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題 名 | 闌尾、痔瘡及腹腔鏡膽囊切除術病患住院日適當性之研究=The Study of Appendectomy, Hemorrhoidectomy and Laparoscopic Cholecystectomy Patients' Appropriateness of Hospital Stay |
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作 者 | 王慈蜂; 溫信財; 陳杰峰; 李碧玲; | 書刊名 | 病歷管理期刊 |
卷 期 | 7:2 2008.04[民97.04] |
頁 次 | 頁65-74 |
分類號 | 419.44 |
關鍵詞 | 診斷關係群; 論病例計酬; 住院適當性; DRG; m-AEP; Diagnosis related group; Case payment; Appropriateness of hospital stay; Modified-appropriateness evaluation protocol; |
語 文 | 中文(Chinese) |
中文摘要 | 中央健康保險局為避免珍貴之住院資源遭到濫用,於1995年7月起,即採用論病例計酬制度(Case Payment),並預計於2008年實施診斷關係群 (Diagnosis Related Group, DRG),期望經由定額支付,誘使醫院及醫師有效利用醫療資源,由於健保局醫審小組訂定之「費用審查注意事項」,僅概略性的規定:「保險對象住院天數是否過長,原則上應尊重主治醫師之專業判斷」,在無明確基準規範下,前瞻性付費制度之實施是否能達成預期目標,有效減少不適當住院日,有賴客觀之住院工具驗證之。 本研究以某教學醫院病患為研究對象,經系統隨機抽樣,選取實施論病例計酬制度前後,闌尾切除術(0167A)、痔瘡或痔瘡併肛門廔管切除術(0158A) 及腹腔鏡膽囊切除術(494A)合適病例152份。再由本研究訓練兩位醫師為審查者,以m-AEP (Modified-Appropriateness Evaluation Protocol)為工具,分別審查病患「隨機一天」及「出院前一天」之病歷記錄,以判定其住院是否適當,另邀請兩位一般外科專科醫師,以其臨床專業,亦對152名病患進行住院適當性之判定,並以其判定為效標,檢定m-AEP之效度,結果發現: 論病例計酬制度實施後,「出院前一天」住院適當性,由論病例計酬前的34.7﹪,顯著提升為論病例計酬後的68.8﹪,由此推斷,實施論病例計酬,將提供醫院財務誘因,且以控制住院天數做為節制病人醫療費用的重要手段。以Kappa α檢定專科醫師與兩位審查醫師一致性,論病例計酬前分別為0.404及0.426,論病例計酬後分別為0.457及0.447;而兩位審查者間使用m- AEP之一致性,論病例計酬前為 0.6,論病例計酬後為0.794,均達到Landis和Koch再現性佳(Good Reproducible)的水準;而不適當住院原因中,以「病人之病情,沒有留在急性醫院照護之必要」之比率最高,結果與歐美研究相符。故若未來運用於保險審查時,醫院管理部門可以m-AEP進行住院日篩檢及病歷寫作內容之審查,而後續研究上,應對m-AEP之基準再做檢討,並請相關醫學會參與。 |
英文摘要 | The Bureau of National Health Insurance (BNHI) adopted case payment system in July 1995 to inhibit abuse of inpatient services. The Diagnosis Related Group (DRG) system would also be implemented in 2008. These reforms were expected to increase hospital efficiency. Unfortunately, the BNHI medical review guidelines only state “the necessity of hospital stays depends on attending physicians' professional judgment”. Without explicit criteria, BNHI can't tell whether the case payment system has been effective in decreasing the length of inappropriate hospital stays. Therefore, using an objective tool to evaluate the appropriateness of hospital stay is urged. In this study, a total of 152 cases undergoing procedure of appendectomy, hemorrhoidectomy and laparoscopic cholecystectomy, both before and after the case payment system was implemented, were randomly selected from a teaching hospital. Two physician reviewers evaluated each case's medical record. The appropriateness of both a randomly selected day and the day before discharge were reviewed using a modified Appropriateness Evaluation Protocol (m-AEP). Furthermore, the validity of the m-AEP was examined by general surgeons' expert judgments. The results indicated that, after the case payment system was implemented, the appropriateness of the day before discharge judged by general surgeons was significantly increased. The appropriateness rate was raised from 34.7% to 68.8%. We believe that the case payment system has given an incentive to hospitals to contain medical costs by better controlling the length of stay. Before and after the case payment system, the Kappa α between general surgeons and two reviewers were 0.404, 0.426, and 0.457, 0.447, respectively, and the consisstency of two reviewers was 0.6 and 0.794. All reached a good, reproducible level based on Landis and Koch's guidelines. The most common reason described for an inappropriate hospital stay was “For patients whose medical condition does not justify continued stay in an acute care hospital.” This finding agrees with those of similar studies conducted in the United State and European. However, in order to suit local needs, we suggest that the m-AEP should be further revised, and should include the opinions of medical specialty associations. |
本系統中英文摘要資訊取自各篇刊載內容。