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  • 學位論文

醫院門診限量對急診、住院醫療品質之影響—以某公立醫學中心為例

The Impacts of Outpatient Volume Control on the Medical Quality of Inpatient Department and Emergency-Case of a Public Medical Center

指導教授 : 廖宏恩
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摘要


健保自民國87年起因醫療支出高於保費收入,為了解決收支平衡,抑制醫療費用快速上漲,從八十七年起開始分階段實施總額支付制度,自九十二年七月開始,正式實施「醫院自主管理」,九十三年健保更因應品質提升、成本管控而推出「卓越計畫」。不過,部分醫院為爭取更大的生存空間,在評估自身醫院型態及業務量成長空間,紛紛做出應變行為,如門診限號、關閉夜間門診、非急診刀延後再開的情況,致使病患就醫可近性降低;而此「醫院自主管理」及「卓越計畫」的實施,使民眾就醫可近性打了折扣,亦可能連帶影響醫療品質。 因此,本研究目標有三:(1)觀察研究醫院實施門診限量後,住院與急診服務量的變化。(2)比較研究醫院實施門診限量前後,急診檢傷分類程度與住院病例組合指標(CMI)值之變化。(3)分析門診限量政策對住院與急診相關醫療品質之變化。希望藉此研究瞭解研究醫院因應卓越計畫,所採取之門診限量相關措施措施,對急診及住院服務量的變化及病患就醫時醫療品質是否有影響,以作為民眾就醫時之參考及院方制訂政策方向時之參考,並提供健保局作為監測醫療服務提供者之醫療品質之參考。 本研究以某公立醫學中心為研究對象,採回溯性方法,利用F-test及獨立樣本t檢定之統計分析,以91年、92年及93年三年中之7-12月資料,作為研究時間,比較研究醫院採取積極限制門診量前後,對於急診、住院之服務量及醫療品質指標,包含:24小時內重返急診率、72小時內重返急診率、急診留觀大於72小時、14天再入院率、平均住院天數等之影響。 研究結果發現門診限量措施下,急診服務量上有增加之趨勢,但無證據可以直接證明兩者有替代效應;急診檢傷第二級分類在門診限量期間,顯著增加;住院之CMI值則未因門診限量而改變;至於對醫療品質之影響,急診指標中,急診轉他院人次、急診留觀大於72小時人次及0-72小時重返急診人次有顯著增加;住院指標中14天再住院率顯著增加,但若扣除再住院化學治療部分,則與91-92年份無差異;住院指標中,門診限量措施下(93年7-9月)與非積極門診限量下(93年10-12月),住院的平均住院天數有顯著增加。 研究建議:(1)為維持一定之醫療品質,避免因過度負荷,急診需做必要之機動措施,以減緩急診擁擠所帶來之可能錯誤增加、不安全行為增加等潛藏傷害。(2)因研究醫院在門診限量情形下,其相關之醫療品質未有顯著下降,雖民眾可近性降低,但此結果符合健保局實施卓越計畫之初衷,故建議健保局在審查參與卓越計畫醫院之資格時,應更審慎考量。(3)門診限量措施僅為總額預算下不得以之權宜措施,完善之轉診制度及家庭醫師制度,才是有效率的醫療資源分配的長久之計。

並列摘要


The growth of medical expenditure is higher than that of premium revenues since 1998. To curb the escalating medical expenditure, Bureau of National Health Insurance began to implement phased-in Global Budget Payment Scheme by medical category at that time. Furthermore, a “Hospital Self-Management” and “Center for Excellence Plan” were respectively introduced on 2003 and 2004 to assure medical quality and control costs. Consequently, many hospitals responded to take actions, such as controlling the outpatient volume, closing the night clinics, and postponing the non-emergency surgeries, which may lead to jeopardize people’s access to health care. The potential impacts on medical quality might emerge. Therefore, this dissertation aims at: (1) Observing the volume changes in inpatient and emergency rooms after limiting the outpatient volumes of a case hospital; (2) Comparing the changes in emergency department triage and inpatient Case-Mix Index (CMI) before and after launching the outpatient volume control policy; (3) Analyzing the impacts of outpatient volume control policy on medical quality. Hopefully, our findings regarding the quality impacts of hospital’s behavior could be reference for peoples who seek health care, for hospital administrators who make the decision, and for the health authority who monitor the health services. A public medical center was called for as a research source for our study. In addition, we collected July to December data of Year 2002, 2003, and 2004 retrospectively to analyze the impacts of outpatient volume control policy on the volume changes in inpatient and emergency department as well as medical quality indicators, including returning to the emergency department within 24 hours, returning to the emergency department within 72 hours, retaining in the emergency department over 72 hours, readmission rate within 14 days, and average length of stays. Inferential statistics, such as F-test and Independent t-test, were employed in the study. The study observed increasing service volume of the emergency department, and increasing the second class of emergency department triage right after the outpatient volume control policy put into action. But there was no evidence to verify the substitute effect between the services volume of outpatient and emergency department visits. For the impacts on medical quality of the emergency department, we found an increasing volume of retaining in the emergency department over 72 hours, an increasing number of transferring to other hospitals, and increasing volume of returning to the emergency department within 72 hours. For the impacts on medical quality of the inpatient department, there is a significant increase in the average length of stays as well as readmission rate within 14 days. However, after deducting the number of patients who returned back to the hospital for one-day chemotherapy or radiotherapy, there was no difference in terms of readmission rate within 14 days among Year 2001, 2002, and Year 2003. The suggestions are shown as follows. (1) To maintain good quality, the emergency increase manpower dispatch shall keep maneuverable to avoid potential overburden. (2) The outpatient volume control policy of the study case, though reduced the access of people’s medical seeking, didn’t sacrifice the medical quality. From the viewpoint of original purpose in implementing “Center for Excellence Plan” monitored by the Bureau of national Health Insurance, it seemed that the case hospital still met the eligibility and fulfilled its requirements. (3) The outpatient volume control policy is merely a short term contingent strategy, comprehensive referral system and family physician design will be the remedy to distribute the medical resources efficiently in the long run.

參考文獻


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被引用紀錄


林桂枝(2009)。影響兒科急診病患72小時再返之相關因素-以2005-2007年北部某醫院為例〔碩士論文,臺北醫學大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0007-2107200909202300

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