不同醫師專科別及機構層級別對多重慢性病患的照護結果之探討

詹舒涵

doi:10.6342/NTU201600881

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不同医师专科别及机构层级别对多重慢性病患的照护结果之探讨

Outcomes of Patients with Mutiple Chronic Conditions among Specialists and Different Level of Hospitals

詹舒涵 , 硕士　　导师：郭年真　　

繁体中文 DOI： 10.6342/NTU201600881

多重慢性疾病；专科照护；照护过程品质；药物遵从；医疗利用； Multiple Chronic Conditions ； specialist ； quality of process care ； medication possession ratio ； Healthcare Utilization

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摘要 │ 参考文献 (136) │ 国际计量

摘要〈TOP〉

研究背景:
由於医疗科技进步以及人口老化的趋势，使得一个人同时罹患多种慢性疾病的情形越来越多，这类病人的基层门诊利用和多重用药明显增加，此外由於疾病较为复杂，使得接受的照护不连续和医疗人员提供的照护不协调等，可能影响病人照护结果，但目前关於多重慢性病患照护模式及其接受的照护情形之相关实证研究仍有限。
研究目的：
探讨国内多重慢性病患就诊科别及就医层级之分布，以及在不同照护模式之下多重慢性病患的照护结果的关系。
研究方法：
本研究采回溯性研究法，资料来源为国家卫生研究院发行2005-2010年糖尿病病人的抽样归人档，而所有的追踪年份为2004-2013年的资料。以多阶层模型探讨在控制病人特质(性别、年龄、共病症、都市程度)後，病人照护模式(就诊科别、就医层级)与病人自罹患多重慢性疾病起，每年重覆量测之照护过程面品质、住院、急诊医疗利用及药物遵从之关系。
研究结果：
    本研究结果发现，糖尿病於内分泌科接受治疗之病人各项过程面照护品质达成率较好，高血压则皆为内分泌科、心脏血管内科之检验检查指标达成率较好。在冠状动脉疾病之照护方面，心脏血管内科在「空腹血脂检查」、「血清肌酸酐」、「血清麸胺酸丙酮酸转胺基」等检查之达成率优於其他科别，其余检查项目则为内分泌科达成率较高。在药品遵从指标，三类疾病组合病人同样糖尿病就诊於内分泌科之病人药品持有较佳；罹患高血压及冠状动脉疾病则在心脏血管内科就医之药品持有率较佳。在医疗利用部分，急诊次数、住院次数，糖尿病为就诊於家医科、心脏血管内科之急诊次数较少，高血压及冠状动脉为内分泌科较少；住院天数，糖尿病为就诊於家医科、心脏血管内科之较少，同时罹患糖尿病与高血压病人，其高血压就诊之家医科、心脏血管内科与内科之住院天数较内分泌科少，冠状动脉疾病为就诊分别於心脏血管内科、内分泌科住院天数少。
结论：
    本研究结果显示，由不同科别医师照护的多重慢性病患，其照护过程面品质、医疗利用及药物遵从皆有差异，在照护过程面品质多为内分泌科达成率较好，医疗利用分别家医科、心脏血管内科及内分泌科之利用较少，药物品持有为内分泌科、心脏血管内科表现较好。因此有必要透过政策介入引导医师改变过去以单一疾病为导向照护方式，并重视多重慢性疾病患者之照护品质与照护结果，由於本研究选用部分照护结果，建议未来研究可再选用如死亡率、再入院率等不同照护结果进行分析，并且进一步探讨不同科别医师照护结果不同之背後原因。

并列摘要〈TOP〉

Background:
An ageing population and advances in life-extending medical technologies has lead to an increasing number of individuals that suffer from multiple chronic conditions. These patients require higher than average medical services and polypharmacy. The complexity of these cases often results in fragmented medical care and difficulties in the co-ordination of health care providers. Furthermore, little research has been conducted regarding different specialists and hospital levels (Academic Medical Centers, Metropolitan Hospitals, Local Community Hospitals, Physician Clinics) for multiple chronic conditions.
Purpose:
The purpose of this study was to further understanding of the effect that different specialists and different levels of hospitals have on patients with multiple chronic diseases in Taiwan. The relationships among different care models and patient outcomes were also analyzed. 
Methods:
This retrospective observational study is based on data from the Longitudinal Cohort of Diabetes Patients (LHDB) that was compiled by the National Health Research Institute (NHRI) for the years from 2005 to 2010. The representative samples were followed between 2004 and 2013. The patients in this study fell into three categories: diabetic patients with hypertension, diabetic patients with coronary artery disease, and diabetic patients with hypertension and coronary artery disease. After controlling for patient characteristics (sex, age, comorbidity, urbanization) we used multilevel modelling to elucidate the relationship between care models (specialist, hospital level) and diabetes indicators, hospitalization, medical emergencies, and medication possession ratios.
Results:
After controlling for patient characteristics, we found that patients suffering from diabetes had better outcomes when they were cared for by the Department of Endocrinology. Furthermore, patients with hypertension and coronary artery disease had better outcomes when cared for by the department of Cardiology and Endocrinology. When it came to the medication possession ratio (MPR), diabetic patients cared for by the Department of Endocrinology, and hypertension and coronary artery disease patients who were cared for by the Department of Cardiology had better outcomes. When it came to medical services, diabetic patients cared for by the Department of Family Medicine and Cardiology, and hypertension and coronary artery disease patients cared by the Department of Endocrinology needed fewer emergency services. Diabetic patients cared for by the Department of Family Medicine and Cardiology, and coronary artery disease patients cared for by the Department of Cardiology had shorter hospital stays. Diabetic patients with hypertension who were cared for by the Department of Family Medicine, the Department of Cardiology, and the Department of Internal Medicine had shorter hospital stays than those who were cared for by the Department of Endocrinology.
Conclusion:
The Department of Endocrinology showed better performance on most of the indicators. In regards to medication possession ratio (MPR), the Department of Endocrinology and Cardiology showed better performance. Departments of Family medicine, Endocrinology and Cardiology were utilized less for healthcare services. It is necessary to develop policies and continue physician education so physicians can change their care models; in the past they generally focused on a single disease but now they must develop a deeper understanding of the challenges that face patients with multiple chronic diseases. Future studies might further analyze care outcomes and explore the factors that influence the outcomes emerging from the care of different specialist physicians.

参考文献 ( 136 ) 〈TOP〉

Agborsangaya, C. B., Lau, D., Lahtinen, M., Cooke, T., & Johnson, J. A. (2012). Multimorbidity prevalence and patterns across socioeconomic determinants: a cross-sectional survey. BMC Public Health, 12, 201. doi: 10.1186/1471-2458-12-201
连结：
Agborsangaya, C. B., Lau, D., Lahtinen, M., Cooke, T., & Johnson, J. A. (2013). Health-related quality of life and healthcare utilization in multimorbidity: results of a cross-sectional survey. Qual Life Res, 22(4), 791-799. doi: 10.1007/s11136-012-0214-7
连结：
Akker, M. v. d., Buntinx, F., & Knottnerus, J. A. (1996). comorbidity or multimorbidity what's in a name a review of literature. EUR J Gen Pract 2, 65-70. doi: 10.3109/13814789609162146
连结：
Alonso-Moran, E., Orueta, J. F., Esteban, J. I., Axpe, J. M., Gonzalez, M. L., Polanco, N. T., . . . Nuno-Solinis, R. (2015). Multimorbidity in people with type 2 diabetes in the Basque Country (Spain): Prevalence, comorbidity clusters and comparison with other chronic patients. Eur J Intern Med, 26(3), 197-202. doi: 10.1016/j.ejim.2015.02.005
连结：
Alonso-Moran, E., Orueta, J. F., Fraile Esteban, J. I., Arteagoitia Axpe, J. M., Marques Gonzalez, M. L., Toro Polanco, N., . . . Nuno-Solinis, R. (2014). The prevalence of diabetes-related complications and multimorbidity in the population with type 2 diabetes mellitus in the Basque Country. BMC Public Health, 14, 1059. doi: 10.1186/1471-2458-14-1059
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