| 摘要: | 中央健康保險局為了能落實財務分擔風險，從民國91年7月實施醫院總額支付制度，以醫院自主管理模式，不論各階段都以「十四日內再住院率」作為監測醫療品質的替代指標。「再住院率」同時也是台灣品質指標計劃（Taiwan Quality Indicator Project，TQIP）重要的醫療品質監測指標之一，醫院評鑑基準亦將「十四日內再住院」列為醫療品質改善活動檢討的項目，未來實施前瞻性診斷關聯群支付制度（DRGs /PPS），醫療機構為成本控制考量，部分病患可能在疾病未痊癒之下提早出院、醫療提供者取巧分段住院或其他相關因素影響病患再住院，有關再住院管理仍是健保局持續加強審查的重點，亦是醫院管理重要主題之ㄧ。
本研究目的為分析醫院再住院率、確認出院後90日內不同間隔日數再住院風險影響因素，進而建構再住院病患之預測模式。本研究從某醫學中心94年1月1日至94年12月31日期間，選用至少住院一次病患，總計5,931人為研究對象，得再住院群組樣本3,026人、對照組為非再度住院2,905人，以該研究對象的疾病分類資料檔內容作為分析，運用SPSS 10.0 for Windows 套裝軟體系統進行描述性及推論性統計分析。
研究結果：該醫學中心90日內再住院率為17.84%，14日內、15-30日內、31-60日內及61-90日內再住院率分別為6.31%、5.96%、3.60%及1.97%。醫療費用分析對照組病患之平均醫療費用＄50,748，再住院群組病人的第一次住院平均醫療費用為＄68,347，而在高醫療費用＄60,001以上再住院群組則占了33.5%與對照組的21.9%，高了11.6%。在較低之醫療費用＄40,000以內，對照組反而有較高比例62.4%、再住院組則是49.4%。以邏輯斯迴歸分析不同間隔日數再住院之風險因素，發現出院後90日內不同間隔日數再住院共同的風險因素，有年長者、住院日數較長、論量計酬案件，診斷數目愈多者及缺血性心臟病。除了上述，出院後14日內再住院風險因素另有男性、醫師年資5年以內、患有尿道及泌尿道疾病、膽石症、肝及肝內膽管惡性腫瘤及心臟衰竭者。15-30日內再住院風險因素，另有醫師年資5年以內、患有膽石症、腦動脈阻塞、肺炎者。31-60日內再住院風險因素，另有患有膽石症、肝及肝內膽管惡性腫瘤及心臟衰竭者。61-90日內再住院風險因素另有患有肝及肝內膽管惡性腫瘤者。
有效的運用再住院預測模式，可掌握少數高危險群再住院的病患，如能針對此一族群確定的風險因素加以防範注意，尤其是年長的病患，必須提早出院準備計畫及加強醫療照護過程。未來Tw-DRGs的實施，建議醫療院所應擴大及落實臨床路徑的實施，加強醫療照護品質，預防再住院的發生及控制合理醫療費用。
To realize the financial risk reduction, the Bureau of National Health Insurance has implemented the Global Budget Payment System by the self management mode and considered the rate of readmission within 14 days for all stages a substitute indicator for medical quality monitoring since July, 2002. Besides, the remarked rate is an essential indicator for the above monitoring by Taiwan Quality Indicator Project (TQIP). Moreover, attributed to the mentioned readmission listed in the hospital accreditation standard, handling readmission becomes an important issue of hospital management. According to scholars, due to Diagnostic Related Groups/ Prospective Payment System (DRGs/PPS) -caused hospital cost control, some uncured patients may be discharged early, and medical providers may be tricky for segmented admission, or other associated factors may affect readmission. Therefore, despite Taiwan-developed diagnosis related groups systems (Tw-DRGs) by the rate executed in 2008, the rate remains intensively examined by the Bureau.
The purpose of this study is to analyze the readmission rates, identify the risk factors of readmission within 90 days, and establish the predictive pattern. A total of 5,931 recipients with at least one hospitalization were selected by a medical center from January 1st, 2005, to December 31st, 2005 for this study, including 3,026 recipients who had hospital readmissions and 2,905 hospitalized but non-readmitted recipients as a control group. The International Classification of Diseases database-based data of the two groups were descriptively and inferentially analyzed by the SPSS 10.0 for Windows software package.
Resultantly, the rate of readmission within 90 days, 14 days, 15-30 days, 31-60 days, and 61-90 days accordingly was 17.84%, 6.31%, 5.96%, 3.60%, and 1.97%. The average cost for the control group and the fist readmission was ＄50,748 and＄68,347, respectively. Concerning the high medical cost (＄60,001 more), the percentage of the readmission group (33.5%) was 11.6% more than that of the control group (21.9%). About the lower medical cost (＄40,000 less), the percentage of the latter was 62.4%; that of the former, 49.4%.
The logistic regression-analyzed risk factors of readmission within 90 days with different intervals were the senile, longer hospital days, fee-for-service cases, cases of more diseases, and ischemic heart disease. Additionally, the risk factors of readmission within 14 days, 15-30 days, 31-60 days, and 61-90 days orderly were significantly associated: (1) male, doctors with less than 5 years working experience, other disorders of urethra and urinary tract, cholelithiasis, malignant neoplasm of liver and intrahepatic bile ducts, and heart failure; (2) doctors with less than 5 years working experience, cholelithiasis; (3) cholelithiasis, malignant neoplasm of liver and intrahepatic bile ducts, and heart failure; (4) malignant neoplasm of liver and intrahepatic bile ducts.
The efficient application of the readmission predictive pattern may detect few of the patients at high-risk of readmission. The high risk factors, especially for the senile patients, should be avoided by early discharge planning and medical care process strengthening. For prospective Tw-DRGs fulfillment, scaling-up of medical organization-practiced clinical path which enforces medical quality, prevents readmissions and controls hospital costs is recommended.
Keyword: Readmission, Readmission rate, Quality of medical care,Outcome indicators |
