論質計酬於老年思覺失調症病人之醫療利用情形

研究背景：根據世界衛生組織2022年資料顯示，思覺失調症影響約全球2400萬人，300人中就有1位思覺失調病人，盛行率為0.32%，在成人中盛行率為0.45%，目前衛生福利部110年資料顯示台灣思覺失調症盛行率為0.43%，根據美國和英國的估計，思覺失調症的盛行率在45歲及以上人群中為0.6%至1%，在65歲及以上人群中為0.1%至0.5%(Cohen et al.，2018)，在美國，到2025年，將有110萬人或大約四分之一的思覺失調症病人年齡在55歲以上(Cohen et al.，2008)，而思覺失調症會影響個人、家庭、社會、教育及職業，同時在疾病負擔沉重，109年資料統計思覺失調醫療總費用為136億元，在所有疾病中排名11名；而為鼓勵醫護人員主動積極介入治療，使思覺失調病人能固定規則接受治療，提高病人治療之依從性，於2010年1月1日起提出「全民健康保險思覺失調症醫療給付改善方案」，目的為促使醫療院所提高思覺失調症疾病之醫療照護品質，以提昇病患之生活功能與品質、降低社會成本。目的：至今鮮少有針對老年思覺失調症病人之醫療利用相關研究，本研究旨在評估「思覺失調症醫療給付改善方案」介入，對於老年思覺失調症病人於醫療利用之影響。方法：本研究使用衛生福利資料科學中心精神主題式資料庫，研究對象為2015-2017年思覺失調症病人，分為加入及未加入給付改善方案，以單因子變異數分析社會人口學變項對精神科門診利用次數及精神科醫療費用自然對數值是否具顯著性差異，並以複回歸對精神科門診就醫次數及醫療費用自然對數值進行統計分析。研究結果：加入思覺失調症醫療給付改善方案組，其精神科門診就診次數及醫療費用較高，然而論質計酬方案於南部醫院實施效果較佳，精神科門診就醫次數較高且未顯著增加精神科醫療費用，有較佳的醫療利用成果，複迴歸分析結果顯示影響精神科門診次數的因子包含年齡、精神科醫療費用、南部醫院、醫院權屬別、共病症均有顯著影響；而顯著影響醫療費用的因子有年齡、年平均門診次數以及都市化程度分類為一般鄉鎮市區及農業市鎮。結論：思覺失調症醫療給付改善方案介入，雖然顯著增加了門診就診次數，但同時具有較高的醫療費用，然而論質計酬方案於南部醫院實施效果較佳，有較佳的醫療利用成果；而整體研究結果並未達到計畫中降低社會成本的目的，可能為老年思覺失調症的就醫因素有較多複雜因子影響，無法以單一面向解釋，而思覺失調症醫療給付改善方案整體實際成效還須將病人醫療品質納入考量，方能檢視整體方案成效。

Background : According to the World Health Organization's 2022 data, schizophrenia affects about 24 million people worldwide, and 1 in 300 people suffers from schizophrenia. The prevalence rate is 0.32%, and the prevalence rate among adults is 0.45%. The current 110-year data from the Ministry of Health and Welfare shows that the prevalence of schizophrenia in Taiwan is 0.43%. According to estimates from the United States and the United Kingdom, the prevalence of schizophrenia is 0.6% to 1% in people aged 45 and over, and in 65-year-olds. 0.1% to 0.5% in the population and above (Cohen et al., 2018). In the United States, by 2025, 1.1 million people, or approximately one in four people with schizophrenia, will be over the age of 55 (Cohen et al., 2008). Schizophrenia affects individuals, families, society, education and occupation, and at the same time has a heavy burden of disease. According to statistics in 2010, the total medical expenses for schizophrenia were 13.6 billion yuan, ranking 11th among all diseases. In order to encourage medical staff to actively intervene in treatment, so that patients with schizophrenia can receive treatment on a regular basis and improve the compliance of patients with treatment, the "National Health Insurance Medical Benefit Improvement Plan for Schizophrenia" was proposed on January 1, 2010. The purpose is to urge medical institutions to improve the quality of medical care for schizophrenia, so as to improve the life function and quality of patients and reduce social costs.Objective: So far, there are few studies on the medical utilization of elderly patients with schizophrenia. The purpose of this study is to evaluate the impact of the intervention of the "Medical Benefit Improvement Plan for Schizophrenia" on the medical utilization of elderly patients with schizophrenia.Methods: This study uses the psychiatric thematic database of the Center for Health and Welfare Data Science. The research objects are schizophrenia patients from 2015 to 2017. They are divided into those who have joined and those who have not joined the benefit improvement program. One-way variance analysis is used to analyze the impact of sociodemographic variables on psychiatric disorders. Whether there is a significant difference in the number of outpatient visits and the natural logarithm of psychiatric medical expenses, and using regression regression to analyze the number of psychiatric outpatient visits and the natural logarithm of medical expenses.Results: In the schizophrenia medical benefit improvement plan group, the number of psychiatric outpatient visits and medical expenses were higher. However, the quality-based remuneration plan was more effective in Southern Hospital, with higher psychiatric outpatient visits and no significant increase in psychiatric medical care. There are better medical utilization results. The regression analysis results show that the factors that affect the number of psychiatric outpatient visits include age, psychiatric medical expenses, Southern Hospital, hospital ownership, and comorbidities, all of which have a significant impact; and significantly affect medical expenses. The factors of age, the average number of outpatient visits per year, and the degree of urbanization are classified into general townships, urban areas and agricultural towns.Conclusion: The intervention of the medical benefit improvement plan for schizophrenia significantly increased the number of outpatient visits, but at the same time, it had higher medical expenses. However, the quality-based payment plan was implemented better in Southern Hospital and had better medical utilization results; and overall The results of the study did not achieve the goal of reducing social costs in the plan. It may be that there are many complex factors affecting the medical treatment factors of senile schizophrenia, which cannot be explained in a single aspect. The quality of the patient's medical care must be taken into consideration before the overall program effectiveness can be reviewed.