運用資料探勘技術評估整合與連續健康照護服務之管理績效及照護效益_

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題名：	運用資料探勘技術評估整合與連續健康照護服務之管理績效及照護效益
作者：	游慧真
作者(外文)：	Huey-Jen You
校院名稱：	元智大學
系所名稱：	資訊管理學系
指導教授：	詹前隆
學位類別：	博士
出版日期：	2015
主題關鍵詞：	連續性照護；整合性照護；醫療利用；決策樹；優推族群；牙周病統合照護計畫；Continuity of Care；Integrated Care；Medical Utility；Decision tree；Priority Groups；Comprehensive Periodontal Treatment Project
原始連結：	連回原系統網址
相關次數：	被引用次數:期刊(0) 博士論文(0) 專書(0) 專書論文(0) 排除自我引用:0 共同引用:0 點閱:19

多重慢性疾病盛行率逐年提高，使得醫療照護的整合性和協調性成為重要議題。連續性照護(Continuity of Care, COC)高的病人將會有較少的急診及住院利用情形，以及比較好的照護結果。整合性照護(Integrated Care, IC)對醫療利用具有正向效益，但是疾病種類、照護族群、健康狀態和治療方式的不同會有不同的整合照護結果，面對醫療資源有限，找出最有效益的族群加以整合以達到最佳照護結果是相當重要的。再者，臨床治療過程整合同樣可以提供完整性、持續性、高品質的照護結果。過去許多連續性照護的研究，大多聚焦在單一慢性狀態，或醫病關係的照護結果的研究，鮮少對多重慢性病狀態患者與醫療照護系統照護結果進行評估，因此本論文以多重慢性病患為主要研究對象，三個研究目的，第一，透過連續性照護的整合性指標，驗證不同慢性病狀態（所有慢性狀態、主要慢性狀態）在不同照護層次（醫師層次、醫院層次）的連續性照護結果。第二，評估門診整合照護(Out-Patient- Integration Care, OPIC)的實施結果，以及找出多重慢性病人最具整合效益之優先照護族群。第三，評估臨床治療過程整合和傳統治療之效益。
該資料來源來自於全民健康保險署健保資料庫，本論文有三個主軸，主軸一使用280,840樣本，利用主成分分析將密度、分散度與序位性指標整合為整合性指標(Integrate Continuity of Care, ICOC)以便測量連續性照護結果，並使用(Generalized Estimating Equations model, GEE)驗證。主軸二為個案控制研究法，分成實驗組和對照組，兩組共135,704個樣本，利用傾向配分法(Propensity Score Method, PSM)和差異中差異Difference in Difference, DID)來比較兩組間醫療利用情形，並使用決策樹找出OPIC計劃案優先照護族群。主軸三同樣為個案控制研究法，將有接受牙周病統合照護計畫(Comprehensive Periodontal Treatment Project, CPTP)並完成三個階段治療照護者為實驗組(65,342人)，未參加統合照護計畫但有接受牙周病主要治療者之個案為對照組(106,740人)，以牙周治療後4項指標(再治療Retreatment、根管治療Endodontics、牙體復形Operative dentistry及拔牙dental extraction)為預後指標，利用Logistic迴歸評估實驗組是否較傳統對照組有較好的表現。
本論文主要發現，(1)多重慢性病病人，在醫療機構連續性照護越高，有越低的急診率及住院率，而在醫生連續性照護越高，有越高的急診率(odds ratio > 1; Exp(β) = 2.116)及住院率(odds ratio > 1; Exp(β) = 1.688)。慢性病常有共病現象，單一在醫師層次無法完全滿足其照護需求，因為這種病人需要更多不同專科醫師間之協調性照護，或醫療機構應整合不同專科以增加照護效益，該突顯以病人為中心多專科協調照護之專業價值。而單一主要慢性病患者，無論是在醫療機構或醫師接受照護之連續性越高，都會有比較低的急診率及住院率。(2)整合性照護對多重慢性病人具有正向照護結果，參加門診整合照護實驗組相較於對照組醫療費用及就醫次數是較低的。有兩群--"年紀較大且疾病複雜的"，以及"年經但疾病較簡單的"，在接受門診整合照護後具顯著的正向效益，而重大傷病、查爾森共病指標、以及慢性病數是決策樹重要的分類節點。(3)實驗組在接受牙周統整性照護後，再治療、根管治療、牙體復形及拔牙的發生上皆遠比對照組來的低(Odds Ratio < 1)。顯見，實施臨床治療過程的整合照護具有較高的照護品質。

以文找文

The increasing prevalence of multiple chronic conditions has accentuated the importance of coordinating and integrating health care services. Patients with better continuity of care (COC) have a lower utilization rate of emergency department (ED) services, lower hospitalization and better care outcomes. Integrated care (IC) has positive care outcomes for high medical utility and high medical complexity patients. However, the care outcomes of integrated care may vary, depending on the population group. Faced with limited medical resources, it has become critical to identify the priority populations experiencing the most benefits and conduct relevant integration to achieve optimal care outcomes. Besides, integrated of clinical treatment procedures also can providing a complete, continual, and high-quality care to patients.
Previous COC studies have focused on the care outcome of patients with a single chronic condition or that of physician-patient relationships; few studies have investigated the care outcome of patients with multiple chronic conditions, and researchers suggested an integrated index to assess the COC. Hence, the focus of this study is on multi-chronic patients. The study first proposes an integrated continuity of care (ICOC) index to verify the association between COC and care outcomes for patients of two different scopes of chronic conditions (all chronic conditions and major chronic conditions) at the physician and the medical facility level. Second, the study also looks to evaluate the effectiveness of the Out-Patient- Integration Care (OPIC) and to identify priority groups that will experience the greatest benefit. Third, we also evaluate the effectiveness of the Patients receiving Comprehensive Periodontal Treatment Project (CPTP) and Conventional Periodontal Treatment (CPT).
The data resource of study was taken from the National Health Insurance Administration. There were three stages of the study. The first stage used a dataset of 280,840 subjects. Principal Component Analysis (PCA) was used to integrate the indices of density, dispersion and sequence into ICOC to measure COC outcomes. A Generalized Estimating Equations model was used to verify the care outcomes. The second stage used case-control method and divided 135,704 subjects into two groups, the OPIC group and the control group. Propensity Score Method (PSM) and Difference in Difference (DID) were used to compare medical utility between groups. Decision tree was used to identify the priority populations for OPIC program. The third stage used case-control method. The patients who had participated in the CPTP and completed the 3-stage periodontal treatments were recruited in the experimental group (65,342 patients). The patients who had not participated in the CPTP but had received conventional periodontal treatment were selected in the control group (106,740 patients). Using the four parameters (retreatment, endodontic therapy, operative restoration, and tooth extraction) as prognostic indicators, we performed logistic regression analyses to evaluate whether patients in the experimental group had better clinical outcomes than those in the control group.
The major findings of this study included: (1) The higher the COC at medical facility level, the lower the utilization rate of ED services and hospitalization for patients with multiple chronic conditions. In contrast, the higher the COC at physician level, the higher the utilization rate of ED services (odds ratio > 1; Exp(β) = 2.116) and hospitalization (odds ratio > 1; Exp(β) = 1.688). The chronic disease is often accompanied by multi-comorbidity, the need for medical care cannot be entirely met only at the physician level. Because of the increasing need for coordination of care among such patients, different specialists and medical facilities should integrate in order to enhance the efficiency of care. This indicates that a patient-centered, multi-specialty-oriented health care structure for multi-chronic patients is important. When only those patients with both major chronic conditions and the highest number of medical visits were considered, it was found that the higher the COC at both medical facility and physician levels, the lower the utilization rate of ED services and hospitalization. (2) Integrated care (IC) had positive care outcomes in multiple chronic conditions. The OPIC group saved both medical expenditure and the number of visits per year per patient when compared with the control group. We found the "Older and Complicated" and the "Younger and Simple" were two groups for which integrated care via the OPIC program was effective. Catastrophic illnesses, the Charlson Comorbidity Index (CCI), the number of chronic conditions (NCC) and age were the most important classification nodes in decision tree. (3) The patients participating in the CPTP had significantly lower rates of retreatment, endodontic therapy, operative restoration, and tooth extraction than those in the control group (all P-values < 0.001). We conclude that integration of clinical treatment procedures has better high-quality care to patients.

以文找文

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