醫院結核病個案管理模式之探討

Analysis of Tuberculosis Case Management Models in Hospitals

李婉萍(Wang-Ping Lee)

指導教授 ： 許玫玲

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(2006年)

摘要

中央健康保險局於民國90年11月起推動「醫療給付改善方案試辦計畫」，針對結核病等五大慢性疾病，以「疾病管理」的精神將醫療保險給付與醫療品質結合，強調個案管理，以達全程治療的目標，提升結核病等慢性病患的照護品質。 本研究的目的在瞭解國內醫院目前對於結核病個案管理工作的現況，並分析醫院結核病個案管理模式的內涵。另一方面，進一步分析醫院特性對於樣本醫院採取的個案管理模式內涵之影響力。 本研究的研究母群體為衛生署90-93年度醫院評鑑結果屬於地區(含)以上之醫院，扣除已歇業及裁撤醫院後，共有492家醫院。問卷填答對象則為上述醫院中負責執行結核病個案管理工作之人員。研究人員於民國95年3月初開始寄發問卷，經由三次問卷寄發與催收後，至5月底共有388份問卷回覆，回覆率達78.9％。在回覆問卷中表示有收治結核病病患的醫院計有244家，佔回覆問卷之62.9％；其中有4家區域醫院雖有收治結核病病人，但回覆不參加此調查研究，因此本研究之實際有效研究樣本為240家醫院。所使用之統計分析方法包含卡方檢定及邏輯斯蒂迴歸分析(logistic regression analysis)，以分析醫院特性與醫院所採取的個案管理模式內涵的關連性。 研究結果顯示，樣本醫院所採行之結核病個案管理模式的內涵可歸類為人力配置、收案管理、資料建立、治療管理、護理指導、回診管理及轉介管理等七項。而推論性檢定結果則顯示：(1).人力配置 - 醫院評鑑等級與醫院是否設置專任結核病個案管理人員之人力配置達統計上的顯著差異(χ2 = 69.1, p < 0.001)。醫學中心設置專任個案管理人員最多，而地區醫院則大多設置非專任的個案管理專員。另一方面，相較於未加入「結核病醫療給付改善方案」的醫院而言，有加入該方案的醫院會任用專任人員以執行結核病個案管理工作的可能性高達四倍之多(OR = 4.29, p < 0.001)。(2).收案管理 - 醫院評鑑等級與醫院收治結核病病人是否有收案條件達統計上的顯著差異(χ2 = 19.9, p < 0.001)。不同於區域醫院及地區醫院大多設定有收案條件的情形，僅有20%的醫學中心會設定收案條件。(3).資料建立 - 醫院評鑑等級與醫院所採行之資料建立方式達統計上的顯著差異(χ2 = 23.8, p < 0.001)。相較於醫學中心及區域醫院而言，地區醫院較不可能針對結核病病患的相關資料來自行開發資料管理系統。另一方面，有加入「結核病醫療給付改善方案」的醫院除使用疾病管制局的的結核病資訊管理系統外，另外自行開發結核病個案資料管理系統的可能性則為未加入該方案醫院的2.49倍(p < 0.01)。(4).治療管理 - 醫院評鑑等級與醫院是否有成立結核病診治委員會以進行治療管理達統計上的顯著差異(χ2 = 52.3, p < 0.001)。相較於地區醫院而言，醫學中心及區域醫院成立上述診治委員會的比例較高。另一方面，有加入「結核病醫療給付改善方案」的醫院設立結核病診治委員會的可能性則為未加入該方案醫院的3.82倍(p < 0.001)。(5).護理指導 - 醫院評鑑等級與醫院是否由結核病個案管理人員執行護理指導並未達統計上的顯著差異。然而，有加入「結核病醫療給付改善方案」的醫院較未加入該方案的醫院可能針對結核病病患設置特定的護理指導地點(OR＝4.04, p < 0.001)。(6).回診管理 - 醫院評鑑等級與醫院是否有替必須回診病人主動預約掛號達統計上的顯著差異(χ2 = 14.2, p < 0.001)；區域醫院採取此管理模式的比率最高。(7).轉介管理 - 醫院評鑑等級與醫院是否有採取轉介管理亦達統計上的顯著差異(χ2 = 14.4, p = 0.001)；地區醫院較可能會於病人出院時通知其轄區衛生所護士。 綜而言之，本研究發現醫院特性對於醫院所採取的個案管理模式之內涵具有顯著性的影響力。依據研究結果，本研究對於衛生主管機關提出建議如下：(1).有計畫性地培育醫院結核病防治人才；(2).將醫院結核病個案管理之人力配置納入醫院評鑑項目；(3).建立完備的結核病病患收治醫療網；(4).推廣結核病個案管理模式；(5).結核病資訊系統使用應整合以增進使用者的可近性；及(6).加強衛生所公共衛生護士在結核病病患收治所扮演的角色。

關鍵字

個案管理模式 ； 醫療給付改善方案試辦計畫 ； 結核病 ； 醫院

並列摘要

The Bureau of National Health Insurance (BNHI) implemented the pay-for-quality demonstration program in November 2001, targeting tuberculosis, breast cancer, cervical cancer, asthma, and diabetes. The aim of the program is to encourage health care organizations to adopt the strategy of disease management by assembling healthcare teams as to to improve the medical care outcomes of patients with the aforementioned chronic diseases. And the key successful factor of disease management is to establish a case management model. The purposes of this study were to investigate the current state of tuberculosis patient management in Taiwan’s hospitals, and identify components of tuberculosis case management models. Furthermore, the impact of hospital characteristics on the inclusion of various tuberculosis case management model components was analyzed. Using the 2001-2004 hospital accreditation data, the study population comprised 492 district hospitals or above in Taiwan, after excluding those hospitals that were no longer in operation. People who were in charge of tuberculosis patient management in those hospitals were explicitly asked to respond to the survey. In early March 2006, self-administered questionnaires were mailed out to those identified hospitals. Two rounds of follow-up mailings were carried out. In the end, there were 388 questionnaires returned by late May, representing a 78.9% response rate. Among those questionnaires, there were 244 hospitals (62.9%) engaging in treating tuberculosis patients; however, four of them declined to participated in this survey further. As such, the final effective sample size was 240. Chi-squared test and logistic regression analysis were conducted to examine the impact of hospital characteristics on the adoption of tuberculosis case management models. The results showed that sample hospitals’ tuberculosis case management model components could be classified as: manpower allocation, admission management, data buildup, treatment management, nursing instruction, revisit management, and referral management. Inferential statistics results were as follows. (1). Manpower allocation – Hospital level was significantly related to if sample hospitals would employ full-time tuberculosis case managers (χ2 = 69.1, p < 0.001). Medical centers were more likely to designate full-time tuberculosis case managers. On the other hand, district hospitals tended to appoint part-time tuberculosis case managers instead. Moreover, the likelihood of those hospitals that enrolled in the tuberculosis pay-for-quality demonstration program appointing full-time tuberculosis case managers was as high as four times that of non-enrolled hospitals (OR = 4.29, p < 0.001). (2). Admission management - Hospital level was also significantly related to if sample hospitals would prescribe rules regarding admitting tuberculosis patients (χ2 = 19.9, p < 0.001). Medical centers were less likely to lay down such kind of rules, compared to their counterparts. (3). Data buildup - Hospital level was significantly related to methods of data buildup of sample hospitals as well (χ2 = 23.8, p < 0.001). District hospitals tended to use the tuberculosis patient database management system provided by the Center for Disease Control (CDC) of Taiwan, rather than design their own systems, compared to their counterparts. In addition, compared to non-enrolled hospitals, hospitals that enrolled in the tuberculosis pay-for-quality demonstration program were more likely to design their own tuberculosis patient database management systems, along with using the existing system of the CDC (OR = 2.49, p < 0.01). (4). Treatment management - The results showed that the possibility of if sample hospitals would create an ad hoc committee to be responsible for treating tuberculosis patients differed significantly by hospital level (χ2 = 52.3, p < 0.001). District hospitals were less likely to establish such a committee, among all. Furthermore, hospitals that enrolled in the tuberculosis pay-for-quality demonstration program were more likely to create such a committee, compared to their counterparts (OR = 3.82, p < 0.001). (5). Nursing instruction – The results revealed that hospital level was not significantly related to if sample hospitals would designate tuberculosis case managers in charge of related nursing instruction. However, hospitals that enrolled in the tuberculosis pay-for-quality demonstration program were more likely to set up specific nursing instruction places for tuberculosis patients than non-enrolled hospitals (OR＝4.04, p < 0.001). (6). Revisit management - Hospital level was significantly related to if sample hospitals would actively arrange revisits for their tuberculosis patients (χ2 = 14.2, p < 0.001). District hospitals were more likely to have revisit management, compared to their counterparts. (7). Referral management – Finally, hospital level was significantly related to if sample hospitals would carry out referral management for their tuberculosis patients as well (χ2 = 14.4, p = 0.001). Among all levels of hospitals, district hospitals were most likely to notify those responsible community public nurses when their tuberculosis patients were discharged. In conclusion, this study demonstrated that hospital characteristics did exert impact on the inclusion of various tuberculosis case management model components by hospitals. According to research findings, the following policy recommendations were proposed: (1). The government should systematically develop tuberculosis management manpower. (2). Hospital accreditation items should include manpower allocation with respect to tuberculosis case management. (3). The government should establish a comprehensive medical care network for treating tuberculosis patients. (4). The government should promote tuberculosis case management models aggressively. (5). Various tuberculosis patient database management systems need to be integrated to increase the accessibility for users. (6). The role played by community public health nurses should be enhanced regarding treating tuberculosis patients.

並列關鍵字

case management model ； pay-for-quality demonstration program ； tuberculosis ； hospital

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