醫院品質報告卡之風險校正

Risk adjustment for hospital report cards

醫療照護品質的測量與改善，是近代醫學發展過程中持續被關注之議題。許多國家均發展出醫院品質報告卡，提供病患就醫選擇之參考、或提供雇主、醫療保險人選擇醫療服務提供者之依據。但品質指標的測量結果除了反應照護品質差異外，也常受到病例組合差異的影響。在進行跨醫院之比較時，必須應用風險校正方法，調整病例組合的差異以求公平。傳統上常用於風險校正的統計方法是羅吉斯迴歸和一般線性迴歸，近期亦常見以多階層迴歸建構風險校正模式。常見之風險因子包括人口統計因子、先前利用因子、疾病嚴重度、共病狀態、生理因子、自評健康狀態等。由於台灣的醫療品質指標發展未導入風險校正的技術，導致跨機構間的比較受到限制，因此亟需發展台灣本土化的指標風險校正模式，促進品質指標之可比較性。建議未來主管機關選擇報告卡之品質指標時，應將個別指標之信度納入考量，以避免醫療機構可能被錯誤的歸類到品質表現較好或較差的組別，減損其參考價值。

Numerous countries develop and publish hospital report cards with the aim of assisting patients, employers, and/or insurers in the selection of appropriate healthcare providers. The variations in quality presented in these reports may be an indication of actual differences in quality; however, it's plausible that the results are biased due to improper adjustments for case-mix or incorrect interpretations. This underlines the importance of using a statistical risk adjustment method when dealing with patient risk data. Use of such methods would improve the quality of comparisons across hospitals. Logistic regression and linear regression are commonly used for the adjustment of risk; however, hierarchical models have been appearing in more recent studies and published report cards. Demographic factors, prior healthcare utilization, severity of illness, physiological risk factors, and self-reported health status are widely used as risk adjustors. Taiwan has built local systems for the monitoring of clinical quality; however, the lack of a reliable mechanism for risk adjustment makes it difficult to compare the quality of care across hospitals. Thus, the development of local risk adjustment models is an urgent requirement for improving the quality of hospital report cards. In accordance with our review, we suggest that the government evaluate the reliability of quality indicators and be more selective with regard to public reporting, in order to prevent the misclassification of outliers, which would otherwise limit the usability of report cards.