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

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

10.6342/NTU201600881

詹舒涵

多重慢性疾病 ； 專科照護 ； 照護過程品質 ； 藥物遵從 ； 醫療利用 ； Multiple Chronic Conditions ； specialist ； quality of process care ； medication possession ratio ； Healthcare Utilization

國立臺灣大學健康政策與管理研究所學位論文

2016年

碩士

郭年真

繁體中文

研究背景: 由於醫療科技進步以及人口老化的趨勢，使得一個人同時罹患多種慢性疾病的情形越來越多，這類病人的基層門診利用和多重用藥明顯增加，此外由於疾病較為複雜，使得接受的照護不連續和醫療人員提供的照護不協調等，可能影響病人照護結果，但目前關於多重慢性病患照護模式及其接受的照護情形之相關實證研究仍有限。 研究目的： 探討國內多重慢性病患就診科別及就醫層級之分布，以及在不同照護模式之下多重慢性病患的照護結果的關係。 研究方法： 本研究採回溯性研究法，資料來源為國家衛生研究院發行2005-2010年糖尿病病人的抽樣歸人檔，而所有的追蹤年份為2004-2013年的資料。以多階層模型探討在控制病人特質(性別、年齡、共病症、都市程度)後，病人照護模式(就診科別、就醫層級)與病人自罹患多重慢性疾病起，每年重覆量測之照護過程面品質、住院、急診醫療利用及藥物遵從之關係。 研究結果： 本研究結果發現，糖尿病於內分泌科接受治療之病人各項過程面照護品質達成率較好，高血壓則皆為內分泌科、心臟血管內科之檢驗檢查指標達成率較好。在冠狀動脈疾病之照護方面，心臟血管內科在「空腹血脂檢查」、「血清肌酸酐」、「血清麩胺酸丙酮酸轉胺基」等檢查之達成率優於其他科別，其餘檢查項目則為內分泌科達成率較高。在藥品遵從指標，三類疾病組合病人同樣糖尿病就診於內分泌科之病人藥品持有較佳；罹患高血壓及冠狀動脈疾病則在心臟血管內科就醫之藥品持有率較佳。在醫療利用部分，急診次數、住院次數，糖尿病為就診於家醫科、心臟血管內科之急診次數較少，高血壓及冠狀動脈為內分泌科較少；住院天數，糖尿病為就診於家醫科、心臟血管內科之較少，同時罹患糖尿病與高血壓病人，其高血壓就診之家醫科、心臟血管內科與內科之住院天數較內分泌科少，冠狀動脈疾病為就診分別於心臟血管內科、內分泌科住院天數少。 結論： 本研究結果顯示，由不同科別醫師照護的多重慢性病患，其照護過程面品質、醫療利用及藥物遵從皆有差異，在照護過程面品質多為內分泌科達成率較好，醫療利用分別家醫科、心臟血管內科及內分泌科之利用較少，藥物品持有為內分泌科、心臟血管內科表現較好。因此有必要透過政策介入引導醫師改變過去以單一疾病為導向照護方式，並重視多重慢性疾病患者之照護品質與照護結果，由於本研究選用部分照護結果，建議未來研究可再選用如死亡率、再入院率等不同照護結果進行分析，並且進一步探討不同科別醫師照護結果不同之背後原因。

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.

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