兒童固定就醫場所與醫療利用

Regular sources of care and children’s health care utilization

10.6288/TJPH.201806_37(3).106102

黎伊帆(YI-FAN LI)；江東亮(TUNG-LIANG CHIANG)

兒童 ； 固定就醫場所 ； 門診 ； 急診 ； 住院 ； children ； regular sources of care ； ambulatory care ； emergency services ； hospitalization

台灣公共衛生雜誌

37卷3期（2018 / 06 / 19）

244 - 253

繁體中文

目標：探討兒童的固定就醫場所對門診、急診，以及住院利用的影響。方法：資料來自台灣出生世代調查研究，共有18,845名兒童同時完成6個月至66個月共4次調查，完訪率為88.7%。自變項為兒童在6個月至36個月時分別以診所、醫院為固定就醫場所，以及沒有固定就醫場所3組，依變項為兒童66個月時的醫療利用。結果：63.5%的兒童有固定就醫場所，其中44.7%為診所、18.8%為醫院。父母親教育程度較低、母親為非本國籍、家庭月收入多在3萬元以下的兒童，其沒有固定就醫場所的百分比較高。控制社會人口學特性及健康狀況，以診所為固定就醫場所者門診利用較高，然而，以醫院為固定就醫場所（急診OR=1.6；住院OR=1.8）與沒有固定就醫場所（急診OR=1.2；住院OR=1.4）其急診及住院情形顯著高於以診所為固定就醫場所者。結論：以診所為固定就醫場所的兒童，其急診、住院利用率顯著低於以醫院為固定就醫場所、或是沒有固定就醫場所的兒童，建議政府宜推出鼓勵相關財務誘因與診所品質資訊透明化的政策，以鼓勵家長選擇診所為固定就醫場所。

Objectives: The aim of this study was to determine the relationship between children's regular sources of care (RSOC) and health care utilization including ambulatory care (AC), emergency services (ES), and hospitalization (HOSP) care in Taiwan. Methods: Data came from the Taiwan Birth Cohort Study. A total of 18,845 children were included. Their parents completed four waves of interview surveys between 6 and 66 months of age, with a response rate of 88.7%. The independent variable was children's RSOC including RSOC in clinics, RSOC in hospitals, and no RSC when the children were 6 to 36-months old, and the dependent variable was medical utilization when the children were 66-months old. Results: A total of 63.5% of the children had a RSOC including 44.7% in clinics and 18.8% in hospitals. Children were less likely to have a RSOC with parents' of lower education, foreign-born mothers, and a household monthly income less than 30,000 NTD dollars. After controlling for children's gender, maternal nationality, socioeconomic characteristics, and health status, children with RSOC in hospital was significantly associated with higher likelihood of ES and HOSP (ES, OR=1.6; HOSP, OR=1.8) as were those who did not have a RSC (ES, OR=1.2; HOSP, OR=1.4), compared with those who did not have a RSOC. Conclusions: Children with RSOC in clinics was significantly associated with lower likelihood of ES and HOSP. This suggests that the government implemented financial incentive and transparency of quality in clinics policies for encouraging parents to use clinics as the RSOC.

1. 江東亮、楊志良、張秀蓉(2016)。陳拱北與全民健保。台灣衛誌，35，107-12。
   連結：
2. 許績天、韓幸紋、連賢明、羅光達(2011)。部分負擔調整對醫療利用的衝擊：以2005年政策調整為例。台灣衛誌，30，326-36。
   連結：
3. 蔡文正、龔佩珍(2003)。民眾對基層診所評價與就醫選擇影響因素。台灣衛誌，23，181-93。
   連結：
4. 全國法規資料庫：全民健康保險法。http://law.moj.gov.tw/LawClass/LawAll.aspx?PCode=L0060001。引用2017/05/16。Laws & Regulations Database of The Republic of China. National Health Insurance Act. Available at: http://law.moj.gov.tw/LawClass/LawAll.aspx?PCode=L0060001. Accessed 16 May, 2017.
5. Andersen, RM(1995).Revisiting the behavioral model and access to medical care: does it matter?.J Health Soc Behav,36,1-10.
6. Andersen, RM,Yu, H,Wyn, R,Davidson, PL,Brown, ER,Teleki, S(2002).Access to medical care for lowincome persons: how do communities make a difference?.Med Care Res Rev,59,384-411.
7. Blewett, LA,Johnson, PJ,Lee, B,Scal, PB(2008).When a usual source of care and usual provider matter: adult prevention and screening services.J Gen Intern Med,23,1354-60.
8. Chen, LC,Schafheutle, EI,Noyce, PR(2009).The impact of nonreferral outpatient co-payment on medical care utilization and expenditures in Taiwan.Res Social Adm Pharm,5,211-24.
9. DeVoe, JE,Fryer, GE,Phillips, R,Green, L(2003).Receipt of preventive care among adults: insurance status and usual source of care.Am J Public Health,93,786-91.
10. DeVoe, JE,Tillotson, CJ,Wallace, LS,Lesko, SE,Pandhi, N(2012).Is health insurance enough? A usual source of care may be more important to ensure a child receives preventive health counseling.Matern Child Health J,16,306-15.
11. Donabedian, A(1980).Explorations in Quality Assessment and Monitoring.Ann Arbor, Mich:Health Administration Press.
12. Grøholt, EK,Stigum, H,Nordhagen, R,Köhler, L(2003).Health service utilization in the Nordic countries in 1996: influence of socio-economic factors among children with and without chronic health conditions.Eur J Public Health,13,30-7.
13. Halfon, N,Newacheck, PW,Wood, DL,St Peter, RF(1996).Routine emergency department use for sick care by children in the United States.Pediatrics,98,28-34.
14. Jones, DS,McNagny, SE,Williams, MV,Parker, RM,Sawyer, MF,Rask, KJ(1999).Lack of a regular source of care among children using a public hospital emergency department.Pediatr Emerg Care,15,13-6.
15. Kiil, A,Houlberg, K(2014).How does copayment for health care services affect demand, health and redistribution? A systematic review of the empirical evidence from 1990 to 2011.Eur J Health Econ,15,813-28.
16. Lohr, KN,Brook, RH,Kamberg, CJ(1986).Use of medical care in the Rand Health Insurance Experiment. Diagnosis- and service-specific analyses in a randomized controlled trial.Med Care,24(9 Suppl),S1-87.
17. Mafi, JN,Wee, CC,Davis, RB,Landon, BE(2017).Association of primary care practice location and ownership with the provision of low-value care in the United States.JAMA Intern Med,177,838-45.
18. Manning, WG,Newhouse, JP,Duan, N,Keeler, EB,Leibowitz, A,Marquis, MS(1987).Health insurance and the demand for medical care: evidence from a randomized experiment.Am Econ Rev,77,251-77.
19. Monette, S,Séguin, L,Gauvin, L,Nikiéma, B(2007).Validation of a measure of maternal perception of the child's health status.Child Care Health Dev,33,472-81.
20. Petterson, SM,Rabin, D,Phillips, RL, Jr,Bazemore, AW,Dodoo, MS(2009).Having a usual source of care reduces ED visits.Am Fam Physician,79,94.
21. Rosenblatt, RA,Wright, GE,Baldwin, LM(2000).The effect of the doctor-patient relationship on emergency department use among the elderly.Am J Public Health,90,97-102.
22. Ryan, S,Riley, A,Kang, M,Starfield, B(2001).The effects of regular source of care and health need on medical care use among rural adolescents.Arch Pediatr Adolesc Med,155,184-90.
23. Stirbu, I,Kunst, AE,Mielck, A,Mackenbach, JP(2011).Inequalities in utilisation of general practitioner and specialist services in 9 European countries.BMC Health Serv Res,11,288.
24. Tsai, J,Shi, L,Yu, WL,Lebrun, LA(2010).Usual source of care and the quality of medical care experiences: a cross-sectional survey of patients from a Taiwanese community.Med Care,48,628-34.
25. Turbitt, E,Freed, GL(2016).Regular source of primary care and emergency department use of children in Victoria.J Paediatr Child Health,52,303-7.
26. Wen, SW,Goel, V,Williams, JI(1996).Utilization of health care services by immigrants and other ethnic/cultural groups in Ontario.Ethn Health,1,99-109.
27. 行政院經濟建設委員會全民健康保險研究計劃專案小組(1990)。全民健康保險制度規劃報告。台北=Taipei:行政院經濟建設委員會=Council for Economic Planning and Development, Executive Yuan, R.O.C. (Taiwan)。
28. 張苙雲(1998)。「逛醫師」的邏輯：求醫歷程的分析。台灣社會學刊，21，59-87。
29. 衛生福利部(1986)。衛生福利部：醫療保健計畫：建立醫療網計畫（核定本）。台北：衛生福利部，1986。Ministry of Health and Welfare, R.O.C. (Taiwan). Medicine and Healthcare Plan: Project to Establish a Healthcare Network (Approved Version). Taipei: Ministry of Health and Welfare, R.O.C. (Taiwan), 1986. [In Chinese]。
30. 衛生福利部(1978)。衛生福利部：加強農村醫療保健計畫。台北：衛生福利部，1978。Ministry of Health and Welfare, R.O.C. (Taiwan). Rural Medicine and the Healthcare Improvement Program. Taipei: Ministry of Health and Welfare, R.O.C. (Taiwan), 1978. [In Chinese]。
31. 衛生福利部：85年全民健康保險統計─特約醫事服務機構門住院費用申報狀況─按層級別分。http://w3.mohw.gov.tw/CHT/DOS/Statistic.aspx?f_list_no=312&fod_list_no=1732。引用2017/05/16。Ministry of Health and Welfare, R.O.C. (Taiwan). 1996 National Health Insurance statistics - status of contracted healthcare provider outpatient/inpatient expenditure reporting by level. Available at: http://w3.mohw.gov.tw/CHT/DOS/Statistic.aspx?f_list_no=312&fod_list_no=1732. Accessed 16 May, 2017.[In Chinese]
32. 衛生福利部中央健康保險署：部分負擔及免部分負擔說明。https://www.nhi.gov.tw/Content_List.aspx?n=BCB1A5D2CBACD6E0&topn=3185A4DF68749BA9。引用2017/06/01。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). Explanation of copayment and the copayment exempt portion. Available at: https://www.nhi.gov.tw/Content_List.aspx?n=BCB1A5D2CBACD6E0&topn=3185A4DF68749BA9. Accessed June 1, 2017. [In Chinese]
33. 衛生福利部中央健康保險署：104年全民健康保險統計─門住院醫療費用申報狀況─按特約類別分。https://www.nhi.gov.tw/Content_List.aspx?n=E58E18A8731A7D71&topn=CDA985A80C0DE710&upn=7894A690C22FBCB6。引用2017/05/16。National Health Insurance Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). 2015 National Health Insurance statistics - status of outpatient/inpatient medical expenditure reporting - by type of contract. Available at: https://www.nhi.gov.tw/Content_List.aspx?n=E58E18A8731A7D71&topn=CDA985A80C0DE710&upn=7894A690C22FBCB6.Accessed 16 May, 2017. [In Chinese]

1. 蔡金玲,郭年真(2020)。週日門診開診狀況與忠誠病人急診利用之相關性探討。台灣公共衛生雜誌，39(6)，656-668。