照護連續性議題的省思與未來發展方向

Re-thinking continuity of care and future directions

10.6288/TJPH201736106052

陳啟禎(CHI-CHEN CHEN)；陳麗光(LIKWANG CHEN)；鄭守夏(SHOU-HSIA CHENG)

照護連續性 ； 測量指標 ； 行政資料為基礎的測量 ； 病患觀點 ； 回顧 ； continuity of care ； measurement ； claim-based measurement ； patient perspective ； review

台灣公共衛生雜誌

36卷4期（2017 / 08 / 15）

324 - 336

繁體中文

近年來，許多研究者利用行政資料建構照護連續性的測量指標，且多數研究發現照護連續性可改善照護結果。然而，這種量性測量能否代表照護連續性的概念，值得深思。本文以「照護連續性的概念與測量指標之發展脈絡」、「應用量化照護連續性指標的限制」，以及「病人觀點的照護連續性測量工具的發展」三部份為主軸進行文獻回顧。結果發現，研究者普遍認為照護連續性為多範疇的概念，而以行政資料為基礎的量化照護連續性指標係測量一段時間內患者看診次數集中或分散於不同看診醫師間的程度，我們認為這無法反應照護連續性多範疇的概念。此外，量化指標亦無法反應在不同照護場域與醫療環境中照護連續性的本質。最後，以病患為觀點的照護連續性測量逐漸受到重視，建議研究者可以發展病患觀點的照護連續性測量工具，並探究量化指標與各範疇病患觀點指標間的相關性，與各類照護連續性測量指標對照護結果的影響。

Along with the availability of administrative claim data in recent years, researchers have constructed claim-based continuity of care (COC) measurements and found that better COC was associated with favorable health outcomes. Can these claim-based COC measures, however, represent the concept of COC? This issue deserves investigation. This article reviews the following: (1) the evolution and implication of the concept and measurement of COC; (2) the limitation of application of claim-based quantitative measures of COC; and (3) COC measurement from the patient perspective. We found that COC was a multi-dimensional concept in previous studies; however, the claim-based COC measures describe the concentration or dispersion of physician visits among healthcare providers, and we consider that these quantitative measures might not reflect the multi-dimensional concept of COC. In addition, claim-based COC measures may not reflect the essence of care continuity in different care contexts and the medical care environment. Finally, COC measures from the patient perspective has gradually become more important. We suggest that researchers may develop measurement tools for COC from the patient perspective. Furthermore, researchers should examine the relationship between claim-based COC measures and COC measures from the patient perspective in various dimensions, and examine the effects of various COC measures on health outcomes.

1. 林宜柏、吳肖琪(2015)。慢性肺部阻塞門診照護連續性之相關因素探討。台灣衛誌，34，404-12。
   連結：
2. 邱翰憶、鄭守夏、董鈺琪(2016)。心臟衰竭病人出院後照護連續性及就醫機構層級與照護結果及費用之相關性。台灣衛誌，35，66-79。
   連結：
3. 梁亞文、陳文意、張曉鳳(2016)。照護連續性對高齡者急診與非緊急急診之影響探討。台灣衛誌，35，152-63。
   連結：
4. 陳啟禎、鄭守夏(2013)。照護連續性之文獻回顧。台灣衛誌，32，116-28。
   連結：
5. 衛生福利部中央健康保險署：2011年全民健康保險統計動向。台北：衛生福利部中央健康保險署，2013。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). Trends in the Statistics of National Health Insurance in 2011. Taipei: National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan), 2013. [In Chinese]
6. Organization for Economic Co-operation and Development (OECD). Doctors' consultations (indicator). Available at: https://data.oecd.org/healthcare/doctors-consultations.htm. Accessed April 20, 2017.
7. Adler, R,Vasiliadis, A,Bickell, N(2010).The relationship between continuity and patient satisfaction: a systematic review.Fam Pract,27,171-8.
8. Aller, MB,Vargas, I,Garcia-Subirats, I(2013).A tool for assessing continuity of care across care levels: an extended psychometric validation of the CCAENA questionnaire.Int J Integr Care,13,e050.
9. Alpert, JJ,Kosa, J,Haggerty, RJ,Robertson, LS,Heagarty, MC(1970).Attitudes and satisfactions of lowincome families receiving comprehensive pediatric care.Am J Public Health Nations Health,60,499-506.
10. Bachrach, LL(1981).Continuity of care for chronic mental patients: a conceptual analysis.Am J Psychiatry,138,1449-56.
11. Beadles, CA,Voils, CI,Crowley, MJ,Farley, JF,Maciejewski, ML(2014).Continuity of medication management and continuity of care: conceptual and operational considerations.SAGE Open Med,2,2050312114559261.
12. Bentler, SE,Morgan, RO,Virnig, BA,Wolinsky, FD(2014).Evaluation of a patient-reported continuity of care model for older adults.Qual Life Res,23,185-93.
13. Bentler, SE,Morgan, RO,Virnig, BA,Wolinsky, FD(2014).Do claims-based continuity of care measures reflect the patient perspective?.Med Care Res Rev,71,156-73.
14. Bice, TW,Boxerman, SB(1977).A quantitative measure of continuity of care.Med Care,15,347-9.
15. Breslau, N,Reeb, KG(1975).Continuity of care in a university-based practice.J Med Educ,50,965-9.
16. Carmichael, LP(1976).The family in medicine, process or entity?.J Fam Pract,3,562-3.
17. Chan, CL,You, HJ,Huang, HT,Ting, HW(2012).Using an integrated COC index and multilevel measurements to ver i fy the care outcome of pat ient s with multiple chronic conditions.BMC Health Serv Res,12,405.
18. Charney, E,Bynum, R,Eldredge, D(1967).How well do patients take oral penicillin? A collaborative study in private practice.Pediatrics,40,188-95.
19. Chen, CC,Chen, SH(2011).Better continuity of care reduces costs for diabetic patients.Am J Manag Care,17,420-7.
20. Chen, CC,Cheng, SH(2016).Continuity of care and changes in medication adherence among patients with newly diagnosed diabetes.Am J Manag Care,22,136-42.
21. Chen, CC,Tseng, CH,Cheng, SH(2013).Continuity of care, medication adherence, and health care outcomes among patients with newly diagnosed type 2 diabetes: a longitudinal analysis.Med Care,51,231-7.
22. Chen, HM,Chen, CM(2017).A Chinese version of the Patient Continuity of Care Questionnaire: reliability and validity assessment.J Clin Nurs,26,1338-50.
23. Chen, L,Yip, W,Chang, MC(2007).The effects of Taiwan's National Health Insurance on access and health status of the elderly.Health Econ,16,223-42.
24. Chen, TJ,Chou, LF,Hwang, SJ(2006).Patterns of ambulatory care utilization in Taiwan.BMC Health Serv Res,6,54.
25. Cheng, JS,Tsai, WC,Lin, CL(2015).Trend and factors associated with healthcare use and costs in type 2 diabetes mellitus: a decade experience of a universal health insurance program.Med Care,53,116-24.
26. Cheng, SH,Chen, CC(2014).Effects of continuity of care on medication duplication among the elderly.Med Care,52,149-56.
27. Cheng, SH,Chen, CC,Hou, YF(2010).A longitudinal examination of continuity of care and avoidable hospitalization: evidence from a universal coverage health care system.Arch Intern Med,170,1671-7.
28. Cheng, SH,Hou, YF,Chen, CC(2011).Does continuity of care matter in a health care system that lacks referral arrangements?.Health Policy Plan,26,157-62.
29. Cheng, TM(2003).Taiwan's new national health insurance program: genesis and experience so far.Health Aff,22,61-76.
30. Chou, S,Deily, ME,Li, S(2014).Travel distance and health outcomes for scheduled surgery.Med Care,52,250-7.
31. Chu, HY,Chen, CC,Cheng, SH(2012).Continuity of care, potentially inappropriate medication, and health care outcomes among the elderly: evidence from a longitudinal analysis in Taiwan.Med Care,50,1002-9.
32. Dolovich, LR,Nair, KM,Ciliska, DK(2004).The Diabetes Continuity of Care Scale: the development and initial evaluation of a questionnaire that measures continuity of care from the patient perspective.Health Soc Care Community,12,475-87.
33. Donaldson, MS(2001).Continuity of care: a reconceptualization.Med Care Res Rev,58,255-90.
34. Freeman, G,Shepperd, S,Robinson, I,Ehrich, K,Richards, S(2001).Continuity of Care: Report of a Scoping Exercise Summer 2000 for the SDO Programme of NHS R&D.London:National Coordinating Centre for the Service Delivery and Organisation=NCCSDO.
35. Freeman, GK,Olesen, F,Hjortdahl, P(2003).Continuity of care: an essential element of modern general practice?.Fam Pract,20,623-7.
36. Gulliford, M,Cowie, L,Morgan, M(2011).Relational and management continuity survey in patients with multiple long-term conditions.J Health Serv Res Policy,16,67-74.
37. Gulliford, MC,Naithani, S,Morgan, M(2006).Measuring continuity of care in diabetes mellitus: an experiencebased measure.Ann Fam Med,4,548-55.
38. GuthrieB,Saultz, JW,Freeman, GK,Haggerty, JL(2008).Continuity of care matters.BMJ,337,a867.
39. Hadjistavropoulos, H,Biem, H,Sharpe, D,Bourgault-Fagnou, M,Janzen, J(2008).Patient perceptions of hospital discharge: reliability and validity of a Patient Continuity of Care Questionnaire.Int J Qual Health Care,20,314-23.
40. Haggerty, JL,Reid, RJ,Freeman, GK,Starfield, BH,Adair, CE,McKendry, R(2003).Continuity of care: a multidisciplinary review.BMJ,327,1219-21.
41. Haggerty, JL,Roberge, D,Freeman, GK,Beaulieu, C,Bréton, M(2012).Validation of a generic measure of continuity of care: when patients encounter several clinicians.Ann Fam Med,10,443-51.
42. Hansen, RA,Voils, CI,Farley, JF(2015).Prescriber continuity and medication adherence for complex patients.Ann Pharmacother,49,293-302.
43. Hennen, BK(1975).Continuity of care in family practice. Part 1: dimensions of continuity.J Fam Pract,2,371-2.
44. Hsu, CH,Chou, YJ,Pu, C.(2016).The effect of continuity of care on emergency room use for diabetic patients varies by disease severity.J Epidemiol,26,413-9.
45. Huang, ST,Wu, SC,Hung, YN,Lin, IP(2016).Effects of continuity of care on emergency department utilization in children with asthma.Am J Manag Care,22,e31-7.
46. Hwang, DK,Liu, CJ,Pu, CY,Chou, YJ,Chou, P(2014).Persistence of topical glaucoma medication: a nationwide population-based cohort study in Taiwan.JAMA Ophthalmol,132,1446-52.
47. Institute of Medicine(1996).Primary Care: America's Health in a New Era.Washington, DC:National Academy Press.
48. Jee, SH,Cabana, MD(2006).Indices for continuity of care: a systematic review of the literature.Med Care Res Rev,63,158-88.
49. King, M,Jones, L,Richardson, A(2008).The relationship between patients' experiences of continuity of cancer care and health outcomes: a mixed methods study.Br J Cancer,98,529-36.
50. Kowalyk, KM,Hadjistavropoulos, HD,Biem, HJ(2004).Measuring continuity of care for cardiac patients: development of a patient self-report questionnaire.Can J Cardiol,20,205-12.
51. Laditka, JN,Laditka, SB,Probst, JC(2005).More may be better: evidence of a negative relationship between physician supply and hospitalization for ambulatory care sensitive conditions.Health Serv Res,40,1148-66.
52. Lai, YR,Yang, YS,Tsai, ML(2016).Impact of potentially inappropriate medication and continuity of care in a sample of Taiwan elderly patients with diabetes mellitus who have also experienced heart failure.Geriatr Gerontol Int,16,1117-26.
53. Lewis, C(1971).Does comprehensive care make a difference? what is the evidence.Am J Dis Child,122,469-74.
54. Liao, PJ,Lin, ZY,Huang, JC,Hsu, KH(2015).The relationship between type 2 diabetic patients' early medical care-seeking consistency to the same clinician and health care system and their clinical outcomes.Medicine,94,e554.
55. Lin, IP,Wu, SC,Huang, ST(2015).Continuity of care and avoidable hospitalizations for chronic obstructive pulmonary disease (COPD).J Am Board Fam Med,28,222-30.
56. Lin, W,Huang, IC,Wang, SL,Yang, MC,Yaung, CL(2010).Continuity of diabetes care is associated with avoidable hospitalizations: evidence from Taiwan's National Health Insurance scheme.Int J Qual Health Care,22,3-8.
57. Maciejewski, ML,Hammill, BG,Bayliss, EA(2017).prescriber continuity and disease control of older adults.Med Care,55,405-10.
58. McWhinney, IR(1975).Continuity of care in family practice. Part 2: implications of continuity.J Fam Pract,2,373-4.
59. Parchman, ML,Burge, SK(2004).The patient-physician relationship, primary care attributes, and preventive services.Fam Med,36,22-7.
60. Pu, C,Chou, YJ(2016).The impact of continuity of care on emergency room use in a health care system without referral management: an instrumental variable approach.Ann Epidemiol,26,183-8.
61. Rodriguez, HP,Rogers, WH,Marshall, RE,Safran, DG(2007).The effects of primary care physician visit continuity on patients' experiences with care.J Gen Intern Med,22,787-93.
62. Rogers, J,Curtis, P(1980).The concept and measurement of continuity in primary care.Am J Public Health,70,122-7.
63. Saultz, JW(2003).Defining and measuring interpersonal continuity of care.Ann Fam Med,1,134-43.
64. Saultz, JW,Lochner, J(2005).Interpersonal continuity of care and care outcomes: a critical review.Ann Fam Med,3,159-66.
65. Shortell, SM(1976).Continuity of medical care: conceptualization and measurement.Med Care,14,377-91.
66. Smedby, O,Eklund, G,Eriksson, EA,Smedby, B(1986).Measures of continuity of care. A registerbased correlation study.Med Care,24,511-8.
67. Starfield, B(1980).Continuous confusion?.Am J Public Health,70,117-9.
68. Steinwachs, DM(1979).Measuring provider continuity in ambulatory care: an assessment of alternative approaches.Med Care,17,551-65.
69. Tsai, HY,Chou, YJ,Pu, C(2015).Continuity of care trajectories and emergency room use among patients with diabetes.Int J Public Health,60,505-13.
70. Uijen, AA,Bosch, M,van den Bosch, WJ,Bor, H,Wensing, M,Schers, HJ(2012).Heart failure patients' experiences with continuity of care and its relation to medication adherence: a cross-sectional study.BMC Fam Pract,13,86.
71. Uijen, AA,Schellevis, FG,van den Bosch, WJ,Mokkink, HG,van Weel, C,Schers, HJ(2011).Nijmegen Continuity Questionnaire: development and testing of a questionnaire that measures continuity of care.J Clin Epidemiol,64,1391-9.
72. van Walraven, C,Oake, N,Jennings, A,Forster, AJ(2010).The association between continuity of care and outcomes: a systematic and critical review.J Eval Clin Pract,16,947-56.
73. Wang, MJ,Lin, SP(2010).Study on doctor shopping behavior: insight from patients with upper respiratory tract infection in Taiwan.Health Policy,94,61-7.
74. Ware, NC,Dickey, B,Tugenberg, T,McHorney, CA(2003).CONNECT: a measure of continuity of care in mental health services.Ment Health Serv Res,5,209-21.
75. Wei, X,Barnsley, J,Zakus, D,Cockerill, R,Glazier, R,Sun, X(2008).Assessing continuity of care in a community diabetes program: initial questionnaire development and validation.J Clin Epidemiol,61,925-31.
76. Weiss, LJ,Blustein, J(1996).Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans.Am J Public Health,86,1742-7.
77. 陳曉梅、曾勤媛、陳靜敏、紀珮君、葉芳枝(2013)。連續性照護量表之發展與信效度檢定：於老年慢性病患出院準備服務之運用。護理暨健康照護研究，9，261-6。