visits, general medical outpatient visits, preventive health care outpatient visits, and other outpatient visits were significantly lower on the chain of Changhua Fruit Merchant infection and the Nationwide level 3 alert event than on the non-epidemic event (P<.0001 , P<.0002, P<.009, P<.002); (3) For patients with diabetes or hypertension or chronic kidney disease with long-term prescription, in the disease combination (chronic kidney disease, diabetes + hypertension, diabetes + kidney disease and diabetes + hypertension + kidney disease) and People living in other areas were 2.45 times, 0.81 times, 0.79 times, and 0.75 times more likely to delay the return visit than those with only hypertension and those living in Ershui township,however, there is no statistically significant correlation with the date of the epidemic event, gender and age; (4) For patients with diabetes, hypertension or chronic kidney disease who has long-term prescriptions, those who have had a delayed record on the non-epidemic event day are 5.37 times more likely to have a delayed record on the epidemic event day than those who have never had a delayed record. Demographic characteristics were not statistically significantly correlated. Conclusions: This study found that although the total number of outpatient visits and the number of daily outpatient visits in the Ershui township health center in Changhua county were significantly lower after the COVID-19 pandemic than before the COVID-19 pandemic, there was no significant difference in the number of outpatient visits for chronic disease patients with long-term prescriptions. As for patients with chronic diseases who hold long-term prescription ,there was no significant correlation between their delayed return behavior and the event day of the COVID-19 in Taiwan. Limitation Suggestions: Limitation: The data in this study are medical records of a single township and primary medical institutions (health center), and may not be estimated to other counties and medical institutions at other levels. Suggestions: It is recommended to expand the research scope to (1) outpatient data of all health centers in the same county and city, (2) medical institutions at different levels in the same county and city, (3) different regions in Taiwan (North, Central and South), urbanization or epidemic situation , or a period in which the analysis can be expanded (e.g., a community pandemic in Taiwan in May 2022), and different research methods (such as qualitative research) can be used to analyze the differences in outpatient volume and medical behavior under different conditions. In practice, more attention should be paid to patients with only a single chronic disease, and their return-visit behavior should be tracked more closely.

並列關鍵字

COVID-19 ； chronic disease ； medical behavior ； heath center

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