醫院總額支付制度實施前後醫療照護品質及其影響因素之探討研究

Quality of Healthcare and Related Factors Before and After the Implementation of Hospital Global Budget Payment System

林峻鋒(Rick Lin)

指導教授 ： 葉玲玲

亞洲大學/健康學院/健康管理研究所/碩士(2006年)

摘要

中 文 摘 要
前言：我國自2002年7月開始實施醫院總額支付制度，總額支付制度的實施雖可有效控制醫療費用，但醫療院所可能為了進一步控制成本而影響民眾的就醫品質。所以，有必要針對醫院總額支付制度實施前後，進行研究瞭解醫院醫療照護品質的改變，並分析其影響因素。
目的：藉由醫院總額醫療照護品質指標與實證醫學疾病管理品質指標以瞭解全民健保醫院總額支付制度實施前後，醫院醫療照護品質之改變及其影響因素。
方法：本研究以國家衛生研究院全民健保學術研究資料庫進行次級資料分析，使用20萬人「承保抽樣歸人檔」，以2000年至2004年的健保資料進行醫療照護品質分析。研究對象為中央健康保險局510家特約醫院，將以Pair-t檢定、迴歸等統計方法對醫院的醫院總額醫療照護品質指標及實證醫學疾病管理品質指標進行統計分析。
結果：本研究在控制其他變項後，醫院總額實施後有顯著改變的醫療照護品質指標包括，門診注射劑使用率及修正版、門診抗生素使用率、門診同一處方制酸劑重複使用率（修正版）、出院後十四日內同醫院再住院率（修正版）、出院後三日內急診率及修正版、上呼吸道感染使用抗生素率及合併腎臟病ICD-9-CM 585之糖尿病患者使用Metformin藥物比率品質指標顯著下降，達統計上顯著意義；門診開立慢連處方箋百分比及修正版、同醫院門診用藥日數重複率、門診用藥日數重複率及修正版、三十日以上超長期住院率品質指標顯著上升，並達統計上顯著意義。
比較17家醫學中心在醫院總額醫療照護品質門住診指標與實證醫學疾病管理品質指標之表現情形。有6家醫院雖然在醫院總額醫療照護品質指標門住診部份皆達成一半以上指標，但實證醫學疾病管理品質指標中卻有2家醫院未達成一半以上指標。
結論：醫院總額實施後有顯著改變的醫療照護品質指標包括，門診注射劑使用率及修正版、門診抗生素使用率、門診同一處方制酸劑重複使用率（修正版）、出院後十四日內同醫院再住院率（修正版）、出院後三日內急診率及修正版、門診開立慢連處方箋百分比及修正版、同醫院門診用藥日數重複率、門診用藥日數重複率及修正版、三十日以上超長期住院率、上呼吸道感染使用抗生素率及合併腎臟病ICD-9-CM 585之糖尿病患者使用Metformin藥物比率。而醫院總額醫療照護品質指標的修正版更可充分表現其品質指標意義，建議以修正版進行持續監測，另外應對醫院再加強實證醫學疾病管理品質指標的監測。

關鍵字

醫院總額支付制度 ； 醫療照護品質 ； 品質指標 ； 實證醫學 ； 疾病管理

並列摘要

Abstract
Introdution:
Hospital Global Budget Payment System has been executed since July, 2002. Although the execution of Hospital Global Budget Payment System can efficiently control the medical expenditures, hospitals and clinics might become the cause of lowering the healthcare quality by controlling costs further. Therefore, it is necessary to study and comprehend the changes of healthcare quality of hospitals and analyze the related factors before and after the execution of Hospital Global Budget Payment System.

Purpose:
Be aware of the changes of healthcare quality of hospitals and the related factors before and after the execution of Hospital Global Budget Payment System based on the quality indicators of hospital global budget healthcare and of evidence-based medicine disease management.

Methods:
The research proceeds the secondary information analysis according to the National Health Insurance Research Database provided by National Health Research Institutes, analyzing healthcare quality with two hundred thousand people sampling from the enrollment files maintained by the Bureau of National Health Insurance based on the health insurance data from 2000 to 2004. The objects of study are the 510 hospitals appointed by the Bureau of National Health Insurance, which will be gathered statistics from and analyzed about quality indicators of hospital global budget healthcare and of evidence-based medicine disease management by the means of statistics such as Pair-t examination, regression, and so on.

Results:
After other variables are controlled, there is an obvious change of some items of quality indicators of healthcare after the execution of hospital global budget in this research, which includes utilization rate of injections in outpatient services and its revised version, utilization rate of antibiotics in outpatient services, repeated utilization rate of antacid from the same prescription in outpatient services (the revised version), rate of re-admission within 14 days after discharging from the same hospital (the revised version), rate of emergency treatment within 3 days after discharging from the hospital and its revised version, utilization rate of antibiotics for the infection of the upper respiratory tract, and utilization rate of Metformin for the diabetics with a complication of kidney disease ICD-9-CM 585. The quality indicators for the above mentioned items all descend obviously, which mark great significance in statistics. On the other hand, the items such as rate of prescribing chronic continuous prescriptions in outpatient services, rate of inappropriate days of medicine taking in the same hospital in outpatient services, rate of inappropriate days of medicine taking in outpatient services and its revised version, and rate of overlong hospitalization for more than 30 days have the quality indicators ascend obviously which mark great significance in statistics.
In the comparison of the performance of 17 medical centers on the quality indicators of hospital global budget healthcare in outpatient and inpatient services and of evidence-based medicine disease management, 6 medical centers achieve more than 50% of the indicators in the part of hospital global budget healthcare quality in outpatient and inpatient services. However, two of the six hospitals doesn’t reach 50% or above in the part of quality indicator of evidence-based medicine disease management.

Conclusion:
The quality indicators of healthcare that have an obvious change after the execution of hospital global budget include utilization rate of injections in outpatient services and its revised version, utilization rate of antibiotics in outpatient services, repeated utilization rate of antacid from the same prescription in outpatient services (the revised version), rate of re-admission within 14 days after discharging from the same hospital (the revised version), rate of emergency treatment within 3 days after discharging from the hospital and its revised version, rate of prescribing chronic continuous prescriptions in outpatient services, rate of inappropriate days of medicine taking in the same hospital in outpatient services, rate of inappropriate days of medicine taking in outpatient services and its revised version, rate of overlong hospitalization for more than 30 days, utilization rate of antibiotics for the infection of the upper respiratory tract, and utilization rate of Metformin for the diabetics with a complication of kidney disease ICD-9-CM 585. Since the revised version of quality indicator of hospital global budget healthcare can be more significant as an indicator, we suggest using the revised version to monitor continuously and reinforcement the monitor of quality indicator of disease management toward hospitals in additionally.

並列關鍵字

Hospital Global Budget Payment System ； Healthcare Quality ； Quality Indicator ； Evidence-Based Medicine ； Disease Management

參考文獻

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