精神分裂症患者醫療資源使用之影響因子探討

Effects of patients with schizophrenia on the utilization and expenditure of medical services

林偕益(Jie-Yi Lin)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/公共衛生學研究所碩士在職專班/碩士(2004年)

摘要

目的：探討影響精神分裂症患者醫療資源使用之因子，提供健保未來規劃精神分裂症給付制度及機構決策之參考，以提升對精神分裂症患者優質的治療服務。
研究方法：以全民健保1999年1月1日至1999年6月30日期間診斷代碼顯示為精神分裂症(ICD-9-CM代碼為295)之個案入院之病患為研究樣本，共4415位病患，於當次住院醫療費用，及個案出院後一年內之門、住、急診次數，和醫療費用為主要分析資料。採用SPSS統計軟體進行資料整理及統計分析，分為描述性統計、推論性統計方法分析，最後並利用多變項迴歸統計分析法建立以病患特質、疾病特質、醫療提供者特性為因子的醫療資源利用預測模組。
研究結果：本研究發現（1）精神分裂症患者在住院日數以及醫療費用上的變異性相當大。（2）影響住院醫療費用的因素依次為住院日數、住院狀態、醫院層級、健保區域及是否有合併症。住院醫療費用以住院日數長、急性病床、醫學中心、中區與台北分局、有多重診斷者發生費用較高；性別與年齡層則無影響。（3）以精神分裂症病患當次的住院醫療相關因子預測出院後一年內之醫療資源使用情形，無論再住院次數、門診次數或是醫療費用方面，預測效果有顯著，但預測能力不高。（4）關於出院後之醫療品質，住院日數較長者於一年內急診利用、及出院後14日內再住院機率，皆比短期住院者較高。（5）在醫院類別方面，於精神專科醫院住院的病患所發生的金額高於一般綜合醫院住院的病患；但是以每人日費用的比較上，一般綜合醫院住院者所發生金額反較高。
結論：精神分裂症病患的住院日數及醫療費用變異性相當大，且住院日數為住院醫療費用的最大影響預測因素，因此醫療機構在面對論質計酬制度時應宜設法檢討建立精神分裂症的臨床治療規範，以降低個別治療上的變異性；另外同時結合社區照護系統或療養機構，避免病患長期滯留，以兼顧優質的照護品質。

關鍵字：縱貫性研究、精神分裂症、合併症、醫療資源使用

關鍵字

精神分裂症 ； 縱貫性研究 ； 醫療資源使用 ； 合併症

並列摘要

Purpose: This study aims to analyze factors influencing medical utilization and costs in patients with schizophrenia. The method could be used as a source of reference for the Bureau of National Health Insurance (BNHI) to implement quality service and the reimbursement of fees.

Methods: Claims data of the BNHI was used as the data source for analysis. A total number of 4,415 subjects with the diagnosis of 295 on ICD-9-CM admitted for treatment from Jan 1st to June 30th, 1999 were examined. They were analyzed for the cost of each hospitalization, and one-year follow-up for the outpatient and emergency visits. Multiple regression models were applied for the prediction of utilization and costs with various factors involving patients’ characteristics, illness severity and comorbidity, and the medical resources provided.

Results: Main findings of the analyses are as follows: First, there were great variations in the length of hospitalization and the total costs. Second, factors influencing the cost of hospitalization were days of treatment, types of admission, hospital levels, presence of comorbidity, and different offices of the BNHI in their reimbursement. Higher costs were found in longer length of hospitalization, acute ward, and medical centers, with comorbidity, the BNHI offices responsible for Taipei and Taichung (middle Taiwan region). Age and gender of schizophrenic patients, however, exerted no significant differences. Third, the costs for each admission was predictive for higher utilization of medical resources in one-year follow-up, readmission rate, outpatient visits and the total costs. Fourth, those with longer length of admission had higher risk of readmission within 14 days of discharged and higher utilization of emergency services. Fifth, the overall costs of treatment was higher in the mental than the general hospitals, but the per day cost of treatment was higher at the general hospital setting.

Conclusions: There was a wide variation in the costs of treatment for inpatient schizophrenia, and it was mainly accounted for by the differences in their length of hospitalization. A therapeutic guideline for inpatient treatment of schizophrenia is suggested, to narrow such differences and to enhance a quality treatment. Other treatment modalities like community mental health service is also suggested in order to avoid long-term stay in inpatient treatment of schizophrenia.

Keyword：follow-up study、schizophrenia、comorbidity、utilization

並列關鍵字

follow-up study ； schizophrenia ； comorbidity ； utilization

參考文獻

一、中文參考文獻

1. 中央健康保險局(2002)，第二代精神用藥健保使用新方向與須知，台北

2. 吳景寬(2004)，從醫學中心到基層醫療院所兼談精神分裂症論質計酬方案，精神醫學通訊，23(1):5

3. 李新民(2003)，急性精神分裂症個案實施臨床路徑照護之可行性探討，長庚大學醫務管理研究所碩士論文

4. 周立修(2003)，精神分裂症患者長期住院預測因子探討－以某精神科專科教學醫院為例，高雄醫學大學公共衛生研究所在職專班