加護病房設置專責重症專科醫師對照護品質和醫療資源使用之影響 —以南部某醫學中心為例

Impact of the Intensivists System on Quality of Care and Resources utilization of Intensive Care Unit : Example of a Southern Taiwan Medical Center

鍾月枝(Yueh-Chin Chung)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2006年)

摘要

中文摘要
研究目的：評估加護病房設置專責重症專科醫師(Intensivists)對於醫療資源利用效益，醫療照護品質之提昇是否具長期成果。探討加護病房死亡率、醫院死亡率之風險因子。預測影響加護病房費用、天數的相關因素，藉以作為發展台灣專責重症專科醫師之實証資料。
研究方法：本研究設計採用類實驗研究法(Quasi-Experimental Study Design)，資料來源和樣本為某醫學中心內科加護病房1998-2005年病患，總共收集個案數為2007人。主要研究變項為性別、年齡、APACHE II分數、疾病型態、ICU死亡率、醫院死亡率、平均ICU天數、平均住院天數、平均呼吸器使用天數、平均ICU費用、平均ICU每人每日費用、預估死亡率。探討專責重症專科醫師設置之成效及影響ICU死亡率之風險因子，以及預測影響ICU費用、ICU天數的相關因素。分析方法採用SPSS for windows 12.0版軟體進行描述性分析、獨立樣本T檢定、單因子變異數分析、多元邏輯式迴歸分析、多元複迴歸分析等推論性統計分析。
研究結果：
1、 設置專責重症專科醫師後，除疾病嚴重度（APACHE II分數）較高外，病患人口特質方面無顯著差異。
2、 品質方面，平均ICU天數、平均住院天數、平均呼吸器使用天數、ICU標準化死亡比，均呈現明顯下降，醫療資源耗用方面，平均ICU每人每日費用，則呈現上升趨勢，但未達統計意義。
3、 ICU死亡率之風險因子方面，APACHE II 15-24分Vs.<15分者，Adjust OR為3.27；APACHE II?d25分Vs.??15分者Adjust OR為16.36。使用呼吸器Vs.未使用呼吸器者Adjust OR為4.65。設置前Vs.設置後Adjust OR為2.18。
4、 醫院死亡率之風險因子包含APACHE II分數、平均呼吸器使用天數、呼吸器使用狀況等因子。
5、 影響ICU費用的相關因素方面，包含APACHE II分數、疾病型態、平均ICU天數、呼吸器使用狀況等因素。
6、 預測影響ICU天數之重要因素，有APACHE II分數、平均呼吸器使用天數、呼吸器使用狀況等因素。
討論與建議：加護病房設置專責重症專科醫師可提高照護品質降低病患死亡率、加護病房天數、住院天數、呼吸器使用天數，減少醫療資源使用。換言之，設置後可兼具提高醫療品質和降低醫療資源使用效益。本結果為本土實證研究之證據，可作為日後實施之參考，並可提供衛生行政單位作為訂定或修訂支付制度指標的依據。
關鍵詞：專責重症專科醫師、Intensivists、重症醫學、醫療品質、醫療資源利用、加護病房

關鍵字

專責重症專科醫師 ； Intensivists ； 重症醫學 ； 醫療品質 ； 醫療資源利用 ； 加護病房

並列摘要

Abstract
Objective: To evaluate the effects of health resources utilization, care quality and long term influences after administration of full-time intensivists. Risk factors of both intensive care unit (ICU) and hospital mortality rates, ICU expenditures and ICU stay were also explored for affording an evidence base to develop intensivists in Taiwan.

Methods: Quasi-experimental study design method was used to study patients in a medical ICU of a medical center from 1998 to 2005. Totally 2007 patients was collected. Main study variants included gender, age, APACHE II score, disease patterns, ICU mortality rate, hospital mortality rate, ICU stay, hospital stay, ventilator days, total ICU expenditures, daily ICU expenditures and predicted mortality rate. The risk factors of ICU mortality rate, prediction factors of ICU expenditures and ICU stay were explored. Statistical analysis with SPSS for windows 12.0 edition was used for Descriptive Statistics, Two-Independent Samples T- Test, One-Way ANOVA , Multiple Logistic Regression Analysis and Multiple Linear Regression Analysis.

Results:
1. There is no significant differences in demographic characters of patients except APACHE II score is higher in after-intensivists group.
2. The care quality is better in after-intensivists group including ICU stay, hospital stay, ventilator days and ICU standardized mortality ratio. The daily ICU expenditures increases but doesn’t reach statistical significance.
3. The risk factors to of ICU mortality rate include: The adjust odds ratio (OR) is 3.27 in patients of APACHE II score 15-24 vs APACHE II <15; the adjust OR is 16.36 in patients of APACHE II score≧25 vs APACHE II score < 15; the adjust OR is 4.65 in patients using ventilator vs no ventilator. The adjust OR is 2.18 in before-intensivists vs after-intensivists.
4. The risk factors of hospital mortality include APACHE II score, ventilator days, ventilator use and input of intensivists.
5. The prediction factors for ICU expenditures include APACHE II score, diseases pattern, ICU stay and use of ventilators.
6. The prediction factors for ICU stay include APACHE II score, ventilator days and use ventilators.

Discussion and suggestions: The administration of full-time intensivists in the ICU can effectively reduce mortality rate, shorten patient’s ICU stay, hospital stay, using ventilator days and decrease utilization of health resources. In other words, both of care quality and health resources utilization are better after administration of intensivists. Our data can benefit for native evidence base to develop the introduction of full-time and provide some data for health administration department to make or modify the payment for critical care.

Key words: full-time intensivist, critical care medicine, medical are quality, health resources, intensive care unit

並列關鍵字

full-time intensivist ； critical care medicine ； medical are quality ； health resources ； intensive care unit

參考文獻

參考文獻

【中文部分】

1. 行政院衛生署衛生統計資料網：2004年衛生統計重要指標. http://www.doh.gov.tw/statistic/index.htm

2. 行政院衛生署衛生統計資料網：2004年衛生統計動向. http://www.doh.gov.tw/statistic/data/衛生動向/93/93.htm

3. 行政院衛生署衛生統計資料網：2004年衛生署醫療機構設置標準法. http://dohlaw.doh.gov.tw/chi/FLAW/FLAWDAT0202.asp