台灣醫院急診利用的影響因素分析

An Analysis on the Influencing Factors of Hospital Emergency Department Utilization in Taiwan

李偉民(Wei-Min Lee)

指導教授 ： 楊哲銘

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2014年)

https://doi.org/10.6831/TMU.2014.00039

摘要

中文摘要
台灣在1995年3月1日全面實施全民健保後，不僅降低民眾就醫的負擔，更大幅提高了就醫可近性，但因民眾缺乏分級就醫的觀念使得大醫院人滿為患，而把急診當做快速門診的錯誤就醫習慣，更是使真正需要利用急診醫療的病人得不到緊急醫療救助；為了讓急診部門能被急重症的病患充分使用，協助醫院經營者在規畫急診部門時能規畫妥善的經營策略，因此探討急診醫療利用的影響因素就顯得格外重要。
目的:探討2004年至2010年間不同醫院之急診部門醫療利用情形、進一步分析不同權屬別、醫院層級及不同地區別的醫院急診利用之差異；並透過計算急診賀芬達指數來瞭解台灣醫療網裡17個醫療區的急診競爭情況。
方法:本研究利用國家衛生研究院的健保資料庫之資料，選取2004年到2010年間「門診處方及治療明細檔（CD）」系統抽樣檔為急診的病患，在串連「醫事機構基本資料檔（HOSB）」、「醫事機構病床主檔（BED）」後，選取民眾到醫學中心、區域醫院及地區醫院之急診部門就醫之相關資料進行分析。
結果:在病人特質變項中：男性就醫人次及平均費用皆高於女性；以19-44歲最多，雖然65歲以上比例最少，但平均費用卻最高；就診科別方面以急診醫學科佔最多，不分科佔最少但平均費用卻最高。醫院特質變項中：就醫人次以區域醫院最多、地區醫院最少，平均費用以醫學中心最高、地區醫院最少；權屬別方面，以法人醫院就醫人次最多、私立醫院最少，但平均費用法人醫院與公立醫院相近，私立醫院最少。相較於非假日，假日至急診就醫人次顯著的較高，但平均費用卻顯著的較低。在進一步分析全台灣醫療網17個醫療區中急診部門的賀芬達指數後，發現近年來位於中賀芬達指數區域的醫院就醫人次顯著的持續增加；而位於低度賀芬達指數之高競爭區域的醫院，平均急診費用顯著較高。
結論與建議:雖然台灣目前急診病人的就醫人次以年齡19-44歲最多，65歲以上合併多重慢性病的老人平均費用最高，但對已邁入高齡化社會的台灣，急診的醫療需求會逐年增加，政府部門應對老人醫療應更加用心與重視；近幾年來區域醫院急診就醫人次不斷增加、導致地區醫院快速萎縮，醫政單位應重視並鼓勵地區醫院持續開設急診部門以維持急診醫療的可近性；由賀芬達指數分析瞭解，位居中度急診競爭程度的醫院，急診收入逐年的上升，這提供醫院的經營者如果在中度競爭程度區域規劃急診部門時，規模較大設備完善的急診部門會為醫院帶來不錯的財務收益；在低度競爭程度區域，政府應補助醫院急診部門的開設，以維持醫療可近性；在高度競爭程度區域，政府應監督其各項急診品質指標，以確保急重症急診病患能獲得良好醫療照顧。

關鍵字

急診 ； 急診醫療利用 ； 賀芬達指數

並列摘要

Abstract
Since the implementation of National Health Insurance (NHI) in Taiwan on March 1st, 1995, people’s burden for receiving medical treatment has been lessened, and medical care availability has been enhanced substantially. However, the ignorance about medical service hierarchy causes people flock to big hospitals, taking emergency service as “fast outpatient service”, and thus excludes patients who are really in need for emergency medical care. Therefore, it is really important to explore the factors that influence people’s use of emergency service in order to help hospital executives scheme appropriate operation tactics, allowing the emergency department to be fully used by emergency critical patients.

Objectives: To investigate the use of emergency service in different hospitals during year 2004 to year 2010, and then analyze the difference of using emergency service in hospitals of different ownerships, levels and regions. To understand the competition of emergency service in the 17 medical regions of Taiwanese medical system by calculating the Herfindahl index.

Methods: This research uses data in National Health Insurance Research Database of National Health Research Institutes, picking out emergency patients from the “Ambulatory care expenditures by visits (CD)” files from 2004 to 2010 and connecting to “Registry for contracted medical facilities (HOSB)” and “Registry for contracted beds (BED)”, then selects data about people receiving medical treatment in emergency department of medical centers, metropolitan hospitals and local community hospitals for analysis.

Results: Patient factors: Regarding to the number of visits and the average expense, male patients have higher result than female patients in both factors; the highest is the 19-44 year-old group. Although the above 65 year-old group has the lowest number of visits, it has highest average expense. Hospital factors: The number of visits is highest in metropolitan hospitals, and lowest in local community hospitals, while the average expense is highest in medical centers and lowest in local community hospitals. In regard to ownership factor, the number of visits is highest in corporal hospitals and lowest in private hospitals, yet the average expense is quite close in corporal hospitals and public hospitals, and lowest in private hospitals. Further analysis of the Herfindahl-Hirschman index of the emergency department in hospitals of the 17 medical regions in Taiwanese medical system leads to the discovery that in recent years, the number of visits has increased continually in hospitals of medium Herfindahl-Hirschman index region. In highly competitive (low Herfindahl-Hirschman index) region, the average emergency service expense is significantly higher.

Conclusion and suggestions: Although the number of visits to emergency service is highest in group age 19-44 year-old, and the average expense is highest in group above 65 year-old with multiple chronic diseases, the need for emergence service is increasing because Taiwan is gradually becoming an aging population country. The government should pay more attention to elderly health care. During the recent years, the number of visits to emergency department increases incessantly, causing fast recession in local community hospitals. The medical authority should take account to it and encourage local community hospitals to set up emergency department to increase emergency medical service availability. The fact that hospitals in regions of medium Herfindahl-Hirschman index have rising incomes from emergency service provides hospital executives a future that while setting an emergency department in medium competitive region, one of a larger scale and with better equipment may bring better financial benefits to hospital. In low competitive regions, the government should subsidize emergency service to maintain better medical service availability. In highly competitive regions,the government should supervise each emergency service index to ensure emergency critical patients receive good medical care.

並列關鍵字

Emergency Department ； Emergency Medical Utilization ； Herfindahl-Hirschman Index

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