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系統識別號 U0026-2908201805482000
論文名稱(中文) 失智老人的照護連續性對可避免住院與醫療費用之影響
論文名稱(英文) The effect of continuity of care on potentially avoidable hospitalizations and healthcare costs in older adults with dementia
校院名稱 成功大學
系所名稱(中) 公共衛生研究所
系所名稱(英) Graduate Institute of Public Health
學年度 106
學期 2
出版年 107
研究生(中文) 黃文嬿
研究生(英文) Wen-Yen Huang
學號 T86054076
學位類別 碩士
語文別 中文
論文頁數 71頁
口試委員 指導教授-古鯉榕
召集委員-李中一
口試委員-黃昱瞳
口試委員-王靜枝
中文關鍵字 失智症  照護連續性  可避免住院  住院 
英文關鍵字 dementia  continuity of care  potentially avoidable hospitalization  hospitalization 
學科別分類
中文摘要 背景:
有鑑於失智症人數不斷攀升,世界衛生組織於2012年將失智症列為全球公共衛生優先議題。過去文獻顯示失智症患者比起非失智症患者有較高的住院率及可避免住院率,且住院原因多是共病控制不佳所致。雖然過去發現照護連續性表現較好的老年慢性病患者,照護結果較佳,但卻缺少針對失智症患者進行探討,照護連續性對失智症患者的效益仍不清楚。因此本研究欲探討是否可透過提升門診照護連續性來改善失智症患者的照護結果,降低其住院、可避免住院風險,以及減少醫療費用。

方法:
本研究以衛生福利部衛生福利資料科學中心健保資料庫進行分析,採回溯性世代研究法,研究對象為2011年65歲以上失智症患者,共85,417人。以照護連續性指標(Continuity of Care Index, COCI)計算個案於2011年的失智相關門診照護連續性,依照數值高低區分為:高照護連續性組(COCI=1);低照護連續性組(COCI<1),經傾向分數1:1配對後,兩組各為34,829人。本研究的可避免住院指標是依照美國MACIE (Medicare Ambulatory Care Indicators For The Elderly)的定義,包含以下五種事件: 糖尿病短期併發症、糖尿病長期併發症、心衰竭、慢性阻塞性肺病/氣喘、高血壓。為檢視照護連續性是否能降低可避免住院的風險,遂依五種可避免住院,各別選取樣本,並以羅吉斯迴歸分析照護連續性對於下一年度發生住院及可避免住院的相關性,以及利用廣義線性模型檢視照護連續性對醫療費用的影響。

結果:
失智症患者的COCI平均分數為0.74±0.3,其中50.7%的失智症患者COCI值為1。高COCI組的全因住院勝算比低COCI組顯著較低(OR=0.843;95%CI: 0.816-0.87),但在五種類型的可避免住院(PAH),包含糖尿病短期併發症住院、糖尿病長期併發症住院、慢性阻塞性肺病或氣喘住院、高血壓住院、心臟衰竭住院,兩組皆無顯著差異。高COCI組的失智症患者在總醫療費用、門診費用及住院費用皆較低COCI組少。

結論:
失智相關門診照護連續性提高,有助於降低失智症患者的全因住院風險,然而對於降低可避免住院的發生之效益並未獲證實,原因為台灣的失智症患者常見的可避免住院疾病不同於美國MACIE指標所表列之五項疾病,建議未來研究可進一步探討照護連續性對失智症患者其他可避免住院疾病之影響。本研究結果支持照護連續性可減少醫療費用,尤其住院費用顯著降低,因此建議應持續提升我國失智者之門診照護連續性。
英文摘要 The purpose of this study is to examine the associations between continuity of care (COC) and healthcare outcomes, including all-cause hospitalization, potentially avoidable hospitalizations (PAHs) and medical expenditures on individual with dementia. The subjects of this study were elders with dementia (aged 65 and older) in 2011 from National Health Insurance Research Database (NHIRD), and patients were divided into high COCI group and low COCI group by their continuity of care index (COCI) in 2011. PAHs were classified into five types: (1) serious short-term complications of diabetes; (2) serious long-term complications of diabetes; (3) COPD or asthma; (4) hypertension; (5) heart failure according to MACIE (Medicare Ambulatory Care Indicators For The Elderly) in the US. Medical expenditures were classified into three types, including outpatient, inpatient, and total expenditures.
Logistic regression models were used to identify the effect of COCI in dementia on all-cause hospitalization and PAHs in the subsequent year. Generalized linear models were developed to identify the effect of COCI in dementia on outpatient, inpatient, and total expenditures in the subsequent year.
The findings showed that high COCI in dementia was significantly associated with lower likelihood of all-cause hospitalization and lower medical expenditures than low COCI, but there was no significant effect on PAHs.
論文目次 第壹章、緒論 1
第一節、研究背景 1
第二節、研究目的 4
第貳章、文獻探討 5
第一節、失智症 5
第二節、照護連續性 7
第三節、可避免住院 13
第參章、研究方法 19
第一節、研究假說 19
第二節、資料來源 19
第三節、研究對象 19
第四節、研究設計 23
第五節、研究變項 24
第六節、資料分析 30
第肆章、研究結果 31
第一節、研究樣本之基本特質 31
第二節、全因住院 40
第三節、可避免住院 43
第四節、醫療費用 47
第伍章、討論 53
第一節、本研究主要發現 53
第二節、研究優勢與限制 61
第陸章、結論 62
第柒章、參考文獻 63

參考文獻 Alazri, M., Heywood, P., Neal, R. D., & Leese, B. (2007). Continuity of care: Literature review and implications. Sultan Qaboos Univ Med J, 7(3), 197-206.
Amjad, H., Carmichael, D., Austin, A. M., Chang, C. H., & Bynum, J. P. (2016). Continuity of care and health care utilization in older adults with dementia in fee-for-service medicare. JAMA Intern Med, 176(9), 1371-1378.
Billings, J., Anderson, G. M., & Newman, L. S. (1996). Recent findings on preventable hospitalizations. Health Aff (Millwood), 15(3), 239-249.
Boustani, M., Baker, M. S., Campbell, N., Munger, S., Hui, S. L., Castelluccio, P., . . . Callahan, C. (2010). Impact and recognition of cognitive impairment among hospitalized elders. J Hosp Med, 5(2), 69-75.
Bynum, J. P., Rabins, P. V., Weller, W., Niefeld, M., Anderson, G. F., & Wu, A. W. (2004). The relationship between a dementia diagnosis, chronic illness, medicare expenditures, and hospital use. J Am Geriatr Soc, 52(2), 187-194.
Chang, C. C., Lin, P. H., Chang, Y. T., Chen, N. C., Huang, C. W., Lui, C. C., . . . Lai, W. A. (2015). The impact of admission diagnosis on recurrent or frequent hospitalizations in 3 dementia subtypes: A hospital-based cohort in taiwan with 4 years longitudinal follow-ups. Medicine (Baltimore), 94(46), e2091.
Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987) elopment and validation. J Chronic Dis, 40(5), 373-383. . A new method of classifying prognostic comorbidity in longitudinal studies: dev
Chen, C. C., & Cheng, S. H. (2011). Better continuity of care reduces costs for diabetic patients. The American journal of managed care, 17(6), 420-427.
Cheng, S. H., Chen, C. C., & Hou, Y. F. (2010). A longitudinal examination of continuity of care and avoidable hospitalization: Evidence from a universal coverage health care system. Arch Intern Med, 170(18), 1671-1677.
Cheng, S. H., Hou, Y. F., & Chen, C. C. (2011). Does continuity of care matter in a health care system that lacks referral arrangements? Health Policy Plan, 26(2), 157-162.
Cree, M., Bell, N. R., Johnson, D., & Carriere, K. C. (2006). Increased continuity of care associated with decreased hospital care and emergency department visits for patients with asthma. Dis Manag, 9(1), 63-71.
Davies, S. M., Geppert, J., McClellan, M., McDonald, K. M., Romano, P. S., & Shojania, K. G. (2001). Refinement of the HCUP quality indicators.
Dietrich, A. J., & Marton, K. I. (1982). Does continuous care from a physician make a difference? J Fam Pract, 15(5), 929-937.
Donaldson, M. S. (2001). Continuity of care: A reconceptualization. Med Care Res Rev, 58(3), 255-290.
Haggerty, J. L., Reid, R. J., Freeman, G. K., Starfield, B. H., Adair, C. E., & McKendry, R. (2003). Continuity of care: A multidisciplinary review. BMJ : British Medical Journal, 327(7425), 1219-1221.
Hill, J., Fillit, H., Shah, S. N., del Valle, M. C., & Futterman, R. (2005). Patterns of healthcare utilization and costs for vascular dementia in a community-dwelling population. J Alzheimers Dis, 8(1), 43-50.
Hinton, L., Franz, C. E., Reddy, G., Flores, Y., Kravitz, R. L., & Barker, J. C. (2007). Practice constraints, behavioral problems, and dementia care: Primary care physicians' perspectives. J Gen Intern Med, 22(11), 1487-1492.
Hsiao, F. Y., Peng, L. N., Wen, Y. W., Liang, C. K., Wang, P. N., & Chen, L. K. (2015). Care needs and clinical outcomes of older people with dementia: A population-based propensity score-matched cohort study. PLoS One, 10(5).
Hussey, P. S., Schneider, E. C., Rudin, R. S., Fox, D. S., Lai, J., & Pollack, C. E. (2014). Continuity and the costs of care for chronic disease. JAMA Intern Med, 174(5), 742-748.
Institute of Medicine (IOM). Access to health care in America. Washington DC: National Academy Press, 1993.
Jee, S. H., & Cabana, M. D. (2006). Indices for continuity of care: A systematic review of the literature. Med Care Res Rev, 63(2), 158-188.
Jiang, H. J., Wier, L. M., Potter, D. E. B., & Burgess, J. (2006). Potentially preventable hospitalizations among medicare-medicaid dual eligibles, 2008: Statistical Brief #96 Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US).
Lin, I. P., Wu, S. C., & Huang, S. T. (2015). Continuity of care and avoidable hospitalizations for chronic obstructive pulmonary disease (COPD). J Am Board Fam Med, 28(2), 222-230.
Lin, P. J., Fillit, H. M., Cohen, J. T., & Neumann, P. J. (2013). Potentially avoidable hospitalizations among Medicare beneficiaries with Alzheimer's disease and related disorders. Alzheimers & Dementia, 9(1), 30-38.
Lin, P. J., Zhong, Y., Fillit, H. M., Chen, E., & Neumann, P. J. (2016). Medicare expenditures of individuals with Alzheimer's disease and related dementias or mild cognitive impairment before and after diagnosis. J Am Geriatr Soc, 64(8), 1549-1557.
Maxwell, C. J., Amuah, J. E., Hogan, D. B., Cepoiu-Martin, M., Gruneir, A., Patten, S. B., . . . Strain, L. A. (2015). Elevated hospitalization risk of assisted living residents with dementia in Alberta, Canada. J Am Med Dir Assoc, 16(7), 568-577.
Mondor, L., Maxwell, C. J., Hogan, D. B., Bronskill, S. E., Gruneir, A., Lane, N. E., & Wodchis, W. P. (2017). Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort. PLoS Med, 14(3), e1002249.
Moyle, W., Borbasi, S., Wallis, M., Olorenshaw, R., & Gracia, N. (2011). Acute care management of older people with dementia: A qualitative perspective. Journal of clinical nursing, 20(3‐4), 420-428.
Natalwala, A., Potluri, R., Uppal, H., & Heun, R. (2008). Reasons for hospital admissions in dementia patients in Birmingham, UK, during 2002–2007. Dementia and geriatric cognitive disorders, 26(6), 499-505.
Nutting, P. A., Goodwin, M. A., Flocke, S. A., Zyzanski, S. J., & Stange, K. C. (2003). Continuity of primary care: To whom does it matter and when? Ann Fam Med, 1(3), 149-155.
Nyweide, D. J., Anthony, D. L., Bynum, J. P. W., Strawderman, R. L., Weeks, W. B., Casalino, L. P., & Fisher, E. S. (2013). Continuity of care and the risk of preventable hospitalization in older adults. JAMA Intern Med, 173(20), 1879-1885.
Phelan, E. A., Borson, S., Grothaus, L., Balch, S., & Larson, E. B. (2012). Association of incident dementia with hospitalizations. JAMA, 307(2), 165-172.
Pickens, S., Naik, A. D., Catic, A., & Kunik, M. E. (2017). Dementia and hospital readmission rates: A systematic review. Dement Geriatr Cogn Dis Extra, 7(3), 346-353. doi:10.1159/000481502
Pimouguet, C., Rizzuto, D., Fastbom, J., Lagergren, M., Fratiglioni, L., & Xu, W. (2016). Influence of incipient dementia on hospitalization for primary care sensitive conditions: A population-based cohort study. J Alzheimers Dis, 52(1), 213-222.
Prince, M., Comas-Herrera, A., Knapp, M., Guerchet, M., & Karagiannidou, M. (2016). World Alzheimer report 2016: improving healthcare for people living with dementia: coverage, quality and costs now and in the future. London, UK: Alzheimer's Disease International (ADI).
Prevention Quality Indicators. Agency for Healthcare Research and Quality. http://www.qualityindicators.ahrq.gov/Modules/PQI_TechSpec_ICD09_v60.aspx. Accessed May 3, 2018
Sloan, F. A., & Taylor Jr, D. H. (2002). Effect of Alzheimer disease on the cost of treating other diseases. Alzheimer Disease & Associated Disorders, 16(3), 137-143.
Starfield, B. (1998). Primary Care: Balancing Health Needs, Services, and Technology. New York.
Sun, Y., Lee, H. J., Yang, S. C., Chen, T. F., Lin, K. N., Lin, C. C., . . . Chiu, M. J. (2014). A nationwide survey of mild cognitive impairment and dementia, including very mild dementia, in Taiwan. PLoS One, 9(6), e100303.
Wasson, J. H., Sauvigne, A. E., Mogielnicki, R. P., Frey, W. G., Sox, C. H., Gaudette, C., & Rockwell, A. (1984). Continuity of outpatient medical care in elderly men. A randomized trial. JAMA, 252(17), 2413-2417.
Weiner, M., Powe, N. R., Weller, W. E., Shaffer, T. J., & Anderson, G. F. (1998). Alzheimer's disease under managed care: Implications from Medicare utilization and expenditure patterns. Journal of Investigative Medicine, 46(3), 212A-212A.
Westrick, E., & Kogut, S. (2006). Medicare ambulatory care indicators for the elderly: Refinement of the access to care for the elderly project indicators: MedPAC.
WHO. (2012). Dementia: A public health priority. United Kingdom: World Health Organization.
Worrall, G., & Knight, J. (2011). Continuity of care is good for elderly people with diabetes: Retrospective cohort study of mortality and hospitalization. Canadian Family Physician, 57(1), e16-e20.
Zhao, Y., Kuo, T. C., Weir, S., Kramer, M. S., & Ash, A. S. (2008). Healthcare costs and utilization for Medicare beneficiaries with Alzheimer's. BMC Health Serv Res, 8, 108.
李曉伶, & 吳肖琪. (2013). 台灣慢性病人醫療利用之探討-以慢性腎臟病、糖尿病及高血壓為例. [Medical Utilization by Patients with Chronic Diseases in Taiwan: Chronic Kidney Disease, Diabetes and Hypertension]. 台灣公共衛生雜誌, 32(3), 231-239.
邱柏儒. (2009). 照護連續性之測量工具分析與應用. 臺灣大學. Available from Airiti AiritiLibrary database. (2009年)
胡淑貞, 李中一, 邱靜如, 王亮懿, 古鯉榕, & 莊佳蓉. (2016). 建構領航國際之活躍老化監測暨決策支援系統-資料庫整合與加值分析暨專案管理計畫(104-107年)-105年後續擴充. Retrieved from http://ir.lib.ncku.edu.tw/handle/987654321/175827
梁家欣, 程蘊菁, & 陳人豪. (2014). 失智症之重點回顧. [Dementia: A Focused Review]. 內科學誌, 25(3), 151-157.
陳啟禎, & 鄭守夏. (2013). 照護連續性之文獻回顧. [A Literature Review of Continuity of Care]. 台灣公共衛生雜誌, 32(2), 116-128.
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. [The Association between Continuity of Care and Healthcare Utilization in Taiwan]. 台灣公共衛生雜誌, 29(1), 46-53.
衛生福利部. (2017). 衛生福利部 106 年度「失智照護服務計畫」 徵求作業說明書.
衛生福利部中央健康保險署. (2017). 全民健康保險家庭醫師整合性照護計畫. Retrieved from http://www.lifecare.org.tw/html/files/1.%E5%85%A8%E6%B0%91%E5%81%A5%E5%BA%B7%E4%BF%9D%E9%9A%AA%E5%AE%B6%E5%BA%AD%E9%86%AB%E5%B8%AB%E6%95%B4%E5%90%88%E6%80%A7%E7%85%A7%E8%AD%B7%E8%A8%88%E7%95%AB%E8%A7%80%E6%91%A9%E6%9C%83%E7%B0%A1%E5%A0%B1.pdf.
蘇本華, 蔡雅芳, 張華蘋, & 梁亞文. (2017). 照護連續性對住院醫療利用之影響. [The Effects of Continuity of Care on Hospitalizations in Taiwan: Findings from a National Sample]. 健康科技期刊, 4(1), 44-64.
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