老年人糖尿病、心臟疾病、高血壓性疾病在西醫門診
醫療資源耗用之研究

目的台灣地區因人口結構與生活型態的改變，疾病的型態由急性傳染病轉化成以老年人口為主的慢性疾病；故本研究目的一.探討老年人門診糖尿病、心臟疾病及高血壓性疾病的醫療耗用情形。二.探討老年人門診糖尿病、心臟疾病及高血壓性疾病在性別、醫院層級別及共病型態的醫療資源耗用（就醫次數、醫療費用及各項費用）之比較。三.性別、年齡和共病型態是否可做為門診醫療資源耗用之預測因子。四.以結構方程模式（SEM）來探討性別、年齡及共病型態與醫療資源耗用之路徑關係。方法本研究為回溯性研究，使用國家衛生研究院「全民健康保險學術研究資料庫」，2000-2004年65歲以上老人之承保抽樣歸人檔，以門診處方及治療明細檔(CD)為主，串連醫事機構基本資料檔(HOSB)。以描述性統計的方式來分別描述2000-2004年三大老人慢性病的就醫次數、醫療費用、每一就醫人次的平均費用、不同層級醫療機構的就診頻率及處方簽使用之資料分佈情形。並以變異數分析(ANOVA)來分別比較三大老人慢性病在性別、醫療層級別之就醫次數、醫療費用、藥費、診療費和診察費上的差異；並比較不同共病型態在個人就醫次數及各項醫療費用之差異。以複迴歸分析來分別探討性別、年齡和共病型態對就醫次數、醫療費用之預測力。並以結構方程模式進行研究架構之驗證。結果以各慢性病在總抽樣數中之罹病人數去推估其五年(2000-2004年)門診盛行率，罹患糖尿病者有3754人，門診盛行率為22.99%；有心臟疾病者計5986人，門診盛行率為36.66%；有高血壓性疾病者計9017人，門診盛行率為55.22%；合計至少罹患一種疾病者之門診盛行率為72.57%。高血壓性疾病之費用最高，約佔五年老年人門診支出之10.62%；其次為糖尿病，約佔老年人門診支出之6.51%；心臟疾病約佔老年人門診支出之5.05%；三種慢性病合併來看，五年費用共5億250萬元，約佔老年人門診支出之22.18%。t檢定和變異數分析的結果發現不同慢性病別、共病型態別、性別和醫療層級在醫療費用上均有顯著性差異，尤其三種慢性病在醫療層級之使用上均以醫學中心為最高，且處方簽之開立頻率也均以醫學中心為最高。逐步淘汰複迴歸分析的結果，就醫次數、性別及共病型態最能夠有效預測個人在慢性病上的醫療費用。結構方程模式的最終分析結果顯示：除慢性病別、性別及年齡對醫療耗用有顯著之影響外，透過醫療機構層級所造成的間接效果有不容忽視的影響力。結論與建議如結果所述，老年人三大慢性疾病(糖尿病、心臟疾病、高血壓性疾病)即佔五年老年人門診醫療支出的22.18﹪，藥費佔率高達68﹪，合計至少罹患一種疾病者之門診盛行率為72.57%；在我國現行醫療照護系統仍是著重於提供急性醫療照護下，在急性醫療機構治療慢性病患，乃是一種醫療資源的浪費，隨人口老化,未來慢性醫療照護的需求會越來越高。期以有效控制醫療費用的上漲與照護成效，並供日後研究分析或政策制定參考。故建議如下: （一）推動疾病管理：對高發生率且高費用的慢性病，透過疾病管理可有效降低或延緩併發症或合併症的發生，並得以節省醫療費用。（二）重新評估藥價基準制度：控制慢性病的藥物種類、數目、單價，避開專利期的高貴藥，是重要而確實又不困難，且不致降低醫療品質的可行之道。（三）落實轉診制度：各慢性病之常態看病取藥仍向醫學中心集中，須強制規定？以落實醫學中心應照護急重症患者的分級醫療制度，以期降低醫療費用。 (四)鼓勵醫療機構開立慢性處方簽：對於病情穩定之慢性病人，鼓勵醫師開立慢性病連續處方簽，減少慢性病人經常性的回診就醫，浪費資源。

關鍵字

老年人；糖尿病；心臟疾病；高血壓性疾病；門診醫療資源耗用

並列摘要

Objectives The purpose of this study is to find out from clinical prevalence the characters ( incidence , gender, age ) of geriatric chronic illnesses such as diabetes mellitus (DM) , cardiac disease (CD) , hypertension (HT) ;Inquire into their individual expense in outpatient departments, their difference and impact ; through the study we also find ways for controlling raising of medical care expenditure while maintaining welfare of medical care ; we also hope this study can provide some vital base for later research analysis and for government policy decision making. METHODS This is a retrospective study, by analyzing data from “ National Health Insurance Academic Research Data Bank” of National Health Research Institute, files from year 2000 to 2004 of geriatrics aged more than 65, their OPD prescriptions and therapy details, combined to structure base of hospital organizations , we use descriptive statistics method to narrate the three major geriatric chronic illnesses (from year 2000 to 2004) of their OPD visits, medical fee, drug costs, diagnostic fee, physician pay , calculate average expense of each individual and compare their difference in different ranks of hospital . We use ANOVA method to find their differences; various comobidity of the three diseases also are analyzed; differences of gender, age and comobidity on medical visits and costs area analyzed with multiple regression. The causal pathway is verified by Structural Equation Modeling using Amos 5.0 . RESULTS Through random sampling and statistical analysis, it is estimated that from year 2000 to 2004 there were : Disease DM: patients number are 3754, OPD incidence 22.99 %; Disease CD: patients number are5986, OPD incidence36.66 %; Disease HT: patients number are 9017, OPD incidence 55.22 %;Any of these 3 chronic illness 72.57 %. The medical expenses of each disease in those 5 years were : Disease DM: 6.51 % of 5 year total geriatric OPD expense; Disease CD: 5.05 % of 5 year total geriatric OPD expense; Disease HT: 10.62% of 5 year total geriatric OPD expense; 3 chronic illnesses in whole 22.18%. T-test and ANOVA found that there are significant differences in medical expenditure between disease categories, comobidities, genders and ranks of medical facilities, the medical expenditure of chronic illnesses is the highest in medical centers. CONCLUSIOIN & SUGGESTION From our studies, we found chronic illnesses (esp. diabetes mellitus hypertension cardiac disease) aside from geriatric natural senescence will continue to grow both in patients number and medical expense, and so will always be a heavy burden of financial management of the National Health Insurance , therefore we make suggestions to those who set up national health care policy: (1) Continuing disease managed care: Right now our present medical care system is still focusing and endeavoring on acute disease care, where as to care chronic illed patients in acute medical aid facilities would be a wastage of medical resources , as population aging, the need of chronic illness care will raise exponentially by year, continue present mod of medical care without change surely would cost even more wastage, through disease managed care we can effectively decrease or delay the complications or comobidities of these chronic illness with high incidence and high expense, thereby the whole medical expenditure can be controlled and medical resources saved. (2) Redo drug fee basement system : the three chronic illnesses cost 22.18% of geriatric OPD ( 5 years or annual from year 2000 to 2004 ) OPD medical expense , and drug fee amounted 68% in the cost, to control the medical care expense, control of drugs for these chronic diseases including drug categories, numbers, unit price, avoid high priced patent drugs are methods of easy practice and effectiveness, while in so doing it would not decline the quality of medical care. (3) Reemphasize the transfer or refer system of medical care : to direct medical centers for acute disease and critical care , while local community hospitals and clinic for chronic illness and outpatient care, therefore the national medical resources can be located properly and functioned effectively. Those who provide medical cares: Encourage long term prescription for those chronically illed but stable patients, so as to decline annual medical visits and save the expenditure.