台灣失能榮民眷醫療與長期照護服務使用研究

The Utilization of Medical Care and Long-term Care Services Among Disabled Veterans and Their Family Members in Taiwan

張桂津(Kuei-Ching Chang)

指導教授 ： 吳淑瓊

國立臺灣大學/公共衛生學院/衛生政策與管理研究所/碩士(2007年)

https://doi.org/10.6342/NTU.2007.01932

摘要

本研究的目的為瞭解榮民眷之健康狀況與醫療與長期照護服務使用情形，並探討個人前傾因素(predisposing characteristic)、使能因素(enable factor)、需要因素(need factor)對榮民眷醫療服務與長期照護服務使用之影響。
本研究資料來自2002年行政院衛生署委託台灣大學公共衛生學院執行之「全國長期照護需要評估」計畫，以其中65歲以上失能榮民眷者為研究樣本，共1,344人，其中212人於機構內受訪，1,132人於居家中受訪；樣本特質，69.7%為男性，平均年齡77.7歲，標準差6.5，教育程度45.2%為中學以上畢業，婚姻有偶者佔60.1%，有子女者佔84.5%。
研究結果發現，1,344位65歲以上失能榮民眷總樣本中，有認知障礙者佔39.2%，慢性病平均數2.46，自述患有高血壓者佔53.9%最高，自述患有心臟病者佔33.3%，自述患有關節炎或風溼者佔34.7%，有插管者佔9.8%，只有認知障礙或IADLs(Instrumental Activities of Daily Living)障礙者佔33.5%，ADLs(Activities of Daily Living) 1-2項障礙者佔20.1%，ADLs 3-4項障礙者佔12.1%，ADLs 5-6項障礙者佔34.4%。在醫療服務使用方面，過去一個月使用西醫門診者佔76.1%，過去一年住院使用率43.4%，過去一年急診使用率33.6%，過去半年牙醫門診使用率17.3%。在長期照護服務使用方面，過去一年在家聘用全職看護者佔22.7%，過去一年曾住機構者佔19.0%，過去一年復健服務使用率為15.9%。
在醫療服務使用影響因素方面，邏輯斯複迴歸分析發現，只有慢性病數有顯著影響過去一個月西醫門診使用率，相對於0-1種慢性病，2-3種慢性病(OR= 1.99,95% CI=1.48-2.67)，4種以上慢性病(OR=4.19,95% CI=2.70-6.52)的門診使用機會較高。影響過去一年住院使用率的顯著因素為慢性病數、失能情形、是否插管。相對於0-1種慢性病，2-3種慢性病(OR=1.42,95% CI=1.07 -1.89)，4種以上慢性病(OR=3.19,95% CI=2.25-4.53)的住院機會較高，相對於只有認知障礙或IADLs障礙，0-1項ADL障礙(OR=1.71,95% CI=1.23-2.38)，3-4項ADL障礙(OR=1.62，95% CI =1.09-2.41)，5-6項ADL障礙(OR=2.14，95% CI =1.53-3.00)住院機會較高；有插管(OR=2.34，95% CI=1.51-3.61)比沒有插管者住院使用機會較高。照顧安排、慢性病數、失能情形、是否插管有顯著影響過去一年急診使用率。相對於住機構者，由家人照顧者急診使用機會較高(OR= 2.32，95% CI = 1.46-3.69)；相對於0-1種慢性病，2-3種慢性病(OR=1.47,95% CI=1.07-2.02)，4種以上慢性病(OR=2.96,95% CI=2.05-4.26)的急診使用機會較高；相對於只有認知障礙或IADLs障礙，3-4項ADL障礙(OR=1.68，95% CI =1.11-2.56)，5-6項ADL障礙(OR=2.06，95% CI =1.45-2.95)急診使用機會較高；有插管者急診使用機會比沒有插管者高(OR= 2.00，95% CI= 1.30-3.08)。年齡、慢性病數、失能情形、是否插管有顯著影響過去半年牙醫門診使用率，相對於65-74歲，75-84歲者(OR=0.68,95% CI= 0.49 -0.93)、85歲以上者(OR= 0.47，95% CI= 0.28-0.78)使用牙醫門診的機會比較低；相對於0-1種慢性病，2-3種慢性病(OR=1.55,95% CI=1.06-2.27)，4種以上慢性病(OR= 1.73,95% CI= 1.10 –2.73)使用牙醫門診的機會比較高；相對於只有認知障礙或IADLs障礙，5-6項ADL障礙(OR=0.60，95% CI = 0.39-0.92)使用牙醫門診的機會比較低；有插管者(OR=0.45，95% CI =0.21-0.94)比沒有插管者，使用牙醫門診的機會比較低。
在長期照護服務使用影響因素方面，邏輯斯複迴歸分析發現，教育程度、子女數、婚姻、認知障礙、失能情形、插管顯著影響過去一年長期照護機構使用率，相對於不識字，中學以上(OR=9.70, 95% CI=5.68-16.57)使用機會較高；相對於無子女，1-2個子女(OR=0.14, 95% CI=0.08-0.25)，3個以上子女(OR=0.06, 95% CI=0.03-0.10)使用機會較低；有偶者(OR=0.44, 95% CI=0.29-0.67)比無偶者使用機會較低；有認知障礙者(OR=3.20, 95% CI=2.16-4.67)比無認知障礙者使用機會較高；相對於只有認知障礙或IADLs障礙，3-4項ADL障礙(OR=2.05, 95% CI=1.04-4.02)，5-6項ADL障礙(OR=4.62, 95% CI=2.68-7.95)使用機會較高；有插管者(OR=3.05, 95% CI=1.78-5.22)比沒有插管者，使用機會較高。年齡、教育程度、慢性病數顯著影響過去一年復健服務使用率，相對於65-74歲，75-84歲者(OR=0.64, 95% CI=0.45-0.91)、85歲以上者(OR=0.34, 95% CI =0.18-0.65)使用機會較低；相對於不識字，中學以上(OR=1.64, 95% CI=1.05- 2.57)使用機會較高；相對於0-1種慢性病，4種以上慢性病(OR=1.65, 95% CI=1.01-2.71)使用機會較高。性別、教育程度、子女數、婚姻、居住地、認知功能、失能情形、插管顯著影響過去一年在家聘用全職看護使用率，男性(OR=0.46, 95% CI= 0.31 -0.68)比女性使用機會較低；相對於不識字，中學以上(OR=2.58, 95% CI =1.67 -3.99)使用機會較高；相對於無子女，1-2個子女(OR=0.43, 95% CI= 0.22 -0.84)使用機會較低；有偶者(OR=0.35, 95% CI=0.24-0.51)比無偶者使用機會較低；相對於住鄉鎮者，住縣轄市者(OR=1.56, 95% CI=1.03-2.37)，住直轄市者(OR= 2.03, 95% CI=1.22-3.39)使用機會較高；有認知障礙者(OR=0.64,95% CI=0.45-0.90)比無認知障礙者使用機會較低；相對於只有認知障礙或IADLs障礙，1-2項ADL障礙(OR=2.80,95% CI=1.67-4.71)，3-4項ADL障礙(OR=4.32,95% CI= 2.44 -7.65)，5-6項ADL障礙(OR=8.23,95% CI=5.10-13.28)使用機會較高；有插管者(OR=2.25,95% CI=1.27-3.97)比沒有插管者，使用機會較高。
總而言之，榮民眷在醫療服務的使用，顯著影響因素為需要因素，如認知功能、慢性病數、失能情形等；而在長期照護服務使用的顯著影響因素，除了需要因素外，前傾因素如性別、教育程度，使能因素如子女數、婚姻、居住地、也有重要影響，本研究結果可提供輔導會及其他部會規劃未來老年榮民眷醫療服務與長期照護健康政策時參考。

關鍵字

榮民眷,醫療服務利用,長期照護服務利用

並列摘要

The aims of this study were to examine health status, utilization of medical and long-term care services, and to explore the important factors in individual factors of predisposing factors, enabling factor, and need factors to affect the utilization of medical and long-term care services in veterans and their family members.
This dataset retrieved from the study program of “Long-term Care Need Assessment “ by National Public Health College in 2002 in Taiwan. Of the 1,344 disabled veterans and their family members who were older than 65 years old, 1,132 of them from the community and 212 from institutions. 69.7% of the sample was male, and mean age was 77.7 years old.,SD was 6.5.45.2% of them were junior high school or higher level of education. 60.1% of them were married and lived with spouses, and 84.5% of them had one or more kids.
The study results indicated that 39.2% of the sample was with cognitive impairment. The mean number of chronic conditions by self-reporting was 2.46. 53.9% of them had hypertension; 33.3% of them had heart disease; and 34.7% of them had arthritis. 9.8% of the sample was at least one tube. 33.5% of them were either cognitive impairement or IADLs(Instrumental Activities of Dialy Living) impairment. 20.1% of them were disabled with 1-2 items ADLs(Activities of Daily Living) impairment; 12.1% of them were disabled with 3-4 items ADLs impairment; 34.4% of them were disabled with 5-6 items ADLs impairment. The results related to the utilization of medical and long-term care service were shown that 76.1% had received out-patient medical services in last one month. 43.4% had received in-patient medical services in last one year. 33.6% had received emergency medical service in last one year. 17.3% had received dentist out-patient medical serviced in last half year. 22.7% had received home aid assistant care in last one year. 19.0% had received long-term institutional care in last one year. 15.9% had received rehabilitation care in last one year.
Multiple logistic regression analyses were used to explore the important factors affecting the utilization of medical care services. The number of type of chronic conditions was the significantly important factor to affect the utilization of out-patient medical services in last one month. Compared to the group with 0-1 type of chronic conditions, the group with 2-3 types (OR=1.99, 95% CI= 1.48 -2.67) and the group with more than 4 types (OR=4.19,95% CI=2.70 -6.52) of chronic conditions had more opportunity (odds ratio) to use out-patient medical services in last one month. Number of chronic conditions, level of dependency, and at least one tube were important factors to affect the utilization of in-patient medical services in last one year. Compared to the group with 0-1 type chronic conditions, and the group with 2-3 types (OR=1.42,95% CI=1.07-1.89), the group with more than 4 types (OR =3.19, 95% CI=2.25-4.53) of chronic conditions had more opportunity (odds ratio) to utilize in-patient medical services. Compared to the groups with cognitive and IADLs impairment only, 1-2 items ADLs impairment (OR=1.71, 95% CI=1.23-2.38), and 3-4 items ADLs impairment (OR=1.62, 95% CI=1.09-2.41), the group with 5-6 items ADLs impairment (OR=2.14, 95% CI=1.53-3.00) had more opportunity (odds ratio) to hospitalize last year. At least one tube (OR= 2.34, 95% CI=1.51-3.61) had more opportunity (odds ratio) than no tube to be hospitalized last year. Care arrangements, number of chronic conditions, level of dependency, and tube insertion were statistically significant factors to affect the utilization of emergent medical services in last year. Compared to the group with institutional care, the group with care by family members (OR= 2.32, 95% CI=1.46-3.69) had more opportunity (odds ratio) to use emergent medical care. Compared to the group with 0-1 type chronic conditions, and the group with 2-3 types of diseases (OR=1.47,95% CI=1.07-2.02), the group with more than 4 types (OR=2.96, 95% CI=2.05-4.26) of chronic conditions had more opportunity (odds ratio) to use emergent medical care. Compared to the group with cognitive and IADLs impairment only and 3-4 items ADLs impairment (OR= 1.68, 95% CI=1.11 -2.56), the group with 5-6 items ADLs impairment (OR=2.06, 95% CI= 1.45 - 2.95) had more opportunity (odds ratio) to use emergent medical care. The subjects with tube insertion (OR=2.00, 95% CI=1.30 -3.08) had more opportunity (odds ratio) than the subjects without tube to use emergent medical care. Age, number of chronic conditions, and level of dependency are statistically significant factors to affect the utilization of dentist out-patient medical services in last half year. Compared to the groups with 65-70 years old, the groups with 75-84 years old (OR=0.68, 95% CI=0.49-0.93) and older than 85 years old (OR= 0.47,95% CI=0.28-0.78) had less opportunity (odds ratio) to use dentist services. Compared to the group with 0-1 type chronic condition, the groups with 2-3 types (OR=1.55,95% CI= 1.06-2.27) and more than 4 types (OR=1.73, 95% CI= 1.01-2.73) of chronic conditions had more opportunity (odds ratio) to use dentist services. Compared to the group with cognitive and IADLs impairment only, the group with 5-6 items ADLs impairment (OR= 0.60, 95% CI=0.39-0.92) had less opportunity (odds ratio) to use dentist services. The subjects with tubes (OR= 0.45, 95% CI=0.21-0.94) had less opportunity (odds ratio) to use dentist services than those without tube.
The results related to the important factors affecting the utilization of long-term care services by using multiple logistic regression found that level of education, number of kids, marital status, cognitive impairment, level of dependency, tube insertion were statically significant factors to affect the utilization of long-term institutional services in last year. Compared to the group with illiteracy, the group with junior high school or higher level (OR=9.7, 95% CI=5.68-16.57) had more opportunity (odds ratio) to use long-term institutional services. Compared to the group without kid, the groups with 1-2 kids (OR=0.14, 95% CI=0.08-0.25) and more than 3 kids (OR= 0.06, 95% CI=0.03-0.10) had less opportunity (odds ratio) to use long-term institutional services. Compared to the group lived without spouse, the group lived with spouse (OR=0.44, 95% CI=0.29-0.67) had less opportunity (odds ratio) to use long-term institutional services. Compared to the group without cognitive impairment, the group with cognitive impairment (OR=3.20, 95% CI=2.16-4.67) had more opportunity (odds ratio) to use the services. Compared to the group with either cognitive or IADLs impairment only, the subjects with 3-4 items ADLs impairment (OR=2.05, 95% CI=1.04-4.02), and 5-6 items ADLs impairment (OR=4.62, 95% CI=2.68-7.95) had more opportunity (odds ratio) to use it. The subjects with tube insertion (OR=3.05, 95% CI=1.78-5.22) had more opportunity (odds ratio) than the subjects without tube to use it. Age, level of education, and number of chronic diseases were statistically significant factors to affect the utilization of rehabilitation services in last year. Compared to the group with 65-70 years old, the groups with 75-84 years old (OR=0.64, 95% CI=0.45-0.91), and older than 85 years old (OR= 0.34, 95% CI=0.18 -0.65) had less opportunity (odds ratio) to use it. Compared to the group with illiteracy, the group with junior high school or higher (OR=1.64, 95% CI=1.05 -2.57) had more opportunity (odds ratio) to use it. Compared to the group with 0-1 type chronic condition, the group with more than 4 types of chronic conditions (OR=1.65, 95% CI=1.01-2.71) had more opportunity (odds ratio) to use it. Gender, level of education, number of kids, marital status, residential area, cognitive impairment, level of dependency, and tube insertion were important factors to affect the utilization of home aid assistant services in last year. Male (OR= 0.46,95% CI=0.31-0.68) had less opportunity (odds ratio) than female to use it. Compared to the group with illiteracy, the group with junior high school or higher (OR=2.58, 95% CI=1.67-3.99) had more opportunity (odds ratio) to use it. Compared to the group without kid, the group with 1-2 kids (OR=0.43, 95% CI=0.22-0.84) had less opportunity (odds ratio) to use it. Compared to the group lived without spouse, the group lived with spouse (OR=0.35, 95% CI= 0.24 -0.51) had less opportunity (odds ratio) to use it. Compared to the group resident in urban, the group resident in county (OR=1.56,95% CI=1.03-2.37) and the group resident in megalopolitan (OR=2.03,95% CI=1.22-3.39) had more opportunity (odds ratio) to use it. Compared to the group without cognitive impairment, the group with cognitive impairment (OR=0.64, 95% CI=0.45-0.90) had less opportunity (odds ratio) to use it. Compared to the group with either cognitive or IADLs impairment only, the groups with 1-2 items ADLs impairment (OR=2.80, 95% CI=1.67-4.71), 3-4 items ADLs impairment (OR=4.32, 95% CI=2.44-7.65), and 5-6 items ADLs impairment (OR=8.23, 95% CI=5.10 -13.28) had more opportunity (odds ratio) to use it. The subjects with tube insertion (OR=2.25, 95% CI=1.27-3.97) had more opportunity (odds ratio) to use it than the subjects without tube.
In summary, the medical care services utilization was influenced by need factor such as cognitive impairment, number of chronic conditions, and level of dependency. In addition to the needs factor, predisposing characteristic (i.e., gender, and the level of education) and enabling factors (i.e., number of kids, marital status, and residential area) were important factors to affect the utilization of long-term care services. These findings provided important information for the Taiwan Veterans Affairs and related organizations to plan the medical and long-term care policy for veterans and their family members or elderly people in Taiwan.

並列關鍵字

Veterans and their family members,Medical service utilization,Long-term care services utilization

參考文獻

朱慧凡、吳肖琪(2004)台灣六十五歲以上榮民住院之相關因素分析，中華衛誌，23(4)：297-304。

吳淑瓊、林惠生(1998)台灣功能障礙老人家庭照顧者的全國概況剖，臺灣衛誌，18(1)：44-53。

吳淑瓊、徐慧娟、莊媖智、張明正(1966)功能評估在估計台灣社區老人長期照護需要之應用，中華衛誌，15(6)：533-45。

吳淑瓊、莊坤洋(2001)在地老化：臺灣二十一世紀長期照護的政策方向，臺灣衛誌，20(3)：192-201。

杜明勳(1996)南部某榮民安養之家住家榮民健狀況調查。中華衛誌。15：97-106。