住院日適當性研究--以台北市某區域教學醫院為例

A Study of Appropriateness of Hospital Stay─A Case of Regional Teaching Hospital in Taipei

宋思霈(Sung Szu-Pei)

指導教授 ： 溫信財

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2003年)

摘要

我國全民健保開辦之後，雖然大幅增加就醫可近性，但和其他國家一樣面臨醫療費用持續上漲的問題，且有財務入不敷出的情況，健保局指出，許多醫院被核減的原因大都因為住院申報日數過長。隨著總額制度實施及住診費用比重逐漸增加，非必要的住院將降低住院支付點值且浪費醫療費用，因此住院的適當性更顯重要。 本研究以某區域教學醫院一般外科及腸胃內科為例，瞭解其住院日適當性情形，以專科醫師判定結果為依據，並進一步探討影響住院日不適當的因素及造成的原因。 研究結果顯示，樣本醫院有不適當住院日情形存在，腸胃內科隨機抽一天的不適當率為6.46%，出院前一天為25.09%，一般外科隨機抽一天為2.3%，出院前一天為36.15%。而大部分住院日不適當原因是因為病患該出院但醫院或醫師疏忽未讓病患出院。 在影響不適當住院日的變項上，「假日」的不適當機率高。利用病歷進行回溯性審查時，病歷完整性與適當性的判定無關，但病歷是否記載病情發現與適當性判定顯著有關。 本研究建議醫院管理者可利用客觀，且具信度、效度的住院日適當性判定工具，進行住院日管控，讓病床管理更有效率，並及時進行出院計畫，以減少不必要的住院日；衛生主管機關或中央健保局可發展客觀的住院日適當性審查工具，使醫療審查結果更具說服力、讓醫療院所信服，另一方面，藉由參考基準建立，配合電子病歷發展，可利用電腦進行初步篩選，有爭議時再由專業人員審查，以節省審查人力。

關鍵字

住院日 ； 適當性 ； 適當性評估準則

並列摘要

Although the implementation of National Health Insurance (NHI) improves the accessibility of health care in Taiwan, the Bureau of NHI has to face the problem of deficit due to the continuous increasing of health care expenditure. One of the major reasons of causing the deficit is unnecessary hospital days. Moreover, the reimbursement of inpatient bed was raised 37% since NHI was implemented. The importance of the study on the appropriateness of hospital stay is self-evident. This was a cross-sectional study of a systematic sample of 393 cases, sampling from the department of Gastroenterology (GI) and General Surgery (GS) of a regional teaching hospital. The appropriateness of hospital stay was assessed by using the medical records by GI and GS specialists. Our study will further find out the variables of inappropriate hospital stay. We found the hospital stay selected by randomized were rated as medical inappropriate 6.46% in GI and 2.3% in GS department. The results also showed the in appropriate hospital stay before discharge were 25.09% in GI and 36.15% in GS department. The major reason for those inappropriate stays is “for patients whose medical condition does not justify continued stay in an acute care hospital”. In multivariate analysis, the likelihood of an inappropriate hospital stay was increased by weekend【odds ratio (OR) 2.19, 95% confidence interval (CI) 1.28-3.80】and clinical department【OR: 1.75, CI, 1.01-3.02】.The assessment of appropriateness is affected by the significant findings of medical record, and the result is different from Spain’s study. In order to reduce the unnecessary hospital stay, we suggest the bureau of NHI could adopt a valid and reliable review tool that can be computerized for efficient medical review in short times. The hospital administrators should comply the government policy and develop the discharge to avoid the inappropriate stay.

並列關鍵字

hospital stay ； appropriateness ； appropriateness evaluate protocol

參考文獻

中文部分 中央健保局(2003a)。www.nhi.gov.tw。中央健保局公告。 中央健保局(2003b)。全民健康保險重要統計資料。 行政院衛生署(2002)。行政院衛生署全民健康保險醫療費用協定委員會第七十二次會議記錄。

曾慧玲(2002)。電腦斷層攝影醫療利用及其適當性評估研究。高雄醫學大學公共衛生研究所碩士論文。

溫信財(2002)。入院適當性判定工具及入院適當性相關變項之研究。國立台灣大學醫療機構管理所博士論文。 盧瑞芬、莊逸洲(1998)。全民健康保險重大疾病醫療資源利用分析。中央健康保險局委託研究計畫。

年可預防性住院趨勢分析。中央健康保險局數據處理中心研討會。 英文部分 Alonso J, Munoz A, & Anto JM.(1996). UsingLength of Stay and Inactive Days In the Hospital to Assess Appropriateness of Utilisation in Barcelona, Spain. Journal of Epidemiology and Community Health, 50(2), 196-201.

Apolone G, Alfieri V, Braga A, Caimi V, & Cestrari C. (1991). A Survey of the Necessity of the Hospitalization Day in An Italian Teaching Hospital. Quality Assurance in Health Care, 3(1), 1-9.