| 摘要: | 目的：台灣人口老化，慢性疾病增多及醫療設備日益更新，造成呼吸器依賴病患逐年增加。呼吸器的使用常導致呼吸器相關肺炎之併發症及增加醫療資源支出，中央健康保險署於2000年開始實施『全民健康保險呼吸器依賴病患整合性照護前瞻性支付試辦計劃』，以提昇呼吸器依賴病患的照護品質與降低醫療資源不當利用的問題。
因此，本論文的研究目的如下：
(一)依據不同的人口學特質，比較長期呼吸器依賴病患有無合併呼吸器相關肺炎之住院醫療總費用的差異。
(二)依據不同的人口學特質，比較長期呼吸器依賴病患有無合併呼吸器相關肺炎之醫療照護品質結果(包含回轉加護病房、下轉居家照護、呼吸器脫離成功及呼吸器脫離後死亡)的差異。
方法：本研究以次級資料進行分析，使用資料來源為國家衛生研究院之「全民健康保險研究資料庫」2010年承保抽樣歸人檔，資料期間為2008至2012年，總樣本數為2,992筆，其中長期呼吸器依賴病患共計1,048筆及長期呼吸器依賴合併呼吸器相關肺炎病患共計1,944筆，以探討不同的人口學特質對住院醫療總費用及醫療照護品質結果之差異。資料處理及統計分析係利用SAS 9.4版進行分析，先以復迴歸分析探討長期呼吸器依賴病患有無合併呼吸器相關肺炎對住院醫療總費用之差異比較。接著，採用邏輯斯迴歸分析（Logistic regression analysis）探討長期呼吸器依賴有無合併呼吸器相關肺炎二組病患間的醫療照護品質結果之勝算比。
結果：本研究發現在住院醫療總費用上，性別及年齡與住院醫療總費用均無相關性，但與醫院層級具有統計學上顯著相關性。其次，就人口學特質而言，不論是回轉加護病房、下轉居家照護、呼吸器脫離成功或是呼吸器脫離後死亡，均是男性病患比例皆高於女性病患，70歲以上之病患人數最多及就診於區域醫院為主；最後，醫療照護品質結果部分，回轉加護病房與醫院層級具有統計學上顯著相關性；下轉居家照護與年齡及醫院層級具有統計學上顯著相關性；呼吸器脫離成功與醫院層級具有統計學上顯著相關性；呼吸器脫離後死亡與人口學特質均無相關性。
結論:無論是長期呼吸器依賴有無合併呼吸器相關肺炎之病患，以70歲以上之男性病患居多，並且以就診區域醫院為主。其次，就住院醫療總費用而言，長期呼吸器依賴病患每年平均住院醫療總費用低於長期呼吸器依賴合併呼吸器相關肺炎病患，且與醫院層級具有相關性。再者，就人口學特質而言，在回轉加護病房、下轉居家照護、呼吸器脫離成功或是呼吸器脫離後死亡，均是男性之比例較高，70歲以上之病患人數最多，就診於區域醫院為主；最後，醫療照護品質結果部分，回轉加護病房與醫院層級有相關性、下轉居家照護與年齡及醫院層級具有相關性、呼吸器脫離成功與醫院層級具有相關性、呼吸器脫離後死亡與人口學特質均無相關性。本研究主要限制為健保資料庫欄位定型化的限制、無法確定主要造成呼吸器依賴之疾病及疾病碼的正確性及以申請日期代表病患呼吸器依賴起始日期。因此建議後續研究者可以搭配問卷或是臨床長期病歷追蹤，進一步探討呼吸器依賴患者不同疾病別之呼吸器脫離率、死亡率、院內感染等醫療照護結果。
Introduction: Taiwan's aging population, an increase in chronic diseases and recent advancement in medical equipment has resulted into an increase in ventilator-dependent patients every year. Ventilator use often leads to complications of ventilator-associated pneumonia and increased health care resource utilization. National Health Insurance Administration in 2000 began to implement "National Health Insurance ventilator-dependent patients integrated care prospective payment pilot program" to enhance the quality of care of ventilator-dependent patients and reduce the problem of improper use of medical resources.
Therefore, the purpose of this paper is as follows:
1)Depending on demographic characteristics, the difference in total hospitalization costs in long-term ventilator-dependent patients with and without ventilator-associated pneumonia.
2)Depending on demographic characteristics, the difference in results of quality of medical care in long-term ventilator-dependent patients with and without ventilator-associated pneumonia (including rotation intensive care unit (rotary ICU), home care, successful discharge and death after discharge from respiratory care unit).
Method: This study uses secondary data from Taiwan’s National Health Insurance Research Database, Longitudinal Health Insurance Dataset, 2010 (LHID2010) provided by Ministry of Health and Welfare. The study period was from 2008-2012. The total number of patients were 2,992, where long-term ventilator-dependent patients without ventilator-associated pneumonia were 1,048 patients and with ventilator-associated pneumonia were 1,944 patients. Controlling the demographic characteristics, the difference in hospitalization costs and results of quality of medical care was explored. Data processing and statistical analysis was done using SAS Version 9.4, multiple regression analysis was used to investigate the difference in total hospitalization costs between long-term ventilator-dependent patients with and without ventilator-associated pneumonia. Logistic regression analysis was used to explore the odds ratio for results of quality of medical care between ventilator-dependent patients with and without ventilator-associated pneumonia.
Result: The study found that hospitalization costs was not associated with gender and age, but there was a statistical significant correlation between total hospitalization costs and hospital type. Secondly, in terms of demographic characteristics, whether it is rotating ICU, home care, successful discharge and death after discharge from respiratory care unit, the proportion of male patients are higher than female patients, patients above 70 years accounted for the highest group of patients and regional hospitals had the highest frequency of visits. Finally, rotary ICU and hospital type showed statistical significant correlation with result of quality of medical care; home care showed statistical significant correlation with hospital type and age; successful discharge from respiratory care unit demonstrated a statistical significant correlation with hospital type; death after discharge showed no significant correlation to demographic characteristics.
Conclusion: Long-term ventilator-dependent patients whether with or without ventilator-associated pneumonia, were comprised mainly of male patients over the age of 70, with majority of hospitalization in regional hospitals. Secondly, average annual total hospitalization cost was lower in long-term ventilator-dependent patients without ventilator-associated pneumonia than with ventilator-associated pneumonia and it was correlated with hospital type. Moreover, in demographic characteristics, the rotary ICU, home care, successful discharge and death after discharge from respiratory care unit, where majority of the patients were male over the age of 70, with the highest frequency of visits in regional hospitals; and finally, rotary ICU and hospital type were correlated, home care was correlated to age and hospital type, successful discharge from respiratory care unit demonstrated a statistical significant correlation with hospital type; death after discharge showed no significant correlation to demographic characteristics. The main limitation of this study was the limitation in NHI database field, lack of information about the main cause of illness, reliability of disease code and no definitive initial date of ventilator use. Further studies can be done using follow-up questionnaires or following long-term medical records, to further explore the discharge rate, mortality rate, nosocomial infections and other results of quality of medical care in ventilator-dependent patients with different diseases. |
