照護連續性對高齡者急診與非緊急急診之影響探討

Effects of continuity of care on emergency department use and non-urgent emergency department visits among the elderly

目標：本研究旨在探討實施全民健康保險制度下的台灣高齡者照護連續性對高齡者急診及非緊急急診的影響。方法：本研究採用縱向研究法，利用2008-2009年門診就醫資料推算照護連續性指數（COCI）做為自變項，探討高齡者之照護連續性強度對急診利用及非緊急急診之影響。統計分析方法包含負二項式迴歸分析、邏輯斯迴歸分析，及趨勢卡方檢驗。結果：研究結果顯示，照護連續性顯著影響高齡者急診利用及非緊急急診的發生。在控制其他變項後，迴歸分析結果顯示，相較於低度照護連續性高齡者，中度照護連續性及高度照護連續性的高齡者，其急診利用次數的相對風險分別減少25.17%及35.60%；中度照護連續性及高度照護連續性高齡者，非緊急急診發生風險的勝算比分別為低度照護連續性高齡者的0.87（95% C.I.=0.76-0.99）及0.81（95% C.I.=0.69-0.94）。結論：本研究證實實施全民健康保險制度但缺乏轉診制度的台灣，高齡者照護連續性仍然顯著減少高齡者的急診利用，顯示提升高齡者照護連續性，對高齡者及健康照護系統都有助益。

Objectives: This study determined whether or not continuity of care (COC) is associated with emergency department (ED) visits and non-urgent ED visits by the elderly in Taiwan’s universal health care system. Methods: This study used a longitudinal health insurance database compiled for 2010 from the National Health Insurance Research Database in Taiwan. COC was calculated using the continuity of care index (COCI), which reflects visit concentration with individual clinicians. Negative binominal regression and multivariate logistic regression were performed to determine the effects of COC on the ED and non-urgent ED visits in 2010, respectively. Results: This study showed that lower COC was associated with increased ED and non-urgent ED visits. After adjusting for age, gender, socio-economic status, region, physician visits, Charlson index, and physician density, patients in the medium and high COC groups had 25.17% and 35.60% less ED visits, respectively. In an additional analysis of non-urgent ED visits in which we compared patients in the medium and high COC groups with patients who were in the low COC group, we further showed that the probability of having non-urgent ED visits was reduced for elderly patients with medium and high COC (adjusted odds ratio = 0.87 and 95% CI=0.76-0.99; adjusted odds ratio =0.81 and 95% CI=0.69-0.94, respectively). Conclusions: This study showed that higher COC is associated with decreased ED and non-urgent ED visits by the elderly, even in a universal health care system that lacks a referral system. We conclude that improving the COC is beneficial for patients and the health care system.