建議 - 結論與建議 - 加入論質計酬對照護過程與照護結果之影響─以氣喘為例

第六章結論與建議

第二節建議

給後續研究者的建議

1. 後續研究可針對嚴重度分類模式做進一步改善

本研究的氣喘嚴重度評估模型利用次級資料庫完成模型與驗證效度，大約可以將台灣病患區分為二或三級，若需要更精確的分級，則需要與臨床實務結果比對，以及補充分級表之藥物清單確保不同時期也可使用此模型。

2. 後續研究可建立未成年患者的嚴重度分類模式

由於成年患者與未成年患者的治療方式、症狀評估等都有不同，故本研究之嚴重度分類方法並不適用，待後續研究宜另外建立適用的分類模式。

3. 後續研究可探討氣喘論質計酬參與率低，以及無法提升門診回診次數的問題醫師是病人能否論質計酬制度的關鍵主導者，後續研究應探討是那些原因造成醫師參與意願不高，照護連續性不好的主要原因是醫師還是病患所致，是醫師實務上與醫療指引有落差、制度誘因不足，或是否目前的病患衛教普遍不夠所導致？可以嘗試探討醫師對於氣喘論質計酬方案的態度與意見。

4. 後續研究可繼續探討論質計酬在照護過程和結果的關係，或長期影響

由本研究結果可知論質計酬無法藉改變門診追蹤次數影響照護結果，中介關係不成立，但仍可能對有加入且較嚴重之病人的病情有益，或許可以朝論質計酬為調節變項，探討對照護過程與結果的交互作用。也可以改以更長期的觀察，

看是否在其他指標如氣喘死亡率上，有因加入 P4P 及追蹤次數而改變。

給服務提供者的建議

1. 整體病患的門診追蹤需要加強，尤其輕度病患常會忽略追蹤重要性

有無加入論質計酬和門診追蹤是否有達到建議的三次以上沒有相關，並且可發現多數患者的回診次數皆偏低，而 35 歲以上的人門診次數較 35 歲以下的人多，

嚴重度是中重度的患者相對門診次數也明顯較多。這顯示病患特性對氣喘門診

追蹤會造成影響，然而也應注意病情與年齡較輕患者的追蹤與控制，且普遍上追蹤管理需要加強。可能需要增進大多數病人對氣喘的認識，養成定時回診的習慣。

給政策管理者的建議

1. 論質計酬方案的參與率、氣喘照護追蹤完整率不足，可能需要更多誘因新發成人個案中，僅約八分之一的病患會加入論質計酬，中重度患者雖較輕度容易加入卻也未過半，其未能普及可能與醫師和制度有關，誘因不足以鼓勵醫師有意願將病人納入制度。而氣喘乃一需要定期追蹤控管之疾病，雖然病情輕微者不需要太多的醫療處置，但追蹤後續數年的就診紀錄，仍有一半左右的中重度患者在第一年以後不再至門診就醫，這顯示可能目前台灣氣喘的照護連續性不佳，可能病患並不了解氣喘的疾病特色，多數患者是至基層診所就醫，診所可能沒有疾病管理師輔助，衛教人力較缺乏，需要額外給予服務提供者獎勵來促進衛教。

2. 有無加入論質計酬未能顯著提升門診追蹤，可能需要制度調整

台灣的氣喘控制狀況並不好，門診追蹤是否達到制度建議的三次沒有受到論質計酬影響，而傾向於中重度與年長者會頻繁至門診就醫。可能現今實行之論質計酬制度採包裹給付，給付僅止於結構面的「有無多次回診」而沒有過程面和結果面的品質指標，給付金額又不足以鼓勵醫師改變診療模式，故加入方案後仍與未加入時相近；或者是否回診另有病人方的因素牽涉其中，例如病情嚴重的病人可能因為健康狀況不好較願意多次回診、病患衛教不足等等。

如何促進病患定時到門診就醫以控制病情，氣喘論質計酬制度應還有改善空間。

故需要檢視現今制度是否有缺陷，可能要在制度誘因和指標制定上進行改變，

例如從機構著手，公開各院所的制度實施情形與獎勵機制，再用獎勵進步的方

式，給予門診追蹤率增加者獎金；再者制度面可以提升達成完整追蹤的點數，

或進一步修改現今方案與增加過程面的給付項目。

3. 現今論質計酬可能有抑制氣喘急性發作的效果，仍應推廣

對於氣喘病患者來說，加入氣喘醫療給付改善方案和未加入者並無門診追蹤次數的顯著差異。論質計酬的介入，雖未能在短期內看到在門診追蹤次數上的提升，但可能提升了其他有益於疾病控制的醫療品質層面，例如以衛教促進病人的自我管理能力。介入後使中重度的患者氣喘急性發作的機會未顯著高於輕度病人，表示論質計酬方案應可以抑制氣喘急性發作，降低病人因急性發作導致生活品質不佳甚或生命危險的機率，值得擴大實施。

4. 可利用個案登錄檔作為制度改善依據，建立回報系統

現今實行的支付指標僅有收案、回診追蹤、以及年度照護(回診達三次以上)，但後兩者有無法實際反映照護效果的疑慮，會多次回診的病患可能是病況控制不好所造成，而控制不好除了醫師的處置，病人層面也有影響。這樣的誘因設計可能鼓勵的不是成效改善而是增加醫療耗用。氣喘論質計酬方案現已有每一位加入方案的患者個人資料檔，詳細記錄和管理病人診療項目，包含各項檢查與醫師的評估。未來應可以朝此方向，除了既有的健保申報與病歷紀錄，經由將所有氣喘病患的每次診治過程整合成紀錄檔，就可判斷是因為病人原本病情就不加，還是醫師處方或病人醫囑遵從度不足，導致控制狀況與就醫頻率有所變化。政策管理者也可以依據這些回報資訊，來訂立並發掘出目前最需建立哪些構面的支付誘因，以逐漸走向真正的論成效計酬、促進醫療品質。例如身體檢查和檢驗的結果可作為結果面指標，遵從度不足則可以朝鼓勵建立醫病共同參 與的治療計畫、或提高自我照顧能力方面作改善。

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在文檔中加入論質計酬對照護過程與照護結果之影響─以氣喘為例 (頁 147-182)

建議

第六章 結論與建議

第二節 建議

第六章結論與建議

第二節建議