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  • 學位論文

台灣長期呼吸器依賴制度對醫院間社交網絡的影響與發展

Exploration of Hospitals’ Social Network in Taiwan’s Long-Term Respiratory Care System

指導教授 : 莊秀文

摘要


台灣長期呼吸器依賴患者整合性照護計畫的政策與評鑑標準皆可能會影響 醫院對於長期呼吸器依賴患者的轉院路徑與人數多寡,使得醫療機構之間多年 來已形成一個複雜的醫療社會網絡,為瞭解醫療機構多年來在此制度中運作的 社會網絡結構關係,以及其網絡動態結構的發展狀態,與社會網絡內各個主群落 的特性與差異。有鑑於此,本研究以健保署中區業務組所轄管的醫院為例,透過 社會網絡分析的應用軟體NodeXL,分析病人轉院所衍生的醫院聚落型態,著重 在中區醫院社會網絡結構之變遷,以及所衍伸的醫院間聯盟形態變化,以增進我 們對醫院群聚型態與轉院聯盟的理解,也可對未來醫療社會的發展趨勢有所掌 握,提出針對長期呼吸器依賴整合性照護制度的政策性建議。 將1997–2011 年的中區健保次級資料庫經歸人整理就醫資料後,依照病患 開始長期使用呼吸器的年份、各區歷年長期呼吸器所花醫療費用,以及收治呼吸 器依賴病患之醫院的特質(醫院層級、權屬別、所屬地區等),顯示長期呼吸器 依賴病患自1997 年不斷成長至2004 年,並在2005 年開始維持穩定水平;以 2005 年為分隔點,1997-2004 年為成長期,2005-2011 年為穩定期。 研究結果顯示中區全體資料中有3 成以上的病患有轉院的經歷,其餘病患 自始至終都在同一醫院接受治療從不轉院。而收治呼吸器依賴病患之醫院家數以 臺中縣市最為多數,其家數成長幅度驚人,彰化縣市與南投縣市收納該類病患的 家數並無特別的增長,原因可能與中區各縣市呼吸器依賴資源供應程度不同有關, 因此本研究採納醫院所屬地區之都市化程度為探討變項之一,由結果顯示,中高 度都市化與一般鄉鎮的都市區域其醫院家數較多,而新興市鎮之醫院家數是逐步 的成長,偏遠地區的醫院家數則一直維持在少量的水平。 社會網絡分析的結果,都市化程度愈高的醫院其向內中心性較都市化程度 較低者來的高,病患由各方醫院聚集至該醫院的強度愈強。若醫院中介中心性也 高的情況下,賦予其能影響轉院之路徑的能力,故在網絡中所佔之領導能力愈強。 因接近中心性之定義為與相鄰節點聯繫之頻繁程度,與向內中心性之關係為當 相鄰節點醫院轉入該院之患者愈多,其向內中心性亦愈高。同時群落內醫院之特 徵向量亦受轉院病患的多寡影響,進而使醫院透過病患轉院的方向與次數能影 響網絡結構的能力愈強。以綜觀而言,在中區長期呼吸器依賴病患所形成的社會 網絡結構分為8 大群落,都市化程度較高的醫院多與該都市程度化較高之醫院 自成群落,都市化程度較低的醫院會與他區域都市化稍較高之醫院另自成群落, 但每年的群落消長會因轉院路徑的發生有所轉變。 群落間之特性比較,除社會網絡之指標外,在各網絡內醫院結構特性上也 出現動態變化,包含群落的收斂由成長期10 群落匯集至8 個,各群落之醫院家 數增加,而穩定期群落則顯示進出該群落家數有相當的變化,部分醫院因轉手經 營而導致該群落結構的調整。 總合各結果可看出轉院關係多與地域性相關,以穩定期各群落為例,進行 轉院的PMV 病患共病程度無或輕微者佔總體約7 成,共病程度極重度或重度嚴 重患者本身人數就少,所佔總體轉院的比例約3 成。而偏鄉地區轉院病患的共病 程度,較中高度都市化轉院的病患來的較嚴重,可能是患者因需要較多醫療照護 而轉往醫療資源較豐富之地區,亦有可能是急重症患者在接受一段時期的照護後, 因個人因素想返回家鄉。

並列摘要


Taiwan's Integrated Delivery System (IDS) and policy evaluation standards for prolonged-mechanical ventilator (PMV) patients might affect the number of PMV patients and the referral path of PMV patients, and it also makes hospitals become a complex social network of medical society over these years. To understand the relationship and the structure of medical institutions’ social networks operating in the IDS and Integrated Prospective Programs (IPP) for PMV patients which were launched by the bureau of National Health Insurance (NHI), to observe the dynamic growth features of social network relationships, and to understand the characteristics and differences in various groups. Therefore, this study focused on medical institutions of NHI’s Central Bureau, and used application software NodeXL of Social Network Analysis (SNA) to analyze the hospitals’ settlement patterns formed by patients’ referral path. It discussed about the central district hospitals’ structural changes and the morphological changes of the hospital referral alliance, to enhance our understanding of hospitals’ gather patterns and strategic alliances, but also to grasp the development trend of the medical society in the future, and to propose political either suggestions or recommendations for PMV. Administrative claims data which is PMV patients in 1997-2011 under IPP in Taiwan. According to the year of patients’ started to become PMV, the treatment cost for PMV over years in each district, and the hospitals’ characteristics (like: hospital level,and district, etc.), it shows that the number of PMV in Taiwan had increased since 1997 till 2004, and had maintained at a stable level since 2005 till 2011. Take 2005 as a dividing point year, 1997-2004 is growing period and 2005-2011 is stable period. In the result, it displays that over 30% of PMV in central district would have been transferred, and every year at least 18% of new PMV will transfer to a different hospital in the future and the rest of them were never transferred. The most majority of PMV patients were admitted in Taichung city and county, and the number of hospitals in Taichung counties had an amazing growth, but in Changhua and Nantou counties had not much growing, which may be related to cities and counties in the region depend on the degree of resource supply respirator different, so the degree of urbanization in this study was also adopted to explore. The results shows that the highly urbanized and general metropolitan area have more hospitals, while the number of hospitals in new town is gradually growing, the number of hospitals in remote areas has been maintained at a small level. The sum of all the results can understand that the relationship is more with regional referral. Take stabilization period as an example, PMV patients with mild or none comorbidity accounted for about 70% overall, the degree of comorbidity in patients with extremely severe or severe the number itself is small, the overall share of referral ratio of about 30%. Comorbidity with referral in remote areas is literally higher and serious than in highly urbanized, because patients may need more medical care and transferred to the areas which has more medical resources, there may be critically ill patients were accepting the care as time goes by, due to personal reasons wish to return hometown.

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