臺灣博碩士論文加值系統

急診部門擁擠的現象在世界各國皆已呈現日趨嚴重之現象，而台灣地區隨著醫療的進步及全民健保的實施，醫院急診服務量亦呈現逐年成長之趨勢。2004年台灣地區急診總人次為5,850,207人次，相較於1999年之4,822,585人次成長21.31%。有鑑於急診部門為一全天後提供醫療服務之場所，且當急診部門呈現擁擠狀況時，將會使得醫院資源無法做適當的分配，故如何有效於各時段提供急診醫療服務，以達醫療資源合理之分配及提昇醫療品質則顯非常重要。藉由分析日、夜間急診案件可以促使急診部門資源有效利用，以期於不同時段的服務量皆能提供相同的服務品質，同時可提供病患更好之服務及更高之醫療品質。
目標：探討北台灣地區日、夜間醫院急診醫療資源利用情形、分析高急診利用案件之就醫相關屬性、以及探討不同屬性急診案件之醫療費用利用情形。
方法：本研究方法為橫斷性研究，研究材料採用2004年7月至2005年6月間健保資料庫之「IC卡就醫紀錄主檔」、「門診處方及治療明細檔」、「住院醫療費用清單明細檔」、「在保資料檔」、「投保金額紀錄檔」及「醫事機構主檔」進行分析。
結果：研究結果顯示（1）「就醫時段」以小夜班利用率最多佔44.43%，其次為白班，最後為大夜班。（2）性別部分以男性小夜班最多佔22.9%，年齡層部分則以18-44歲之小夜班18.3%最多，但65歲以上之老人在白天急診的利用情形反居多(7.4%)，且平均醫療點數亦為所有之冠。（3）權屬別部份以私立醫院小夜班之27.44%佔率最多，層級別則以區域醫院小夜班、白班及大夜班分居第一至第三位。地區部份區分三個時段以台北市小夜之22.6%居首，台北市白班次之及台北縣小夜班第三。（4）檢傷分類以第三級小夜之25.2%佔最多，其次為第三級之白班，第三則為第二級小夜。另以疾患類別與檢傷分類來看，第一級之疾患中是以「呼吸道疾患」最多，第二級中則以「損傷及中毒」最多。而就醫科別部分則以小夜之急診醫學科27.32%最多。（5）免部分負擔之件數雖僅佔整體之18.35%，但在各項平均費用中皆高於一般部分負擔之平均費用。若區分為三個時段在醫療點數部份以免部分負擔白班之平均點數3865.5最多。（6）急診高利用者在就醫屬性分析上，可依照「年齡」、「住院註記」及「投保單位類別」3個變項列為主要判別之關鍵因素。（7）由C&RT分析發現，檢傷分類為第一級或第二級、醫院層級為非醫學中心、年齡層在45歲以上且有住院註記者之分群，在急診利用率及平均醫療點數皆有較高的比例。
結論：國、內外探討急診相關議題眾多，但實際將急診就醫時段區分為白天，傍晚及夜間探討急診醫療利用的情形，尚未多見。本研究基於IC卡的實施而得以有此方面的研究機會，在國內屬首篇有此方面的研究。針對本研究各項結果發現，小夜班的人數明顯比其他時段來的多，且此部份並未將留觀的病人列入計算，為確保急重症病患之就醫權益，建議衛生當局可增加急重症在醫院總額之保障措施，以避免醫院對於個案的選擇性而降低民眾就醫的權益。對於民眾部分則建議若選擇夜間急診且檢傷分類屬於第三級、第四級者，應有不同之部分負擔措施。如此不僅可有效控管非急診民眾的利用次數，亦可讓醫院能完善的進行檢傷分類。故不論是在醫療提供者或是利用者，皆可合理有效達到控管，進而可以提供民眾更完善的急診照護及降低急診擁擠的現象。另為能有效管理急診個案的利用情形，建議衛生當局對於急診高利用者應善加利用IC卡申報資料作即時監控，以確保急重症病患之就醫權益。

The overcrowding in the Emergency Department, worldwide, has been exacerbating significantly. Due to progression in medical care as well as the implementation of National Health Insurance (NHI) in Taiwan, services conducted in Emergency Department reflect a tendency of gradual increase annually. As regarding the emergency service delivered in Taiwan, 21.31% of increase among 5,850,207 visits in 2004, compared with 4,822,585 visits in 1999. The Emergency Department contributes greatly in delivering medical service around the clock, in consequence of overcrowding in the district; medical resource cannot be distributed appropriately. Effectively manage health service conducted in each shift in the Emergency Department in order to distribute medical resources reasonably and enhance medical quality is of paramount importance. By analyzing visits during each shift, it is estimated that resources in emergency department can be utilized efficiently; consistent services can be conducted in each shift and the superior medical quality can be achieved to all visits.
Objectives: To evaluate the ‘emergency medical resources utilization’ during each shift, ‘the characters of frequenc user’, and ‘emergency medical expenditures of different types’ in north Taiwan.
Method: A cross-sectional study was conducted by using claim data of NHI from July 2004 to Jun 2005.
Result: Outcomes of this study reveal (1)In terms of health service conducted in each shift, with a percentage of 44.43%, the evening shift has the highest utility rate followed by the day and the night shift respectively. (2)In respect of gender and age distribution, both in the evening shift, male visits and the group aged at 18-44 have demonstrated the proportion of 22.9% and 18.3% separately; whereas; the elderly over 65-year visits more in the day shift (7.4%) and shares the highest rate in the average medical expenditures (3)In ownership, the private hospital shows the highest rate with 27.44% in the evening shift, and in accreditation, the number of visits reaches the top in the evening shift then decline from the day and night shift in metropolitan hospitals. Considering the area, the evening shift in Taipei city reaches the peak with 22.6%, and followed by the day shift in Taipei and the evening shift in Taipei County respectively. (4)In triage, the majority of visits (25.2%) is sorted as 3rd class in the evening shift followed by the day shift, and thirdly is the evening shift with 2nd class. Concerning both category of illness and triage, in 1stclass, the majority of visits are diagnosed with「Diseases of the respiratory system」, and visits diagnosed with「injury and poisoning」 is profound in 2nd class. In the evening shift, a 27.32% of percentage visits emergency medicine. (5)The exempting co-payment is although 18.35% that only accounts for the total amount is all higher than the general co-payment that afforded of part in every average expense. (6)Analyzing characters of the frequent users to emergency department, 「age」, 「marks of admission」 and 「Category of Group Insurance Applicants」 are key factors. (7)By analyzing C&RT, it is found that triage with 1stclass and 2nd class in non–medical center and age group above 45-year with admission demonstrate higher proportion in utilization of emergency department and average medical expenditures.
Conclusion: Though tremendous studies regarding emergency medicine have been reported globally, focuses on utilization of emergency department during day, evening and night shift are rare. This paper, a pioneer attempt in Taiwan, is able to be conducted by taking advantage of implementation of IC Cards. Based upon the results, the evidence shown that excluding clients in observation, visits in the evening shift are profound than others. Hence, the authority should take to increase the emergent critical payments into account at consider Hospital Global Budget, it is believed that screening of clients by hospitals can be eliminated with no harm for clients’ rights. In order to operate non-emergent utilization efficiently as well as a more comprehensive triage conducted in hospitals, the general public, is suggested that triage with 3rd and 4th class should be responsible for alternative co-payment. By doing so, both care givers and receivers are managed appropriately, emergency medicine is delivered thoroughly and overcrowded is diminished. Besides, to manage efficiently in utilization, the authority should highlight the instant frequent users in correspondents with IC Cards, thus rights with emergent critical clients are certified.

書名頁 i
中文摘要 iii
英文摘要 v
表目錄 x
圖目錄 xi
第一章 緖論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第三節 研究範圍 3
第四節 研究流程 4
第五節 章節架構 4
第二章 文獻探討 6
第一節 急診定義 6
第二節 急診檢傷分類制度之概念 9
第三節 影響急診醫療服務之相關研究 12
第四節 急診醫療資源耗用探討 16
第五節 健保IC卡導入背景及其重要性 22
第三章 研究設計與方法 25
第一節 研究架構 25
第二節 研究假說 27
第三節 研究變項與操作型定義 29
第四節 資料來源與處理 31
第五節 資料分析方法 34
第四章 研究結果 38
第一節 描述性統計分析 38
第二節 民眾就醫特質、醫院特質及就醫屬性分析 56
第三節 民眾就醫特質、醫院特質及就醫屬性與醫療費用分析 65
第四節 急診高利用者研究結果 79
第五節 醫療點數預測模式 89
第五章 研究討論 94
第一節 研究方法之探討 94
第二節 研究結果之討論 96
第六章 結論與建議 102
第一節 結論 102
第二節 建議 105
參考文獻 107
中文部分 107
英文部分 109
附錄一：我國檢傷分類表 112
附錄二：全民健康保險投保金額分級表 113
附錄三：全民健康保險保險對象類別 114
附錄四：類別變項虛擬編碼表 115
附錄五：民眾就醫特質、醫院特質及就醫屬性之之交叉分析表 117

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