出院後重返加護病房病人之病人特性及其醫療資源耗用

Patient Characteristics and Medical Resources Utilization of Intensive Care Patients Who Discharged from Hospitals and then Readmitted to Intensive Care Units

蔡君婷(Chun-Ting Tsai)

指導教授 ： 薛亞聖

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2004年)

https://doi.org/10.6342/NTU.2004.00487

摘要

加護病房是收治病情較嚴重與危急病人的醫療救護單位，也是醫院中醫療人力、儀器設備最為密集，耗用醫院大量資源的地方，隨著老年人口的增加，對加護病房的需求也相對提高，如1994年美國的加護病床雖只佔所有病床的10％，加護醫療所耗用的資源卻高達醫療支出的30％。另一方面，由於健康保險對於醫療申報費用的管控，病人在加護病房留置過久，醫療申報費用也會遭到刪減，造成醫院財務上的損失。但若過早將病人移出加護病房，除了可能會因病情不穩定而重返加護病房，且耗費更多的醫療資源，造成病人及醫院財務上的損失。
由於重返加護病房，不但對醫療資源的耗用有相當程度的影響，在醫療品質上更有監控管理的積極意義，故美國急救加護醫學會已將重返加護病房列為重要的品質指標，而醫策會亦將非計畫性重返加護病房列為TQIP的急性照護的品質指標。但是隨著支付制度及以「病人為中心」的醫療照護整合觀念的改變，在評估整體住院醫療品質及醫療資源使用情形時，不能只觀察該病人在當次住院的情形，而是應該觀察這個病人在這此健康照護組織，甚至是在整個醫療體系中所遭受到的待遇，以及最後得到的健康產出結果，因此本研究針對出院後重返加護病房的病人進行現況的探討，並進一步分析其病人特性及其醫療資源利用及耗用。
本研究採用次級實證資料分析，透過全國性的健保申報資料庫對不同層級醫院間及跨院間出院後重返加護病房進行探討，除了瞭解台灣地區加護病房病人整體及出院後重返之現況，評估加護病房病人出院後重返的醫療資源重複使用之現象，並探討出院後重返加護病房作為品質指標的適當性。
研究結果顯示，出院後重返加護病房的危險因子，在人口性別分佈以男性居多、在年齡分佈則以65歲以上的老人族群居多。在疾病型態分佈上，以心血管疾病、呼吸道疾病為主，其次為敗血症、消化道疾病；在慢性病方面，則以慢性肝病及肝硬化及糖尿病為主，而疾病次診斷數越多，其出院後重返的機率則越高。
另外，從研究結果中發現：有出院後重返的前次住院之住院天數較其他加護病房住院人次的住院天數短，則有可能是因為在前一次住院的健康狀態未穩定即出院，而造成出院後重返加護病房的現象發生。而從出院後重返不同家醫院的死亡分佈來看，其出院後重返醫院的評鑑層級越較原醫院低，則死亡率越高，若以層級間轉院的角度來看，大部分出院後重返不同醫院往高層級或往同層級的醫院，此現象應該是合理的，但少部分轉往較低層級的醫院，無法獲得以較佳儀器設備的高密集加護醫療服務，導致其存活率下降，則推論可能有病人傾棄的現象存在。
因為健保資料庫欄位缺損，導致本研究無法更進一步針對同一次住院重返加護病房的情形進行探討，因此本研究建議衛生行政當局保留健保資料庫醫令起迄日欄位，並增添有關病人臨床資訊，如APACHE Ⅱ的診斷碼及分數的欄位，則能透過資料庫分析，對轉入及轉出加護病房的病患進行評估，對日後病人管理及學術研究則有莫大助益。此外，本研究結果發現出院後重返加護病房病人的死亡率、醫療資源利用及耗用情形的確明顯較其他加護病房住院人次高，因此建議可將「出院後重返加護病房」納入整體住院醫療品質指標的監測，但不宜作為獎懲醫院的工具，否則恐會造成刮脂效應的產生；另一方面，應加強分級醫療及確立轉診制度，並以「病人為中心」作醫療資訊的整合，則可減少及降低可避免的醫療費用支出。

關鍵字

品質指標 ； 加護病房 ； 醫療品質 ； 醫療資源耗用 ； 以病人為中心 ； 健康保險 ； 重返加護病房 ； 病人安全

並列摘要

The intensive care units (ICUs) are the medical units which admit critical patients. ICU requires intensive manpower and equipment in the hospital, and utilizes a significant portion of hospital resources. With the increase of aging population, the demand for ICUs grows. Taking an example of the United States, though the number of ICU beds accounted for 10% of all hospital beds, the resources the intensive care utilizes were accounted for 30% of health expenditure in 1994. On the other hand, due to the tight control of health insurances expenditures, the longer the LOS in ICUs are, the more possible the medical claims would be cut down and damage to hospital finance. However, excessively early transferring from ICUs will not only readmit the patients back to ICUs, but also utilize more medical resources, and damage to patients and hospital finance.
The management of readmission to ICU can improve the utilization of medical resources; it has positive influence on medical quality control at the same time. According to these, the Society of Critical Care Medicine Task has set it as one of the important quality indicators, and Taiwan Joint Commission on Hospital Accreditation also has set it as an intensive care indicator of the Taiwain Quality Indicator Project (TQIP). However, with the payment system and the integrated patient centered health care orientation changing, we not only observe the patients’ status of admission, but also the treatment and final health outcome in one’s HMO, even the whole health care system while evaluating the medical quality of admission and medical resources utilization. Therefore, this study discusses the present condition of patients who discharged from hospitals and then readmitted to ICUs, and analyzed their characteristics and medical resources utilization.
This is a secondary empirical data analysis study. Through the analysis of nation-wide NHI database, we probe the present situations of the post-discharging readmission to ICUs in the same and different hospitals among multi-level hospitals, in order to understand the ICU patients in Taiwan and their readmission to ICUs. Also, we would like to appreciate the appropriateness of taking post-discharging readmission to ICUs as one of the quality indicators.
The results show that gender, age, and disease pattern are the risk factors of post-discharging readmission to ICUs. Male and aged 65 years old and upper take the majority of these patients. We discover that cardiovascular and respiratory diseases are their major diagnoses, septicemia, and gastroinstinal diseases appear the next. In the chronic disease diagnoses, chronic liver diseases and liver cirrhosis often give the priority. Notably, the more the second diagnoses are, the higher the probability of post-discharging readmission to ICUs is.
Furthermore, the results show that the patients with post-discharging readmission to ICUs experience had shorter LOS in their preceding hospitalization than the ones without this experience. The reason to explain these could be the excessively early transferring of the patient whose unstable health conditions and it brought out the later readmission to ICUs. Judging from the death rate of post-discharging readmission to ICUs in different hospitals, we find higher mortality in lower level hospital where the patients readmitted to ICUs. It is reasonable that most patients readmitted to ICUs in higher or the same level hospitals, but the results show that there are still a little ones readmitted to lower level hospitals, lacking of better equipments and higher density intensive care service, the survival rate of the readmitted patients dropped, indicating that patient dumping might exist. Due to the column loss of NHI database, we cannot discuss the readmission to ICUs in the same hospitalization for further. Besides, this study finds that the patients who discharged from hospitals and then readmitted to ICUs have higher mortality and medical resources utilization.
According to the above findings, this study suggests that the health related authorities should keep the columns denote the tire of beginnings and endings of the medical orders, and add the clinical information related to the patients, such as the diagnostic codes and scores of APACHE II. Thus, by analyzing the database, we can evaluate the patients admit to or transfer from ICUs, and benefit to patient management and academic researches in the future. This study also suggests that we can absorb the concept, post-discharging readmission to ICUs management, in the monitor of total admission medical quality, but we should avoid to use it as part of the bonus-penalty system in case of the cream skimming effect. On the other side, we should enhance the system of differential medical facilities and referral, and integrate the patient centered medical information, so that we can decline the avoidable health expense.

並列關鍵字

Medical resources utilization ； Patient safety ； Quality indicator ； Medical quality ； Health insurance ； Intensive care unit ； Patient centered care ； Readmission to ICU

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