糖尿病醫療給付改善方案、照護過程品質與可避免住院之相關性探討

Association Between A Pay-for-Performance Program, Process Quality and Avoidable Hospitalizations for Diabetes Care

10.6342/NTU.2014.02265

蔡茜如

糖尿病論質計酬 ； 照護過程品質 ； 可避免住院 ； 多層次分析 ； pay-for-performance ； process quality ； avoidable hospitalizations ； multilevel analysis

國立臺灣大學健康政策與管理研究所學位論文

2014年

碩士

鍾國彪

繁體中文

研究背景：糖尿病相關併發症都可以藉由良好的門診照護品質及治療來加以預防或延遲其發生及惡化。因此國外許多研究使用「可避免住院」作為衡量基層醫療照護可近性與品質的指標。然而，國內研究大多探討論質計酬對於照護過程品質以及醫療利用的影響，對於論質計酬之照護結果品質的影響，卻少有著墨。 研究目的：探討病人加入糖尿病論質計酬方案、照護過程品質與可避免住院間的關係；探討病患層次變項以及醫師層次變項對照護過程面品質之跨層次影響。 材料與方法：本研究為回溯性縱貫研究，採用全民健康保險研究資料庫，並篩選於2004-2005年新診斷糖尿病患進行三年的資料追蹤。以廣義估計方程式，探討在控制病患特性後，病人有無加入糖尿病論質計酬方案，對於照護過程面品質與可避免住院間的影響；進一步檢驗病人有無加入糖尿病論質計酬方案與其發生可避免住院間的關係，是否會受到照護過程品質的中介效果影響。最後以多層次分析方式，同時分析病患層次的變項以及醫師層次的變項對照護過程品質之跨層次的影響。 研究結果：有加入糖尿病論質計酬方案的病患，發生糖尿病可避免住院的機率較低、完成七項檢驗檢查項目的平均值顯著較高、有完成兩項指標性檢查的機率顯著較高；有完成兩項指標性檢查項目的病患，發生糖尿病可避免住院的機率顯著較低。醫師年齡越大對於病患完成七項檢驗檢查項目之平均值越低；相較於其他科別，醫師為新陳代謝科、內科及家庭醫學科對於病患完成七項檢驗檢查項目之平均值顯著較高；相較於基層院所，醫師所屬醫院層級別為醫學中心、區域醫院及地區醫院對於病患完成七項檢驗檢查項目之平均值顯著較高；醫師的專科別及醫師所屬醫院層級別與病人加入糖尿病論質計酬方案，有顯著跨層次交互作用。 結論與建議：加入糖尿病論質計酬方案可有效改善病人之照護過程品質並降低糖尿病可避免住院發生的機率；接受良好的照護過程品質亦能有效改善可避免住院的發生；病患之照護過程品質會受到其主要照護醫師特性而有所影響。建議未來研究可量化可避免住院患者的嚴重程度，如次數、費用等，以進一步評估政策之成效。

Background: The diabetes-related complications can be prevented from getting worse by quality of ambulatory care and proper treatment. Therefore, more and more studies are using avoidable hospitalizations as the measurement to evaluate the quality and the accessibility of primary care. However, a number of studies have examined the impacts of pay for performance programs on the process quality and healthcare utilization, but little is known about the quality measurement of outcome. Objective: The study aimed to examine the association between a pay-for-performance program, process quality and avoidable hospitalizations for diabetes care. And to examine the effect of cross-level interaction between patient-level and physician-level on process quality. Methods: A longitudinal cohort study with 3-year follow-up. New-onset diabetes patient were selected in 2004-2005 form National Health Insurance Research Database. Using generalized estimating equations to examine the association between the pay-for-performance program, process quality and avoidable hospitalizations for diabetes care after adjustment for the characteristics of patients. Furthermore, to examine weather process quality may mediate the relationship between the pay-for-performance program and avoidable hospitalizations. Finally, by using multilevel analysis, to examine the effect of cross-level interaction between patient-level and physician-level on process quality. Results: Patients who participated in the pay-for-performance program have a lower probability of avoidable hospitalizations and have a better process quality of care. The patients who had a better process quality of care may also have a lower probability of avoidable hospitalizations. Patients’ quality of care on process may be influenced by primary care physicians' gender, age, specialist and hospital. Primary care physicians' specialist and hospital also have cross-level interaction on participating in the pay-for-performance. Conclusions: Participating in the pay-for-performance program is an effective way to improve the process quality and to reduce the probability of avoidable hospitalizations for diabetes care. Had a better process quality may also reduce the probability of avoidable hospitalizations. Patients’ quality of care on process may be influenced by primary care physicians' characteristics. In order to evaluate the effect of policy more deeply, further researches could quantify the severity of avoidable hospitalizations, like times, costs, etc.

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