影響醫學中心醫師開立慢性病連續處方箋之因素探討

A study on factors affecting doctors of medical centers to prescribe chronic illness prescription refill slip

吳培滋(Pei-Tzu Wu)

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(2007年)

https://doi.org/10.6833/CJCU.2007.00088

摘要

研究背景：慢性病連續處方箋釋出是推動醫藥分業政策的重點項目之一，若要達到足夠的處方箋釋出量，前提是醫師必須願意開立慢箋。雖然許多研究以問卷調查醫師開立慢箋的意願，但沒有人研究醫師的實際開立行為。目前醫學中心醫師的慢箋開立數較其他層級醫院多，衛生署統計醫學中心慢箋開立率從90年的5.28%上升至93年的16.19%，但距離目標值39.7%仍有很大的提升空間。
研究目的：利用全民健保費用申報資料分析醫師的實際處方行為，並從醫師特性、病患特性、醫院特性三方面探討影響醫學中心醫師開立慢性病連續處方箋的因素。
研究方法：本研究採橫斷面研究法。以Schiffman與Kanuk之消費者行為模式為理論架構，並依據相關的醫師處方行為文獻加以修正。研究資料取自國家衛生研究院全民健康保險研究資料庫，以民國91年系統抽樣的「門診處方及治療明細檔」為主，並擷取其他檔案的相關變數整合而成。研究對象為醫學中心醫師，但以罹患高血壓或糖尿病之醫學中心門診病患為分析單位，統計採羅吉斯迴歸分析。
研究結果：
一、在91年醫學中心的高血壓門診人次約有16%開立慢性病連續處方箋，而糖尿病和高血壓合併糖尿病門診人次開立慢箋的比例各約10%。
二、在單變量分析中：
1.醫學中心診治高血壓或糖尿病門診病患的醫師約97.10%曾經開立過慢箋，而曾經開立過慢箋的醫師，平均每月門診量較高，比較可能為公立醫院醫師，且比較可能在北部或南部的醫院工作。
2.領取慢箋的病患，有較高比例是前三個月曾經拿過慢箋，其就診醫院較可能為南部醫院，而且看診科別前月慢箋開立比例、醫師前月慢箋開立比例、醫師累積慢箋開立張數、醫院前月慢箋開立比例、醫院所在區域慢箋開立比例較高。領取慢箋的糖尿病、高血壓合併糖尿病病患較可能在公立醫學中心就診。而領取慢箋的高血壓病患其醫師前三月門診量較高。又領取慢箋的高血壓、糖尿病病患的就診醫院前三個月的門診量也較高。
三、羅吉斯迴歸分析發現：
1.在醫師因素部份：醫師前個月開立慢箋的比例越高和開立過的慢箋張數越多，再次開立慢箋的機率也越大，而門診量多寡與同科慢箋開立比例高低則對醫師開立慢箋機率並無影響。
2.在醫師特性部份：沒有一致性的影響因子，不過男醫師比女醫師有較高機率給高血壓合併糖尿病病患開立慢箋；面對糖尿病病患，有家庭醫學專科背景的醫師開立慢箋機率也較大。
3.病患特性方面：前三個月拿過慢箋者比較容易再領取慢箋。而糖尿病病患和高血壓合併糖尿病病患的年齡越大領取慢箋的機率越高。合併症數目多寡對領取慢箋的機率並無影響。
4.醫院因素方面：東部的高血壓和糖尿病病患領取慢箋的機率較高。高血壓病患在公立醫學中心比財團法人醫學中心有較高的慢箋開立機率，但糖尿病和高血壓合併糖尿病則未有顯著差異。
結論：醫學中心醫師是否開立慢箋，主要是受醫師本身的慢箋開立經驗多寡，以及病患是否曾經領取慢箋的影響，與醫師的門診量、同儕的慢箋開立比例及病患合併症數目無關。而病患年齡及性別，只影響糖尿病病患和高血壓合併糖尿病病患的慢箋開立率。

關鍵字

慢性病 ； 連續處方箋 ； 處方行為

並列摘要

Background：Releasing refillable prescriptions is one of the key methods to implement the policy on division between medicine and pharmacy. For enough amounts of refillable prescriptions to be released, doctors must be willing to prescribe. Many studies use questionnaires to survey the willingness of doctors on prescribing refillable prescriptions. But no one examines their actual prescribing behavior. Doctors in medical centers prescribe more refillable prescriptions than doctors in other settings. Though the rate of prescribing refillable prescriptions in medical centers has risen from 5.28% of 2001 to 16.19% of 2004 according to the statistics of Department of Health, it is still far away from the goal of 39.7%.
Purpose：The purpose of this study is to investigate the affecting factors, from the aspects of physicians, patients and hospitals, on medical center physicians’ behavior to prescribe refillable prescriptions for chronic diseases.
Methods：A cross-sectional study design is used. The research theory is based on the consumer behavior model of Schiffman and Kanuk with some revision. The data source comes from the National Health Insurance Research Database of National Health Research Institute. A systematic sampling data of Ambulatory care expenditures by visits of 2002 is used as the main dataset, with additional variables aggregated from other data files. The study subjects are doctors of medical centers. However, the analytic units are outpatients of medical centers with hypertension or diabetes. The statistic method used in this study is logistic regression.
Results：
1.In 2002, approximately 16% of hypertension outpatients and 10% of diabetes mellitus outpatients, 10% of hypertension combining with diabetes outpatients in medical centers received refillable prescriptions.
2.About 97.10% of doctors in medical centers who treated hypertensive or diabetic outpatients have prescribed refillable prescriptions. The doctors who have ever prescribed refillable prescriptions have more outpatients per month, and are most likely working in public hospitals and in the north or south regions of Taiwan.
3.The patients who receive refillable prescriptions are more likely to have received refillable prescriptions in the past 3 months, and are more likely to visit the hospitals in the south region of Taiwan. Besides, their doctors are more likely to have higher rates of prescribing refillable prescriptions in the last month, have prescribed more refillable prescriptions in the past, and are more likely to work at a department, at a hospital, at a region that had a higher rate of prescribing refillable prescriptions in the last month. Diabetes or hypertension combining with diabetes patients who received refillable prescriptions are more likely to visit physicians at public medical centers. Hypertension patients who received refillable prescriptions are more likely to visit doctors who have large outpatients in the last 3 months. Hypertension or diabetes patients who received refillable prescriptions are more likely to visit hospitals that have large outpatients in the last 3 months.
4.Findings from the Logistic Regression analysis:
4.1 Physician aspect: The higher rate and amounts of prescribing refillable prescriptions by doctors in the past, the more likely they would prescribe it again. On the other hand, the workload of ambulatory care and the peer’s rate of prescribing refillable prescriptions have no influence.
4.2 Physician properties aspect: There are no consistent influence factors. However, male doctors have a better chance than female doctors to prescribe refillable prescription for hypertension outpatients with diabetes. For diabetes outpatients, Family Medicine physicians have a higher probability than other specialties to prescribe refillable prescriptions.
4.3 Patient aspect: The patients received refillable prescriptions in the past three months are more likely to receive them again. The older the outpatients with diabetes mellitus or hypertension combining with diabetes mellitus, the easier of them to receive refillable prescriptions. The number of comorbidities has no effect on getting refillable prescriptions.
4.4 Hospital aspect: The hypertensive and diabetes outpatients in the eastern region of Taiwan have a better chance to receive refillable prescriptions. There are no differences among physicians at public hospitals and at non-for-profit hospitals on the rates of prescribing refillable prescriptions, but it has influence on physicians cured hypertension outpatients.
Conclusions：Past experiences of physicians and patients on prescribing and receiving refillable prescriptions are the main factors influencing doctors of medical centers if they would prescribe a refillable prescription this time. The workload on outpatients, prescribing rates of colleagues on refillable prescriptions and the number of comorbidities of patients have no impacts. While age and gender of patients will influence the chance of prescribing refillable prescriptions only among the diabetes and the hypertensive patients with diabetes.

並列關鍵字

chronic disease ； chronic illness prescription refill slips ； prescribing behavior

參考文獻

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