急診急性冠心症轉出個案後續就醫探討

The study of reciprocal transfer for acute coronary syndrome patients in emergency department in Taiwan

林麗馨(Li-Hsin Li)

指導教授 ： 李亞欣

中山醫學大學/健康管理學院/醫療產業科技管理學系碩士班/碩士(2016年)

摘要

研究目的：日前國內雖有明文規範轉診制度及醫院分級制度，但無強制規定分級收費差異加上部分負擔規範讓各級醫院的看診費用差異不大，就醫變成自由選擇機制，導致轉診制度遲遲無法落實。本研究因近期觀察某一地區醫院急診轉診原因分析，因無心導管室轉出原因占第一，發現轉出個案再轉回就醫追蹤比例低，以致醫院轉診率高與回診率低的情況，故欲探討查看全民健康資料庫的資料了解急診就醫疑似急性冠心症(ACS)患者，轉出後有執行緊急冠狀動脈介入術術後返診回原轉出醫院的就醫用藥的情況。
研究方法：本研究資料來源為全民健康保險資料庫(NHIRD)2010年的百萬人承保檔，篩選出2012年第一次被申報罹患急性冠心症且經由轉診有執行緊急冠狀動脈介入術個案共計63位，且有追蹤後續一年用藥紀錄共計664次，分析方法使用SPSS 20.0以描述性統計及卡方檢定進行各變項與返診就醫機構及就醫次數的關係。另利用某一地區醫院的病例回溯方式，查看疑似該病症患者轉出後計40位，返院持續就醫追蹤的比例是否與全民健康保險資料庫相符。
研究結果：本研究資料庫篩選後樣本數共計63位，顯示男生發生率是女性的3.2倍。再以交叉分析進一步了解70歲以前的男女性別發生率約5.2：1、71歲後約1.4：1與文獻相符，女性70歲後女性發生率與男性差距逐漸縮小。而從本研究63位個案，術後出院返回原就醫醫院僅25.15%，且定義術後用藥滿一年為使用血小板藥物就醫次數達12次者，僅有47.4%表示再次急性冠心症的機率很高，值得作為政府對民眾再宣導的議題之一。
結論：急診急性冠心症患者若經轉診後至較高層次醫院進行PCI術後追蹤用藥機構情況，僅有25.15%術後回原轉出醫院持續追蹤。術後個案返診用藥一年的就醫次數仍偏低，有52.6%的患者無遵從醫師指示用藥。而性別、年齡、投保區域、投保金額對於術後選擇用藥次數有顯著差異、但對於就醫總次數而無明顯差異。二、病歷回溯的返診率僅12.5%相較資料庫的返診原就醫醫院低。

關鍵字

急性冠心症 ； 轉診 ； 就醫次數 ； 返診率

並列摘要

Objective：Nowadays, no mandatory classification of payment and the rule of copayment make no obvious difference payment at all levels of the hospital, So the healthcare mechanism actually makes patients can choose whichever level of hospital they want without any additional financial burden, although there are clear guidelines of hospital referral system and classification system. It leads to the delays of referral system implementation. This study based on the observation of a certain area hospital emergency referral reason analysis. The rate of non-catheterization operation is the highest among the referral rates and those patients are seldom returned to this hospital which results in high referral rate and low return rate. Therefore we focus on the database of National health library Resources for emergency medical treatment of suspected acute coronary syndrome (ACS) patients after catheterization operation who referral out and return back to the original diagnosis hospital for medical treatment and drug agency.

Method：The sources for the study of health insurance database (National Health Insurance Research Database, NHIRD) 2010 years, selected in 2012 for the first time was suffering from acute coronary syndrome and reporting via the Executive urgent referral percutaneous coronary intervention cases total 63, and there is follow-up by a total of 664 times a year medication record. Another use case back to a district hospital way to view suspected acute coronary syndrome patients in emergency feeding and after cardiac catheterization Executive meter 40 after a high-level hospital, return to the hospital for medical treatment continue to track whether the proportion of National Health Insurance Information library match. Analysis using SPSS 20.0 using descriptive statistics, and chi-square test were relationships among variables and return mechanism and attending physician for medical treatment times.

Results：
Total of 63 samples in this study, the incidence of men is 3.2 times higher than women. By cross-analysis methods that find before the age of 70 male and female incidence of about 5.2: 1,and after 71-year-old about 1.4: 1 is consistent with the literature, 70-year-old female after female incidence gradually narrowing the gap with men. In this study, after discharge returned to assist the referral hospital only 25.15%, and is defined as the use of at least one year after treatment platelet drugs up to 12 times, only 47.4% expressed a high probability of acute coronary syndrome again, it is worth as one of the government to the people again advocacy issues.

Conclusion：
Emergency patients after acute coronary syndrome if referral to a higher level by the hospital for PCI, referral out and return back to the original diagnosis hospital only 25.15% after feeding back into the hospital to keep track .Tthe cases back to the number of drugs a year is still low, 52.6% of patients without medication compliance with physician instructions. The gender, age, insured area, there are significant differences between the insured amount for the choice of drugs after the number, but no significant difference in the total number of medical treatment.

並列關鍵字

acute coronary syndrome ； referral ； track time ； return rate

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