安寧病房健保給付制度改變前後抗生素使用之比較

The Comparison of Antibiotics Prescription in Hospice Care Unit after Payment System Changes

周裕清(Yu-Ching Chou) ； 陳亮恭(Liang-Kuang Chen) ； 林玉茹(Yu-Ju Lin) ； 黃信彰(Shinn-Jang Hwang) ； 陳振文(Tzen-Wen Chen) ； 吳彬源(Pin-Yuan Wu) ； 林明慧(Ming-Hwai Lin) ； 蔡世滋(Shih-Tzu Tsai)

《台灣家庭醫學雜誌》 11卷1期 (2001/03) Pp. 33-39

https://doi.org/10.7023/TJFM.200103.0033

摘要

對於癌末病患的感染症，臨床醫師在評估病患情況決定是否使用抗生素台療時必須從很多方面思考。由於醫療費用給付制度的改變，而影嚮醫療決策的倫理觀，值得關注。財務因素是否會影嚮安寧療護醫師開立抗生素的行為模式是本研究所要控討的主要目的。本文以國內某醫學中心的安寧病房住院患為對象，回溯性調查481位癌末病患於535次住院期間之抗生素使用狀況;並分析民國八十九年七月健保申報改採論日計酬制度前後，財務因素對於醫師開立抗生素的影嚮。結果從民國八十八年七月一日起至九十年六月三十日止，住院過程中使用過抗生素治療274次(51.2%)，其中有108次(39.4%)開立僅出自臨床判斷，此外有87次(31.8%)為接續先前轉至安寧病房前之抗生素治療，79次(28.8%)在病患出現高燒後開立抗生素。分組比較八十八與八十九年度兩年之間醫師開立抗生素的處方案例，無應採用臨床判斷而開立者、或者延續先前病房所使用的抗生素，在統計上並無明顯的差異(p=0.660,p=0.431)。考量營運指標重新校正分析之後，兩者在統計上也沒有明顯的差異(p=0.917,p=0.673)。顯示該醫院中心的安寧病房抗生素的開立不會因為健保給付制度的改變，而傾向不予抗生素治療或開立較便宜的口服抗生素或第一線靜脈注射抗生素，醫師臨床的專業判斷仍是主要的依據。

並列摘要

It takes a great amount of medical causal reasoning for physicians to prescribe antibiotic for terminal cancer patients in a potential infectious circumstance. Because the payment system reimbursed by National Insurance Bureau tremendously affects the allocation of medical practice and health service resources, it is worthy of note that whether the changes of payment system will affect the ethics in decision-making of palliative care service as well. The research was conducted to explore how it impacts physicians on their prescription of antibiotics for the terminal cancer patients. We retrospectively studied the prescription patterns among 535 admissions of 481 patients in a hospice and palliative care unit in a medical center in Taiwan July 1, 999 to June 30, 2001. We also analyzed the impacts to physicians’ prescriptions of antibiotics when payment system was superseded by per diem basis started from July 1, 2000. There were 274 (51.2%) antibiotics prescriptions, including 108 new prescriptions hased on clinical diagnosis, 87 (31.8%) prescriptions repeating previous physician’s orders, and 79 (28.8%) prescriptions made for high fever. We compared the prescriptions made on-site based on clinical diagnosis with those prescriptions repeating previous physicians’ orders. No differences were identified between the two groups with regard to the changes of payment systems (p=0.660, p=0.431), even after factor adjustment to financial index (p=0.917, p=0.673). We concluded that the changes of payment system do not affect physicians to prescribe antibiotics in the hospice and palliative care unit, and the professional judgment remains the guidelines for decision-making.

並列關鍵字

antibiotics ； palliative care ； payment system