探討基層開業醫師對實施「呼吸道診療概況表」之態度及其對醫師行為之影響

Exploring the Attitudes of Primary Physicians toward the Implementation of Tables of Diagnosis &Treatment of Respiratory Tract and Its Impact on Behaviors of Primary Physicians

陳家榆(Chia-Yu Chen)

指導教授 ： 林恆慶

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(2005年)

摘要

本研究旨在探討基層開業醫師對實施「呼吸道診療概況表」之態度其對醫師行為之影響。本研究採問卷調查法，以郵寄結構式問卷的方式蒐集所需的資料，以2005年在衛生署醫政處登記執業的基層開業醫師為母群體，挑出健保局台北分局轄下較常診療呼吸道感染病患的醫師，以一般科、耳鼻喉科、小兒科、內科及家庭醫學科等五大科醫師共2040位做為本研究之研究對象，回收496份，扣除因退休、移民、歇業及地址遷移及該診所無健保業務等因素被退回問卷36份，回收率為24.8%，回收後進行樣本與母群體基本特性的適合度檢定(goodness-of-fit test)，在年齡(p=0.109)及性別(p=0.233)上並無顯著差異。先以卡方檢定進行雙變項分析，再依據分析結果進行羅吉斯迴歸（Logistic Regression）模式之建立，並藉由迴歸分析結果來探討實施醫師檔案對醫師醫療行為之影響。 本研究之主要結果如下： 一、有42.8%的基層醫師對台灣目前的醫療環境使用「門診特定疾病診療概況表」持負面態度者。 二、基層醫師認同使用「門診特定疾病診療概況表」會產生的前三個現象依序為會對醫師的臨床判斷力及自主權造成影響、健保局可以藉此做醫療資源利用率的分析及有助於瞭解醫師對病人醫療照護的模式及結果。 三、醫師在看到健保局寄發的「呼吸道診療概況表」之後，會改變的前三種醫療行為依序是每診次抗生素的使用、每診次用藥品項數及建議病人使用自費藥物，而整體上有超過半數以上的醫師仍然不會改變其醫療行為。 四、「醫師特質」、「執業狀況」及醫師對「門診特定疾病診療概況表」之看法會影響醫師醫療行為。 依據研究結果，本研究提出以下建議：一、衛生主管機關可將「門診特定疾病診療概況表」應用於教育醫師而非獎懲的工具、謹慎選取適合的指標及適用的ICD code、給予較即時性的資料；二、建議基層開業醫師可以正向運用醫師檔案，用來瞭解分析自己對病人醫療照護的模式及結果，以提昇醫療照護品質；三、建議後續研究者，可以使用健保資料庫做實際上醫師是否改變行為的研究，另外，可以醫院醫師為研究對象，並針對醫院醫師與基層開業醫師之看法進行差異比較，會看到更完整的研究對未來使用醫師檔案會有更大的幫助。

關鍵字

呼吸道診療概況表 ； 醫師檔案 ； 基層開業醫師

並列摘要

This study aims to explore the attitudes of primary physicians toward the implementation of tables of diagnosis & treatment of respiratory tract and its impact on physician behaviors. This study used a structured self-administered survey to collect data. The study subjects were 2040 primary physicians registered at the Bureau of Affairs, Department of Health as the general practitioners, ENT, pediatricians, internal medicine, and family practitioners under the Taipei Branch of the Bureau of the National Health Insurance (BNHI). A total of 496 questionnaires were returned, yielding a response rate of 24.8%. The goodness-of-fitness tests found that there were significant differences between population physicians and the respondents in terms of age (p=0.109) and gender (p=0.233). A logistic regression analysis was performed to examine the impact of the implementation of tables of diagnosis & treatment of respiratory tract on physician behaviors. The results of the survey are as follows: 1. The results found that 42.8% of respondents showed the negative attitudes toward the implementation of tables of diagnosis & treatment of disease in OPD. 2. The phenomenon primary physicians found in the use of tables of diagnosis & treatment of disease in OPD were: (1) the effect of judgement & authority of the physicians; (2) the use of “tables of diagnosis & treatment of respiratory tract” as a basis for the analysis of resource utilization by the BNHI; (3) the understanding to physicians of the practice patterns of patient care. 3. After physicians see the “tables of diagnosis & treatment of respiratory tract” that BNHI sends, they will change the three medical attitudes follwing in orders: the use of antibiotics, numbers of medicine in every OPD, and spread of self-expense medicine. Overall, over half of physicians will still not change their medical behavior. 4. “Characteristics of physicians,” “condition of occupation,” and opinions of “tables of diagnosis & treatment of disease in OPD” from physicians will influence medical attitudes of physicians. Based on this study results, some suggestions are concluded as follows: 1. we suggested that the health authority (1) use the tables of diagnosis & treatment of respiratory tract as a education tool instead of a punishment mechanism; (2) select the appropriate indicators and ICD codes; and (3) provide timely feedback. 2. The primary physicians can directly apply physician files and analyze patterns and results of how they treat patients in order to promote quality of medical treatment. 3. It is suggested the further researches can investigate by using BNHI database to see if the attitudes of physicians have changed. Also, they can find physicians in hospitals to become reserching targets and compare different opinions of physicians in hospitals and primary physicians. This comparison will assist the use of physician files to achieve perfect research in the future.

並列關鍵字

tables of diagnosis & treatment of respiratory tract ； physician profiling ； primary physician

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