組織變革對降低跨區就醫的影響

The effect of hospital reorganization on reducing out-of-area heath care utilization

王明聖(Ming-Sheng Wang)

指導教授 ： 陳美美

長榮大學/健康科學學院/醫務管理學研究所/碩士(2009年)

https://doi.org/10.6833/CJCU.2009.00121

摘要

研究背景：
醫療資源分布不均，常會使居住在醫療資源貧乏的鄉村或偏遠地區民眾花費額外的時間和金錢，到醫療資源豐富地區就醫。學者研究發現，在1985-2000年間國內跨區就醫比例為20-30%，其中又以雲林縣的50-60%最為嚴重。為提供更好的醫療服務給雲林當地民眾，政府在2004年將署立雲林醫院交由台大醫院經營，成為台大醫院雲林分院；在2005年，將國軍斗六醫院託付成大醫院，成為成大醫院斗六分院。
研究目的：
探討雲林縣二家醫院經過組織變革後，是否會降低當地民眾跨區就醫比例，及跨區就醫者的醫療服務利用情形。
研究方法：
本研究採類實驗研究法的前後測比較，實驗組為雲林縣，對照組依產業、人口特性、醫療資源等比較後選擇嘉義縣。研究理論架構採用Andersen第一階段醫療服務利用模式為概念基礎，並依據跨區就醫相關文獻加以修改。資料來源為國衛院健保資料庫之承保抽樣歸人檔，擇取2003及2006年雲林縣和嘉義縣的被保險人為研究對象，篩選出雲林縣2003年樣本數6,159人，2006年6,003人；嘉義縣2003年4,165人，2006年4,038人。統計方法採單變量的t檢定、卡方檢定、多變量的複迴歸分析及羅吉斯迴歸分析。

研究結果：
一、雲林縣在組織變革前（2003年）後（2006年）門診跨區就醫率分別為32.0%及31.0%，下降1%；而嘉義縣門診跨區就醫率2003及2006年分別為22.6%及23.1%，上升0.5%。在羅吉斯迴歸分析中，醫院組織變革雖使門診跨區就醫比例下降，但並未達統計學上的顯著差異。

二、雲林縣在組織變革前後住院跨區就醫率分別為62.7%及60.1%，下降2.6%，而嘉義縣住院跨區就醫率2003及2006年分別為23.0%及28.4%，上升4.4%。羅吉斯迴歸分析中，醫院組織變革會降低住院病患跨區就醫比例，達統計學上的顯著差異。
三、雲林縣門診及住院跨區就醫偏向急性疾病，重大傷病、疾病嚴重度較高、有手術，或健保申報費用較高者。
四、雲林縣門診及住院跨區就醫是流向醫療資源較充足或鄰近地區。

結論：
雲林縣在二家醫院組織變革後，降低住院跨區就醫比率，但門診跨區就醫不受影響。跨區就醫病患的疾病嚴重度較高且流向較高層級的醫院或醫療資源較充足的鄰近地區。

關鍵字：跨區就醫、組織變革

關鍵字

組織變革 ； 跨區就醫

並列摘要

Background：
An uneven distribution of medical resources often causes people in rural or remote area with scarce medical resources to spend extra time and money to seek care from medical resources abundant area. Studies found that the out-of-area medical care were 20-30% between 1985 and 2000, while Yunlin County with 50-60% out-of-area medical care was among the worst. In order to provide better medical services to local people, the Government turned Yunlin Hospital, Department of Health, Executive Yuan, R.O.C. into National Taiwan University Hospital Yunlin Branch in 2004. While the Dou-Liou Armed Forces General Hospital become National Cheng Kung University Hospital Dou-Liou branch in 2005.

Purpose：
The purposes of this study are to explore whether the reorganization of two hospitals in Yunlin County would decrease local residents seeking out-of-area health services, and to analyze the health care utilization of out-of-area users.

Methods：
This study uses a quasi-experimental design with before and after comparison. The experimental group is residents of Youlin County. The control group is residents of Chiayi County which is chosen according to its industrial, demographic characteristics, and medical resources. The theoretical framework is adopted from Andersen’s first phase of the use of medical services with some modification based on literature review. Data source is from 2000 Longitudinal Health Insurance Dataset of Institute for National Health Insurance Database. Study subjects are selected from Youlin County with 6,159 samples in 2003 and 6,003 samples in 2006, and from Chiayi County with 4,165 samples in 2003 and 4,038 samples in 2006. Statistical methods of t test, chi-square test, multiple linear regression and logistical regression are used.

Results：
1.In Yunlin County, the proportions of out-of-area outpatient care before and after the hospital reorganization were 32.0% (of 2003) and 31.0% (of 2006) respectively, a reduction of 1%. In Chiayi County, the proportions were 22.6% and 23.1% respectively, an increasing of 0.5%. While hospital reorganization would decrease the proportion of out-of-area outpatient care with logistic regression analysis, the decrease is not statistically significant.
2.In Yunlin County, the proportions of out-of-area inpatient care before and after the hospital reorganization were 62.7% and 60.1% respectively, a reduction of 2.6%. While in Chiayi County, the proportions were 23.0% and 28.4% respectively, an increasing of 4.4%. Hospital reorganization would significantly decrease the proportion of out-of-area inpatient care with logistic regression analysis.
3.Residents of Yunlin County seeking out-of-area outpatient and inpatient services tend to have acute diseases, major injuries, severe illnesses, surgeries, or higher national health insurance claims.
4.Residents of Yunlin County sought out-of-area outpatient and inpatient care from areas with abundant medical resources or from adjacent areas.

Conclusion:
Because of the two hospitals’ reorganization in Yunlin County, the proportion of out-of-area inpatient care among local residents decreased. But the proportion of out-of-area outpatient care remained the same. Patients seeking out-of-area health services tended to have severe illnesses. And they sought care from higher-level hospitals or in neighboring areas with abundant health care resources.

Key words: out-of-area health care utilization, hospital reorganization

並列關鍵字

hospital reorganization ； out-of-area health care utilization

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