台灣基層診所病人複雜度與提供服務項目之探討

Patient complexity and services provided by primary care clinics in Taiwan

目標：經由分析台灣基層診所之病人複雜度，以及可提供文獻常見之基層醫療服務項目之比例，來探討台灣現況之下有多少基層診所可承擔家庭醫師的功能。方法：本研究以2009年至2013年全民健康保險資料庫之一百萬人承保抽樣歸人檔為資料，經由分析基層診所申報之診斷、檢查、年齡分布、藥物和特定診療項目，根據數量、變異性和多樣性變化等構面，進行「病人複雜度」之計算。此外，本研究參考文獻使用之基層照護品質指標，從中歸納出十一項常見之基層醫療服務項目，探討不同科別基層診所提供服務項目之差異。結果：台灣家醫科基層診所的病人複雜度最高，其次是兒科、內科。基層診所提供各項服務之比例，以2013年為例：空腹血脂36.45％，醣化血色素30.80％，微量白蛋白尿25.53％，眼睛檢查8.69％，成人健檢35.26％，流感疫苗有21.53％，子宮頸抹片檢查為8.31％，糞便潛血檢查為14.88％，而戒菸門診為7.46％。癌症篩檢項目中，結腸直腸鏡佔1.32％，乳癌篩檢佔0.17％。僅有不到一成的診所同時能提供流感疫苗等五項診所常見之服務項目，且高達四成的診所未能提供五項中任一項的服務。此外，本研究也發現，病人複雜度和提供服務項目之比例與都市化程度普遍成反比。結論：整體而言，台灣基層家醫科、內科和小兒科診所最接近家庭醫師的角色，但現況之下以達成的比例來說，能夠提供五項以上基層醫療服務項目的診所未達一成，相較於國外的基層診所常提供的服務項目上，仍有很大的進步空間。 Objectives: The primary care system is responsible for the management and coordination of patient care. This study will explore how many primary care clinics are able to take on the functions of family physicians. This will be accomplished through exploring the patient complexity and the services provided by primary care clinics in Taiwan. Methods: In this study, we calculated patient complexity using different dimensions, including quantity, variability, and diversity. We assessed patient complexity in terms of diagnoses, exams, age distributions, medications, specific diagnosis and treatments provided by primary care clinics. In addition, we referenced the quality care indicators used in other countries and then summed up eleven primary care services indicators. Through linear regression and logistic regression, we examined the relationships between division, urbanization and patient complexity and services provided by primary care clinics. We also took into account the relationship between physicians' specialty, demographic characteristics, and primary care services. Results: Patient complexity is the highest for family medicine providers, followed by internal medicine and pediatrics clinics. In 2013, the results suggest that the eleven primary care services that primary care clinics can provide are: fasting blood lipids 36.45%, glycosylated hemoglobin 30.80%, microalbuminuria 25.53%, eye examination 8.69%, health examination 35.26%, influenza vaccine 21.53%, pap smears 8.31%, fecal occult blood test 18.7%, and smoking cessation clinic 7.46%. In cancer screening services, colorectal cancer screening are only 1.32%, and breast cancer screening only 0.17%. Fewer than 10% of primary care clinics provide the five most common services, and nearly 40% of those clinics did not provide any of the above services. In general, the degree of urbanization in the clinics is inversely proportional to the patient complexity and the ratio of clinics providing primary care services. Conclusions: Overall, family medicine, internal medicine and pediatrics clinics in Taiwan are able to take on the functions of primary care providers, but fewer than 10% of the primary care clinics provide top 5 primary care services. Ideally, primary care services could be spread more evenly between providers. Any effort to improve the referral system should be aimed at strengthening the clinics that aren't currently able to meet primary care service needs. This is particularly true of primary care clinics in highly urbanized areas.