「呼吸道診療概況表」實施對基層醫師之影響

The Impact of the Implementation of “Tables of Diagnosis and Treatment of Respiratory Tract” on Primary Care Physicians

本研究旨在探討基層開業醫師對實施「呼吸道診療概況表」之態度及其對醫師行為之影響。本研究採問卷調查法，以郵寄結構式問卷的方式蒐集所需的資料，以2005年在衛生署醫政處登記執業的基層開業醫師為母群體，挑出健保局台北分局轄下較常診療呼吸道感染病患的醫師，以一般科、耳鼻喉科、小兒科、內科及家庭醫學科等五大科醫師共2,040位做為本研究之研究對象，回收496份，扣除因退休、移民、歇業及地址遷移及該診所無健保業務等因素被退回問卷36份，回收率為24.8%，回收後進行樣本與母群體基本特性的適合度檢定(goodness-of-fit test)，在年齡及性別上並無顯著差異。先以單一變項羅吉斯迴歸(logistic regression)進行分析，再依據分析結果進行多變項羅吉斯迴歸模型之建立，並藉由迴歸分析結果來探討實施醫師檔案對醫師醫療行為之影響。研究結果發現有42.8%的基層醫師對台灣目前的醫療環境使用「門診特定疾病診療概況表」持負面態度。在羅吉斯迴歸分析中，在控制其他變項後，發現年齡小於40歲的醫師較41-50歲的醫師，及不同意健保局可以藉此做為醫師的獎懲依據較不會改變對病人的照護模式；認為台灣環境適合使用、贊同日後繼續使用、同意可幫助醫師提昇醫療照護品質、同意可以達到同儕制約的效果、同意健保局可以藉此做醫療資源利用率的分析者較會改變對病人的照護模式。依據研究結果，建議衛生主管機關(1)應用於教育醫師而非獎懲的工具；(2)謹慎選取適合的指標及適用的ICD code；(3)給予較即時性的資料。

This study aims to explore the attitudes of primary care physicians toward the implementation of Tables of Diagnosis & Treatment of Respiratory Tract (TDTRT) and its impact on physician behaviors. This study used a structured self-administered survey to collect data. The study subjects were 2040 primary care physicians registered at the Bureau of Affairs, Department of Health as the general practitioners, ENT, pediatricians, internal medicine, and family practitioners under the Taipei Branch of the Bureau of the National Health Insurance (BNHI). A total of 496 questionnaires were returned, yielding a response rate of 24.8%. The goodness-of-fitness tests found that there were significant differences between population physicians and the respondents in terms of age and gender. A logistic regression analysis was performed to examine the impact of the implementation of TDTRT on physician behaviors. The results showed that 42.8% of respondents had the negative attitudes toward the implementation of TDTRT. The logistic regression analysis showed that controlling for other factors, those aged less than 40 years and those agreed the BNHI can use TDTRT as a basis for reimbursement were less likely to change their behavior pattern for patient care. Those who agreed that healthcare environment is suitable for the implementation of TDTRT, those agreed to continue to use the TDTRT, those agreed the TDTRT can be a basis for peer comparison, and those who agreed the BNHI can use TDTRT as a basis for the analysis of resource utilization were more likely to change their behavior pattern for patient care. Based on our study results, we suggest that the health authority (1) use the TDTRT as an educational tool instead of a punishment basis; (2) select the appropriate indicators and ICD codes; and (3) provide timely feedback.