影響醫師實施臨床指引意願之因素探討－針對臨床指引本身之特性

92 10-11 17.8%

National Guideline Clearing House Cochrane Library

Prospective Payment System, PPS Managed Care, MC

The National

Academy of Sciences IOM

The Institute of Medicine Clinical guidelines

Eddy 1990

Clinical guidelines Clinical practice guidelines

Clinical Path

,

critical path-way, clinical pathpath-way, critical path, clinical protocol, care map, care track

1980 1990

National guideline clearing house AHRQ Agency for Healthcare Research and Quality American Med-ical Association AMA American As-sociation of Health Plans AAHP

IDS

977

PDA European Union

Appraisal of Guidelines for Research and Evaluation in Europe

AGREE ?????????????? ?W26X?hg? ?*@@1?hg? ?V'@5?hg?N@H?hg?J5 ? ?W.Y ? ?.Y? ???????????????? 2002 2000 2002 ?????????? @@ ? @@ ?????????? @@ ? @@ ??????????????

APDRGs All Patients

Diagno-sis-Related Groups DRG

clinical guideline

1.

Davis et.al., 1997; Carrick, 1998; For-moso G et al, Cates et.al., 2001

2.

IOM; Bouvenot J.et al, 2002

Tunis et al, 1994; Hayward et al, 1997; Olesen F et al, 1997; Flores et.al., 2000

3.

clinical flexibility IOM; Flores et.al, 2000

Wolff HM et al, 1998; Flores et.al.,

2000 Flores

et.al., 2000; Cynthia M Farquhar, 2002

4.

Cates et.al., 2001; Bouvenot J.et al, 2002

5. Tunis et

al, 1994; Grilli R.et. al., 1996; James PA et al, 1997; Flores et.al., 2000; Stoddard JJ., Cynthia M Farquhar, 2002

Tunis et al, 1994; Cyn-thia M Farquhar 2002

Warner, 1998

Davis et.al., 1997; Carrick, 1998; Flores et.al., 2000; Cynthia M Farquhar, 2002 1990 91 7 7 1 7 7 92 10-11 SPSS Excel 3160 562 17.8% 503 89.5% 50 8.9% Cronbach Alph 0.86 Chi-Square P 0.246 0.392 26~84 46.5 11.5 26~35 91 16.2% 36~45 194 34.6% 46~55 158 28.2% 56~65 66 11.8% 66 52

9.3% 4 5 0 6 3 80.1% 11.2% 358 63.7% 193 34.3% 154 27.4% ) 45 8.0% 103 18.3% 76 13.5% 102 18.1% 14 2.5% 1 2 4 22.1% 4 0.7% 71 12.6% 44 7.8% ܒտ Ρኵ ԻϷШ(%) ظܒ 503 89.5 τܒ 50 8.9 ӫॎ 553 98.4 Ґ๎ 9 1.6 ᖂॎ 562 100.0 ԑឭቹ Ρኵ ԻϷШ(%) 26~35ྑ 91 16.2 36~45ྑ 194 34.5 46~55ྑ 158 28.1 56~65ྑ 66 11.7 66ྑоΰ 52 9.3 ӫॎ 561 99.8 Ґ๎ 1 .2 ᖂॎ 562 100.0 Ρኵ ԻϷШ(%) кݽᚂৱ 450 80.1 ՞଱ᚂৱ 63 11.2 ӫॎ 513 91.3 Ґ๎ 49 8.7 ᖂॎ 562 100.0 Ρኵ ԻϷШ(%) ϱऋف 358 63.7 Ѵऋف 193 34.3 ӫॎ 551 98.0 Ґ๎ 11 2.0 ᖂॎ 562 100.0

38 6.8 % 53 9.4 % 204 36.3% 1 3 1 23.3% 118 21.0% 105 18.7% 197 35.1% 1 60 12.7 10.3 1 5 141 25.1% 6 10 207 36.8% 11 15 86 15.3% 16 20 28 5.0% 21 25 4.4% Ρኵ ԻϷШ(%) ϴҳᚂ଱ 131 23.3 ؽҳᚂ଱ 118 21.0 ଒ღݲΡᚂ଱ 105 18.7 அቹຨܚ 197 35.1 ڏт 6 1.1 ӫॎ 557 99.1 Ґ๎ 5 .9 ᖂॎ 562 100.0 Ρኵ ԻϷШ(%) 1Ս5ԑ 141 25.1 6Ս10ԑ 207 36.8 11Ս15ԑ 86 15.3 16Ս20ԑ 28 5.0 21ԑоΰ 25 4.4 ӫॎ 487 86.7 Ґ๎ 75 13.3 ᖂॎ 562 100.0 Ρኵ ԻϷШ(%) Ѯѕୢ 154 27.4 ѕୢ 45 8.0 ϛୢ 103 18.3 ࠒୢ 76 13.5 ଽࡎୢ 102 18.1 ݍୢ 14 2.5 ӫॎ 494 87.9 Ґ๎ 68 12.1 ᖂॎ 562 100.0 Ρኵ ԻϷШ(%) ᚂᏰϛЖ 124 22.1 ྥᚂᏰϛЖ 4 0.7 Ҧ᜸ୢ୿ᚂ଱ 71 12.6 Κ᜸ୢ୿ᚂ଱ 44 7.8 ӴୢఀᏰᚂ଱ 38 6.8 ӴୢߨఀᏰᚂ଱ 53 9.4 அቹຨܚ 204 36.3 ӫॎ 538 95.7 Ґ๎ 24 4.3 ᖂॎ 562 100.0

ҁ֯঄ ኿ྥ৯ ȪQ301ȫᖝחࡾЕϞڙۡᔖಒӫᏰ౩ٷᐃЅᜌᐃᚂᏰȄ 9.23 1.51 ȪQ302ȫᖝחࡾЕڙۡࡣᔖܻᚂᏰ෈ѐΰีߒȄ 8.69 1.97 ȪQ303ȫᖝחࡾЕᔖҥᚂᏰϛЖڙۡȄ 5.86 2.95 ȪQ304ȫᖝחࡾЕᔖҥடऋᚂᏰོڙۡȄ 8.26 2.20 ȪQ305ȫᖝחࡾЕᔖҥ߳ᓎΡȞԃϛѵ୊߳׋ȟڙۡȄ 2.29 2.62 ȪQ306ȫᖝחࡾЕᔖҥӨᚂᕛ଱ܚՌॏȄ 4.29 3.07 ȪQ307ȫᖝחࡾЕᔖЕҢ୽ѴϐڙۡޱȄ 5.28 2.57 ȪQ308ȫᖝחࡾЕӵஈ՗ਢȂᔖٷϐڙۡϞϱৠஈ՗ȂϚۣ ӈཎᡐ؁Ȅ 5.40 3.02 ȪQ309ȫᖝחࡾЕ҆໸џоቨ໌ࠢ፴Ȅ 8.70 1.80 ȪQ310ȫᖝחࡾЕ҆໸џо६ճԙҏȄ 7.18 2.60 ȪQ311ȫᖝחࡾЕ҆໸Ϛኇ៪ᚂৱϞՌкܒȄ 8.65 2.02 ȪQ312ȫᖝחࡾЕ҆໸џоٷ௑ݷওғȄ 9.03 1.55 ȪQ313ȫᖝחࡾЕ҆໸џҥᆩၯջາڥுȄ 8.46 2.45 ȪQ314ȫᖝחࡾЕ҆໸џҥ෈ѐȃѐސڥுȄ 8.65 2.01 ȪQ315ȫᖝחࡾЕ҆໸џငҥඡΰ࠮ႫသڥுЅၼҢȄ 7.48 2.71 ȪQ316ȫᖝחࡾЕ҆໸џҢپհ࣏ᚂৱଋጛϞҢȄ 8.43 1.97 ȪQ317ȫᖝחࡾЕ҆໸ඪټΙӋ๝੾௉(੾௉ގ)Ȅ 5.97 3.23 ȪQ318ȫᖝחࡾЕ҆໸ӵݲࡡٱӇΰᄇᚂৱԤ߳៖հҢȄ 8.97 1.76 ȪQ319ȫᖝחࡾЕ҆໸ᇄ୊߳๝п๖ӫȄ 7.43 2.79 ȪQ320ȫᖝחࡾЕ҆໸ඪ݇੾௉ᅖཎ࡙Ȅ 8.48 1.84 ȪQ321ȫᖝחࡾЕϞ௰՗ᔖҥᐿҳȃϴғȃՌкϞᐠᄺஈ՗ࡣ៉ ᅿกЅᆴࠌȄ 8.00 2.45 ȪQ322ȫᖝחࡾЕϞ௰՗ᔖҥடऋᚂᏰོஈ՗ࡣ៉ᅿกЅᆴࠌȄ 7.60 2.45 ȪQ323ȫᖝחࡾЕϞ௰՗ᔖҥ߳ᓎΡȞԃϛѵ୊߳׋ȟஈ՗ࡣ៉ ᅿกЅᆴࠌȄ 4.07 3.17 ȪQ324ȫᖝחࡾЕϞ௰՗ᔖҥӨᚂᕛ଱ܚஈ՗ࡣ៉ᅿกЅᆴࠌȄ 5.89 2.94 ȪQ325ȫᖝחࡾЕᔖڙ࣏ۡӒ୽ܒȞӒ୽ΙमȟȄ 7.70 2.66 ȪQ326ȫᖝחࡾЕᔖڙ࣏ۡୢ୿ܒȞӨୢ୿ΙमȂٽȈоᑪѿܖ ୊߳Ϸ׋࣏൐՝ୢϷȟȄ 5.07 3.23

?????????? @@ ? @@ ?????????? @@ ? @@ ?????????????? Q301 Q302 Q303 Q304 Q305 Q306 Q307 Q309 Q310 Q316 Q317 Q318 Q320 Q308 Q311 Q312 Q319 Q321 Q322 Q323 Q324 Q325 Q326 26 Q301 Q312 Q318 Q309 Q302 Q311 Q314 Q320 Q313

Q316 Q304 Q321 Q325 Q322 Q315 Q319 Q310 Q317 Q324 Q303 Q308 Q307 Q326 Q306 Q323 Q305 2 9.23 1.51 8.69 1.97 1 5 Stoddard et al. 2002 ; 9.23 9.038.97 8.488.468.43 8.26 8.00 7.707.60_7.487.43 7.18 5.975.895.86 5.405.28 5.07 4.29 4.07 2.29 8.65 8.65 8.69 8.70 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 μQ 3 0 1 ν μQ 31 2 ν μQ 3 18 ν μQ 3 09 ν μQ 3 02 ν μQ 3 11 ν μQ 314 ν μQ 3 20 ν μQ 3 13 ν μQ 3 1 6 ν μQ 30 4 ν μQ 321 ν μQ 3 25 ν μQ 3 22 ν μQ 3 1 5 ν μQ 3 1 9 ν μQ 31 0 ν μQ 3 17 ν μQ 3 24 ν μQ 3 0 3 ν μQ 3 0 8 ν μQ 30 7 ν μQ 3 26 ν μQ 3 06 ν μQ 3 2 3 ν μQ 3 0 5 ν

Cates et al. 2001 Davis et.al. 1997 Carrick et al. 1998 Warner et.al. 1998 8.26 2.20 5.86 2.95 5.28 2.57 2.29 2.62 Tunis et al. 1994 82%

American College of Physicians Blue Cross and Blue

shield 6% Hayward et al. 1997 51-77% Stoddard et al. 2002 2002 90% 9.23 8.69 8.40 8.50 8.60 8.70 8.80 8.90 9.00 9.10 9.20 9.30 ಒӫᏰ౩ٷᐃЅᜌᐃᚂᏰ ܻᚂᏰ෈ѐΰีߒ

5.40 3.02 9.01 1.55 cook-medicine Q311 8.42 2.02 : Flores et al. 2000

the National Academy of

Sci-ences IOM, the Institute of

Medicine clinical flexibility Hayward 1997 Flores 2000 Hayward et al. 1997 5.28 4.29 2.29 8.26 5.86 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 ᚂᏰϛЖ டऋᚂᏰོ ߳ᓎΡ ᚂᕛ଱ܚ ЕҢ୽Ѵ

7.48 2.70 8.46 2.45 8.65 2.01 8.65 5.40 7.43 9.03 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 ϱৠϚۣӈཎᡐ؁ Ϛኇ៪ᚂৱՌкܒ џٷ௑ݷওғ ᇄ୊߳๝п๖ӫ 8.65 8.46 7.48 6.80 7.00 7.20 7.40 7.60 7.80 8.00 8.20 8.40 8.60 8.80 ᆩၯڥு ෈ѐȃѐސ ඡΰ࠮Ⴋသ

8.70 1.80 4 Tunis et al. 1994 70% Flores et.al. 2000 Stoddard JJ. 2002 Rao et al. 2002 MRI Zwar N. 2002 Warner et al. 1998 Weingarten et.al. 1998 7.18 2.6% Tunis et al. 1994 68% 8.43 1.97% Stoddard et al. 2002 8.48 1.84 5.97 3.23 8 . 9 7 1.76 Carrick et al. 1998 150 41% Flores et al. 2000

Mitchell et al. 2000 Bertakis et al. 1999 Mckay et al. 1999 7 . 4 3 2 . 7 9 1 6 8.00 2.45 7.60 2.45 5.89 29.4 4.07 3.17% 8.70 7.18 8.43 8.97 _8.48 5.97 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 ቨ໌ࠢ፴ ६ճԙҏ ᚂৱଋጛ ඪټ๝੾௉ ݲࡡΰ߳៖ᚂৱ ඪ݇੾௉ᅖཎ࡙

7 . 7 0 2 . 6 6 5 . 0 7 3.23% Q301 Q304 Q318 Q 3 2 1 Q312 Q 3 1 4 8.00 _7.60 4.07 5.89 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00

୰ڢфဴЅϱৠ T-test P঄ ȪQ301ȫᖝחࡾЕϞڙۡᔖಒӫᏰ౩ٷᐃЅᜌᐃᚂᏰȄ 0.000 ȪQ302ȫᖝחࡾЕڙۡࡣᔖܻᚂᏰ෈ѐΰีߒȄ 0.006 ȪQ303ȫᖝחࡾЕᔖҥᚂᏰϛЖڙۡȄ 0.000 ȪQ304ȫᖝחࡾЕᔖҥடऋᚂᏰོڙۡȄ 0.000 ȪQ305ȫᖝחࡾЕᔖҥ߳ᓎΡȞԃϛѵ୊߳׋ȟڙۡȄ 0.001 ȪQ306ȫᖝחࡾЕᔖҥӨᚂᕛ଱ܚՌॏȄ 0.746 ȪQ307ȫᖝחࡾЕᔖЕҢ୽ѴϐڙۡޱȄ 0.000 ȪQ308ȫᖝחࡾЕӵஈ՗ਢȂᔖٷϐڙۡϞϱৠஈ՗ȂϚۣӈཎᡐ؁Ȅ 0.020 ȪQ309ȫᖝחࡾЕ҆໸џоቨ໌ࠢ፴Ȅ 0.060 ȪQ310ȫᖝחࡾЕ҆໸џо६ճԙҏȄ 0.005 ȪQ311ȫᖝחࡾЕ҆໸Ϛኇ៪ᚂৱϞՌкܒȄ 0.636 ȪQ312ȫᖝחࡾЕ҆໸џоٷ௑ݷওғȄ 0.469 ȪQ313ȫᖝחࡾЕ҆໸џҥᆩၯջາڥுȄ 0.676 ȪQ314ȫᖝחࡾЕ҆໸џҥ෈ѐȃѐސڥுȄ 0.675 ȪQ315ȫᖝחࡾЕ҆໸џငҥඡΰ࠮ႫသڥுЅၼҢȄ 0.035 ȪQ316ȫᖝחࡾЕ҆໸џҢپհ࣏ᚂৱଋጛϞҢȄ 0.000 ȪQ317ȫᖝחࡾЕ҆໸ඪټΙӋ๝੾௉(੾௉ގ)Ȅ 0.003 ȪQ318ȫᖝחࡾЕ҆໸ӵݲࡡٱӇΰᄇᚂৱԤ߳៖հҢȄ 0.043 ȪQ319ȫᖝחࡾЕ҆໸ᇄ୊߳๝п๖ӫȄ 0.000 ȪQ320ȫᖝחࡾЕ҆໸ඪ݇੾௉ᅖཎ࡙Ȅ 0.000 ȪQ321ȫᖝחࡾЕϞ௰՗ᔖҥᐿҳȃϴғȃՌкϞᐠᄺஈ՗ࡣ៉ᅿก ЅᆴࠌȄ 0.000 T-test P 7.70 5.07 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 Ӓ୽ܒ ୢ୿ܒ

Q325 National Guideline Clearing House Cochrane Library 1. 15~20% 17.8% 2. 3. T-test P ᆴ ȪQ322ȫᖝחࡾЕϞ௰՗ᔖҥடऋᚂᏰོஈ՗ࡣ៉ᅿกЅᆴࠌȄ 0.001 ȪQ323ȫᖝחࡾЕϞ௰՗ᔖҥ߳ᓎΡȞԃϛѵ୊߳׋ȟஈ՗ࡣ៉ᅿก ЅᆴࠌȄ 0.000 ȪQ324ȫᖝחࡾЕϞ௰՗ᔖҥӨᚂᕛ଱ܚஈ՗ࡣ៉ᅿกЅᆴࠌȄ 0.023 ȪQ325ȫᖝחࡾЕᔖڙ࣏ۡӒ୽ܒȞӒ୽ΙमȟȄ 0.097 ȪQ326ȫᖝחࡾЕᔖڙ࣏ۡୢ୿ܒȞӨୢ୿ΙमȂٽȈоᑪѿܖ୊߳ Ϸ׋࣏൐՝ୢϷȟȄ 0.002

1. Practice guidelines in Taiwan

2001-2002 129-36

2. 2002

3. 2002

--39 29-33

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9. Farquhar CM, Kofa EW, Slutsky JR. Clinicians attitudes to clinical practice guidelines: a systematic review. Med J Aust. 2002 Nov 4; 177(9):502-6. Com-ment in:Med J Aust. 2003 Apr 7;178 (7):354-5; author reply 355; discussion 355-6.

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A study on factors that influence physicians’ willingness for implementa-tion of clinical practice guidelins was performed through a structured quesimplementa-tion- question-naire. The clinical practice guidelines that have the characteristics such as

match the evidence-based medicine made by association of specialist flexible in use proctective role in legal events national level available on journals and monitoring by an independent organization will be favored by physicians in Taiwan.