臺灣博碩士論文加值系統

背景:
台灣全民健康保險的實施，目的在提高民眾就醫可近性，改善人群健康的不平等。因此有必要探討不同社經地位的民眾是否能獲得相似的健康照護與健康結果。可避免住院指標(hospitalization for Ambulatory care sensitive conditions (ACSC))是一群透過即時適當的初級照護可避免住院的疾病，可用以評估就醫可近性或照護結果。本研究之目的在探討台灣民眾的家庭可支配所得對民眾的ACSC門診利用及可避免住院風險(健康照護結果)之影響。
方法:
以橫斷研究分析家庭可支配所得與ACSC門診利用的關係；並以回溯性世代研究探討家庭可支配所得對次年發生可避免住院風險的影響。資料來源為由衛生署統計室提供2003-2005年主計處之家庭收支調查串聯健保之資料。研究對象為加入全民健保的民眾。可避免住院指標採用由美國的健康照護研究與品質局(Agency for Healthcare Research and Quality (AHRQ))所發展的16項預防品質指標(PQIs)及5項兒童品質指標(PDIs)。可支配所得以家戶人口數校正。控制變項包括性別，年齡，教育，職業，固定就醫機構特質，部分負擔身分，共病指數，前一年可避免住院，每萬人口西醫師數，門診部分負擔政策改變以及都市化程度。統計分析方法採用GEE 的logistic regression與negative binomial regression以控制地區的隨機效應，分別分析是否就醫(門診與住院)以及門診就醫次數。住院風險並進一步以門診利用做分層分析，以控制門診利用與住院之交互作用。
結果:
本研究樣本可避免住院盛行率為1.09%。家庭可支配所得較低、無固定就醫機構、老人、低教育程度、無業者，有顯著較低的ACSC門診利用。而免部分負擔者、老人、低教育程度、健康狀況較差者，有顯著較高的可避免住院風險。
結論:
家戶所得對可避免住院風險無顯著影響，顯示基層照護可近性的改善，有助於縮減不同社會階層民眾健康照護結果的差距。但本研究有關家戶所得與ACSC門診利用有顯著正相關的發現，因係依據橫斷性研究設計，尚待後續研究以更嚴謹方法證實。

Introduction:
The National Health Insurance (NHI) in Taiwan aims to improve the access to healthcare so as to improve the health inequity of the population. It is crucial to understand whether people with different social status can equitably get similar health care and health care outcome after NHI. Ambulatory care sensitive conditions (ACSC) are those, for which hospitalizations are considered potentially avoidable through provision of timely and appropriate primary care and can be applied to measure access to or outcome of healthcare. The objectives of this study are to evaluate the association of disposable household incomes (DHI) with ACSC related outpatient utilization and with the risk of ACSC related hospitalization (ACSCH) in the following year.
Methods:
We conduct a cross-sectional study to analyze the relationship between DHI and ACSC related outpatient utilization, and a retrospective cohort study to evaluate the relationship between DHI and risk of ACSCH using the 2003-5 National Household Income Survey data linked with NHI claim data provided by the Office of Statistics of the Department of Health. The study populations are all enrollees of the NHI. ACSCH are defined by Agency for Healthcare Research and Quality (AHRQ) in the United States using 16 Preventive Quality Indicators (PQIs) and 5 Pediatric Quality Indicators (PDIs). DHI was adjusted by size of the household. Control variables included sex, age, education, occupation, characteristics of usual healthcare sources, copayment waiver, comorbidity index, ACSCH in previous year, physician population ratio per ten thousands, change in the copayment policy, and level of urbanization. We applied logistic regression and negative binomial regression of Generalized Estimating Equation (GEE) to control the random effect of the residential region to analyze the occurrence (of ACSC outpatient utilization & ACSCH) and the number of ACSC outpatient visits respectively. Analysis of risk of ACSCH was further stratified by the number of ACSC outpatient utilization to control its interaction with ACSCH.
Results:
Prevalence of ACSCH was 1.09%. Lower DHI was significantly correlated with lower ACSC outpatient utilization. Other significant correlates included having no usual healthcare sources, being elderly, lower educational attainment and being unemployment. No significant relationship was found between DHI and ACSCH. Furthermore, people without out-of -pocket payments, elderly, lower educational attainment and poor health status had significant higher risk of ACSCH.
Conclusion:
The findings that there is no significant association between household income and risk of ACSC hospitalization may imply that the improved access to healthcare may reduce the gap in health outcome among people with different social status. Our finding of positive association between DHI and ACSC outpatient utilization however, is based on cross-sectional data, therefore should be carefully evaluated in future study based on more rigorous design.

第一章 緣起 ----------------------------------------1
第一節 研究背景與動機-------------------------------------- 1
第二節 研究目的 ----------------------------------------3
第三節 研究問題 ----------------------------------------3
第四節 研究重要性 ----------------------------------------4
第五節 名詞解釋 ----------------------------------------5
第二章 文獻探討 ----------------------------------------6
第一節、可避免照護結果指標 --------------------------------6
第二節、可避免住院相關實證研究 ------------------------------12
第三節、醫療服務利用理論模式 -------------------------------19
第四節 所得衡量方式 ---------------------------------------26
第三章 研究方法 ---------------------------------------28
第一節 研究設計 ---------------------------------------28
第二節 研究架構 ---------------------------------------29
第三節 研究假說 ---------------------------------------30
第四節 研究對象 ---------------------------------------30
第五節 資料來源 ---------------------------------------31
第六節 變項定義與測量 -------------------------------32
第七節 資料處理 ---------------------------------------36
第八節 統計分析 ---------------------------------------38
第四章 研究結果 ---------------------------------------39
第一節 研究對象特性及可避免住院情形之描述性統計 ---------------39
第二節 相關因素對ACSC門診醫療利用的影響 -雙變項分析 -------45
第三節 相關因素對可避免住院的影響-雙變項分析 ---------------50
第四節 相關因素對ACSC門診醫療利用的影響 -多變項分析 -------61
第五節 相關因素對是否發生可避免住院的影響 -多變項分析 -------66
第五章 討論 --------------------------------------100
第一節 研究方法討論 --------------------------------------100
第二節 研究結果討論 --------------------------------------103
第三節、研究限制 --------------------------------------113
第六章 結論與建議 --------------------------------------114
第一節 研究結論 --------------------------------------114
第二節 政策建議 --------------------------------------114
第三節 研究建議 --------------------------------------115
參考文獻 ----------------------------------------------116
附錄 AHRQ可避免住院指標(PQI)定義 ----------------------122

【中文文獻】
王馨儀(2006). 氣喘門診照護對可避免住院之影響. 未出版碩士論文, 國立台灣大學, 台北市.
史青平(2005). 可預防住院之研究-以闌尾炎破裂或穿孔為例. 未出版碩士論文, 國立台灣大學, 台北市.
朱育增、吳肖琪(2010). 回顧與探討次級資料適用之共病測量方法. 台灣公共衛生雜誌, 29(1), 8-21.
吳依凡(2004). 醫療資源可近性對個人醫療利用的影響---台灣地區的實證研究. 國立中央大學, 桃園縣.
李貳連、莊文沂、呂光和、莊文寬、陳隆華(2004). 我國與主要國家所得分配之比較. 南投: 行政院主計處中部辦公室.
林正介、李采娟、陸寧、石磊玉(2000). 與門診照護敏感情況相關之病人與醫院因素. 中台灣醫學科學雜誌, 5(1), 1-15.
侯艷妃(2008). 照護連續性與可避免住院之相關性研究. 未出版碩士論文, 國立臺灣大學, 台北市.
洪明皇、鄭文輝(2007). 所得定義與均等值設定對經濟福利不均的測量影響 經濟研究, 45(1), 11-63.
張雅雯(2002). 醫療利用可近性-台灣老人之實證研究. 國立中央大學, 桃園縣.
張曉鳳(2008). 多比較好？基層醫師供給對可避免住院的影響 -台灣的實證研究. 未出版碩士論文, 中臺科技大學,　台中市.
梁亞文、陳芬如、鄭瑛琳(2008). 台灣的可避免住院及其病患社經狀態. 台灣衛誌, 27(1), 81-90.
莊文寬(2006). 我國經濟發展與所得分配的演變. 南投: 行政院主計處中部辦公室.
陳昕、鄭守夏、蔡淑玲(2007). 利用健保部分負擔調漲估算醫院門診價格彈性:一個自然實驗法的觀察分析. 國立台灣大學, 台北市.
陳昕明(2007). 臺灣地區榮民可避免住院情況之研究. 未出版碩士論文, 國立陽明大學,　台北市.
黃昱瞳(2008). 全民健保部分負擔制度對幼童、年長者及慢性病患健康之影響. 博士論文, 國立陽明大學, 台北市.
黃郁清、支伯生、鄭守夏(2010). 照護連續性與醫療利用之相關性探討. 台灣衛誌, 29(1), 46-53.
黃馨玉(2006). 可避免住院之研究-以細菌性肺炎為例. 未出版碩士論文, 國立台灣大學, 台北市.
楊貴蘭(2004). 探討山地鄉實施 [醫療給付效益提升計畫] 對民眾醫療服務利用影響與可近性之成效─ 以屏東縣牡丹鄉為例. 未發表碩士論文, 國立台灣大學, 台北市.
詹廖明義(2009). 善待健康知能不足病人 溝通是王道. 中國醫訊, 73, 44-48.
廖鈺郡(2009). 所得分配衡量方式之比較. 台北市: 行政院主計處第三局.
劉彩卿、陳欽賢(2001). 研析在全民健保制度下影響台北都會區民眾就診之因素. 經濟研究, 37(1), 69-92.
蔡佳希(2008). 台灣可避免住院情況之整體性分析. 未出版碩士論文, 國立中山大學, 高雄市.
蔡雙卉(2006). 可避免住院研究-以急性腎盂腎炎為例. 未出版碩士論文, 國立台灣大學, 台北市.
盧瑞芬、謝啓瑞 (2000). 醫療經濟學. 台北市: 學富文化事業有限公司.
謝春福(2003). 醫療給付效益提昇計劃前後馬祖地區民眾醫療利用與費用之分析. 未發表碩士論文, 國立臺灣大學, 台北市.

【英文文獻】
Aday, L., & Andersen, R. (1974). A framework for the study of access to medical care. Health Services Research, 9(3), 208.
Agabiti, N., Cesaroni, G., Picciotto, S., Bisanti, L., Caranci, N., Costa, G., et al.(2008). The association of socioeconomic disadvantage with postoperative complications after major elective cardiovascular surgery. J Epidemiol Community Health, 62, 882 - 889.
Agabiti, N., Pirani, M., Schifano, P., Cesaroni, G., Davoli, M., Bisanti, L., et al. (2009). Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy. BMC Public Health, 9(1), 457.
Agency for Healthcare Research and Quality (2004). Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions(Revision 4). Rockville, MD: AHRQ.
Agency for Healthcare Research and Quality (2004). Literacy and Health Outcomes. Rockville, MD: Agency for Healthcare Research and Quality.
Agency for Healthcare Research and Quality (2009). Version 4.1 technical documentation AHRQ Quality Indicators, from http://www.qualityindicators.ahrq.gov/TechnicalSpecs41.htm.
Ahern, M. M., & Hendryx, M. (2007). Avoidable Hospitalizations for Diabetes:Comorbidity Risks. Disease Management, 10(6), 347-355.
Andersen, R. (1968). A behavioral model of families' use of health services. Research Series No. 25. Chicago: Center for Health Administration Studies, University of Chicago.
Andersen, R. (1995). Revisiting the behavioral model and access to medical care: does it matter? Journal of health and social behavior, 36(1), 1-10.
Andersen, R., Davidson, P., & Ganz, P. (1994). Symbiotic relationships of quality of life, health services research and other health research. Quality of Life Research, 3(5), 365-371.
Ansari, Z., Laditka, J., & Laditka, S. (2006). Access to health care and hospitalization for ambulatory care sensitive conditions. Med Care Res Rev, 63, 719 - 741.
Aronson, J., Johnson, P., & Lambert, P. (1994). Redistributive effect and unequal income tax treatment. The Economic Journal, 104(423), 262-270.
Australian Institude of Health and Welfare (2004). National Report on Health Sector Performance Indicators 2003. Canberra: Australian Institude of Health and Welfare.
Baker, D., Parker, R., & Williams, M. (1997). Pauent reading ahility and use of health care services. J Gen Intern Med(12), 50.
Baker, D., Parker, R., Williams, M., & Clark, D. (1998). Health literacy and the risk of hospital admission. J Gen Intern Med, 13, 791-798.
Billings, J., Anderson, G. M., & Newman, L. S. (1996). Recent Findings On Preventable Hospitalizations. Health Affairs, 15(3), 239-249.
Billings, J., Zeitel, L., Lukomnik, J., Carey, T. S., Blank, A. E., & Newman, L. (1993). Impact of socioeconomic status on hospital use in New York City. Health Affairs, 12(1), 162-173.
Bindman, A. B., Chattopadhyay, A., & Auerback, G. M. (2008). Interruptions in Medicaid Coverage and Risk for Hospitalization for Ambulatory Care–Sensitive Conditions. Ann Intern Med, 149, 854-860.
Blustein, J., Hanson, K., & Shea, S. (1998). Preventable Hospitalizations and Socioencomic Status. Health Affairs, 17(2), 177-189.
Brown, A., Goldacre, M., Hicks, N., Rourke, J., McMurtry, R., Brown, J., et al. (2001). Hospitalization for ambulatory care-sensitive conditions: a method for comparative access and quality studies using routinely collected statistics. Canadian journal of public health, 92(2), 155-159.
Canadian Institute for Health Information (2008). Health Indicators. Ottawa, Canada: CIHI.
Canberra Group on Household Income Statistics (2001). Expert group on household Income statistics: Final report and recommendations. Ottawa,Canada: Canberra Group.
Casanova, C., Colomer, C., & Starfield, B. (1996). Pediatric Hospitalization due to Ambulatory Care-Sensitive Conditions in Valencia (Spain). International Journal for Quality in Health Care, 8(1), 51-59.
Duan, N., W, M., Morris, C., & Newhouse, J. (1983). A comparison of Alternative Models for the Demand for Medical Care. Journal of Business and Economics Statistic, 1, 115-126.
Getzen, & E., T. (2000). Health care is an individual necessity and a national luxury: applying multilevel decision models to the analysis of health care expenditures. Journal of Health Economics, 19, 259-270.
Gill, J. M., III, A. G. M., & Nsereko, M. (2000). The effect of continuity of care on emergency department use. Arch Fam Med, 9, 333-338.
Grossman, M. (1972). On the concept of health capital and the demand for health. The Journal of Political Economy, 80(2), 223-255.
Guo, L., MacDowell, M., Levin, L., Hornung, R. W., & Linn, S. (2001). How Are Age and Payors Related to Avoidable Hospitalization Conditions？. Managed Care Quarterly, 9(4), 33-42.
Health Canada (1999). Toward a Healthy Future: Second Report on the Health of Canadians. Ottawa,Canada: Public Health Agency of Canada.
Huang, Y.-T., Lee, Y.-C., & Hsiao, C.-J. (2009). Hospitalization for Ambulatory-care-sensitive Conditions in Taiwan Following the SARS Outbreak: A Population-based Interrupted Time Series Study. J Formos Med Assoc, 108(5), 386-394.

Johnson, W. G., & Rimsza, M. E. (2004). The effects of access to pediatric care and insurance coverage on emergency department utilization. Pediatrics, 113, 483-487.
Kickbusch, I. (2001). Health literacy: addressing the health and education divide. Health Promotion International, 16(3), 289.
Laditka, J. N., & Laditka, S. B. (2004). Insurance Status and Access to Primary Health Care:Disparate Outcomes for Potentially Preventable Hospitalization. Journal of Health and Social Policy, 19(2), 81-100.
Laditka, J. N., Laditka, S. B., & Mastanduno, M. P. (2003). Hospital utilization for ambulatory care sensitive conditions:health outcome disparities associated with race and ethnicity. Social Science & Medicine, 57, 1429–1441.
Laditka, J. N., Laditka, S. B., & Probst, J. C. (2005). More May Be Better: Evidence of a Negative Relationship between Physician Supply and Hospitalization for Ambulatory Care Sensitive Conditions. Health Services Research, 40(4), 1148-1166.
Laditka, J. N., Laditka, S. B., & Probst, J. C. (2009). Health care access in rural areas: Evidence that hospitalization for ambulatory care-sensitive conditions in the United States may increase with the level of rurality Health & Place 15, 761-770.
Laditka, S. B., & Laditka, J. N. (2001). Utilization, Costs, and Access to Primary Care in Fee-for-Service and Managed Care Plans. Journal of Health & Social Policy, 13(1), 21-39.
Lambrew, J. M., Defriese, G. H., Carey, T. S., Ricketts, T. C., & Biddle, A. K. (1996). The Effects of Having a Regular Doctor on Access to Primary Care. Medical Care, 34(2), 138-151.
Manning, W., Morris, C., Newhouse, J., Orr, L., Duan, N., Keeler, E., et al. (1981). A two-part model of the demand for medical care: preliminary results from the health insurance study. Economics and Health Economics. Amsterdam: North-Holland.
Marshall, M., Leatherman, S., & Mattke, S. (2004). Selecting indicators for the quality of health promotion, prevention and primary care at the health systems level in OECD countries. Paris.
Newhouse, J. P., & Phelps, C. E. (1974). Price and Income Elasticities for Medical Care Services.
Niti, M., & Ng, T. P. (2003). Avoidable hospitalisation rates in Singapore,1991–1998: assessing trends and inequities of quality in primary care. J Epidemiol Community Health, 57, 17-22.
Pappas, G., Hadden, W. C., Kozak, L. J., & Fisher, G. F. (1997). Potentially Avoidable Hospitalizations: Inequalities in Rates between US Socioeconomic Groups. American Journal of Public Health, 87, 811-816.

Parker, J. D., & Schoendorf, K. C. (2000). Variation in Hospital Discharges for Ambulatory Care-Sensitive Conditions Among Children PEDIATRICS, 106, 942-948.
Romano, P. S., Roos, L. L., & Jollis, J. G. (1993). Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: Differing perspectives. Journal of Clinical Epidemiology, 46(10), 1075-1079.
Roos, L. L., Walld, R., Uhanova, J., & Bond, R. (2005). Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. Health Services Research 40(4), 1167-1185.
Rutstein, D., Berenberg, W., Chalmers, T., Child, C., Fishman, A., & Perrin, E. (1976). Measuring the quality of medical care. A clinical method. New England Journal of Medicine, 294, 582-588.
Rutstein, D., W, B., TC, C., AP, F., EB, P., & GD., Z. (1980). Measuring the quality of medical care: second revision of tables of indexes. New England Journal of Medicine, 302(20), 1146.
Sarah B. Laditka, P., James N. Laditka, D., PhD, MPA, Melanie P. Mastanduno, R., MPH, Michele R. Lauria, M., MS, & Tina C. Foster, M., MPH, MS (2005). Potentially Avoidable Maternity Complications: An Indicator of Access to Prenatal and Primary Care During Pregnancy. Women & Health, 41(3), 1-26.
Shi, L., Samuels, M. E., Pease, M., Bailey, W. P., & Corley, E. H. (1999). Patient Characteristics Associated With Hospitalizations for Ambulatory Care Sensitive Conditions in South Carolina. Southern Medical Journal, 92, 989-998.
Thai, A. L., & George, M. (2010). The Effects of Health Literacy on Asthma Self-management. Journal of Asthma & Allergy Educators 1, 50-55.
Thomas, J. W., & Penchansky, R. (1984). Relating Satisfaction with Access to Utilization of Services. Medical Care, 22, 553-568.
Weissman, J. S., Gatsonis, C., & Epstein, A. M. (1992). Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. Journal of the American Medical Association, 268(17), 2388-2394.
Wilkinson, R. (1996). Unhealthy societies: the afflictions of inequality. New York: Routledge.
Wilson, K. M., & Klein, J. D. (2000). Adolescents Who Use the Emergency Department as Their Usual Source of Care Arch Pediatr Adolesc Med, 154, 361-365