影響病人違背醫囑自動出院之因素探討─以某區域醫院為例

The Study of Against Medical Advice Discharge Factors-A Reginal Hospital Experience

高淑琴(Shu-Chin Kao)

指導教授 ： 黃崇謙

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(2006年)

摘要

本研究旨在探討影響違背醫囑自動出院病人在個人及醫療因素上的特色，病人與臨床醫師對於醫療服務的期待與感受之間的差異。以北部某區域醫院350位違背醫囑自動出院病人個案病歷分析，及隨機挑選同時期350位經醫師許可出院病人為研究對象，利用回溯性資料進行分析，採用Logistic Regression預測各變數發生之機率，另模擬PZB模式設計結構式問卷測量違背醫囑自動出院病人及臨床醫師對於醫療服務期待與感受之落差缺口。 研究結果發現違背醫囑自動出院病人與醫師許可出院病人在人口學特質及醫療因素上均有顯著差異，以羅吉斯迴歸分析，預測其發生違背醫囑出院之機率：內科病人為外科病人的2.99倍、從急診簽住院為門診簽住院的2.32倍、無住院經驗者為有住院經驗者的1.82倍、男性為女性的1.57倍，另居住在當地及住院期間有人陪伴者發生違背醫囑出院之機率明顯較低（p＜0.001）。在醫療結果方面，預測出院後14天再住院率違背醫囑自動出院為醫師許可下出院的 2.06倍。有關違背醫囑出院病人及醫師對於醫療服務的期待與感受，利用問卷資料統計後發現，在PZB模式之服務五大構面無論是有形性、可靠性、反應性、關懷性、保證性皆達顯著差異，其中以關懷性的落差最大。 依據研究結果建議臨床醫療人員當病人住院進行評估時，若有易違背醫囑出院之特質，則應儘早與病人討論並擬定醫療計畫，以降低違背醫囑出院機率，縱使其出院後亦能有完善的醫療照護體系接手。此外，考量病人出院是在尚未完成治療之階段，基於尊重病人自主權及避免後續爭議，完整的文件記錄是必要的。舉辦醫療人文教育對臨床服務工作者而言有助於醫病關係及醫療品質之提升，可以促進醫療服務之可近性。

關鍵字

違背醫囑自動出院 ； 醫療服務之期待與認知 ； PZB模式 ； 缺口理論

並列摘要

Objectives: This study investigates the against medical advice (AMA) discharges concludes that the majority of the AMA patients leave hospitals for personal and medical reasons. There are medical perception and experience gaps between patients and physicians. Methods: A retrospective chart review and a matching survey based on PZB model was performed. A total of 350 AMA patients discharged from a regional teaching hospital were compared retrospectively with another 350 general physician-approved discharged patients during the same period. The questionnaire compares the medical perception and experience from patients discharged AMA and their attending physicians. Results: Patients who leave hospital against medical advice differ from the general patient population. Logistic regression was performed to predict discharge status from the admission factors. They include a higher proportion of male gender (odds ratio [OR] 1.57; 95% confidence interval [CI] 1.12~2.19),non-hospitalization experiences (OR 1.82; 95% CI 1.33~2.47), admission through the emergency department (OR 2.32; 95% CI 1.63~3.32), general medical patients(OR 2.99; 95% CI 2.11~4.23), living in other city (p＜0.001) and lack of accompanying at the time of admission (p＜0.001). Predicators of readmission with 14days(OR 2.06; 95% CI 0.9651~4.38). Regarding medical perception and experience appear to be significant on reliability, assurance, responsiveness, and empathy aspects. The largest gaps in five constructed differentials is empathy. Conclusions: The study establishes a profile of AMA patients leave hospital. Early identification of targeted patients may facilitate this process. Such as, early discharges planning for appropriate outpatient treatment are recommended, thereby decreasing readmission and improving health outcomes. One challenge that patients who leave hospital AMA authority may not best interest and the doctrine of informed consent, so comprehensive documentation should be planned and reinforced. It has been suggested in postgraduate medical education. Healthcare quality professionals should also receive formal training on patient relations as part of the management program, programs to improve continuity of care and to provide easier access to the health care system.

並列關鍵字

against medical advice (AMA) discharges ； medical perceptions and experience ； PZB model ； Gaps theory

參考文獻

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