Based on the findings, there were three recommendations to BNHI ： 1. Establish strict clinic

「前胎剖腹產陰道生產」論病例計酬實施對醫師執行剖腹產 後自然產之影響∼以某財團法人醫療體系為例

 本研究的研究目的為瞭解中央健康保險局推出「前胎剖腹產陰道生產」（ Va ginal Birth after Cesarean Section, VBAC ）論病例計酬後，在提供此類高風險 產婦之合理給付費用的誘因下，對醫師執行剖腹產後自然產醫療行為之影響。

本研究以台灣某財團法人醫療體系所屬四家醫療機構從民國 92 年 3 月 1 日至 94 年 4 月 30 日之資料，針對 2246 位曾剖腹產的產婦及其 30 位婦產科醫師進 行分析。本研究使用配對 t 檢定來分析 VBAC 論病例計酬實施前後，醫師執 行剖腹產後自然產比率的差異。另一方面，使用邏輯斯蒂迴歸分析來檢定影 響醫師執行剖腹產後自然產之相關因素。 研究結果顯示，在 VBAC 論病例 計酬實施後，醫師執行剖腹產後自然產比率增加 6.06% ，並達到統計上的顯 著差異。在影響醫師執行剖腹產後自然產的相關因素方面，研究結果顯示：

VBAC 論病例計酬實施、產婦主要臨床診斷、醫師性別、醫師年齡、主治醫 師年資、平均每月接生人數、執行剖腹產之方便性、產婦年齡及產婦計畫性 住院生產等因素，對醫師執行剖腹產後自然產具有顯著之影響力。

基於本研究的研究發現，在此建議中央健康保險局： 1. 嚴謹規範初次剖腹產 及再次剖腹產之主要臨床診斷，及具證據醫學基礎之條件； 2. 建立剖腹產個 案之同儕專業審查制度及； 3. 改以校正後剖腹產率來監測各醫療機構之剖腹 產率。

Application of Data Mining for Comorbidity of Acne Patients- An Example of National Health Insurance Research Database

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To reduce the cesarean delivery rate, Taiwan''s Bureau National Health Insuranc e (BNHI) introduced the "Vaginal Birth after Cesarean Section" (VBAC) casepayment on Apr il 1, 2003. The purpose of this study was to investigate the impact of the VBAC casepayment on physicians’ operating VBAC.

The data used in the study were sourced from some nonprofit health care system in Taiwan, in cluding 4 hospitals of that system. The study period covered from March 1, 2002, to April 30, 2004, and involved 2246 expectant women with previous C-section delivery experience and 3 0 attending obstetricians and gynecologists. Paired t-test was used to analyze the VBAC rate b efore and after the introduction of the VBAC casepayment. Logistic regression analysis was p erformed to explore the relationship between the VBAC casepayment and the likelihood of ph ysicians’ operating VBAC, adjusting for controlling variables such as previous C-section deliv ery experience of a expectant woman.

Results indicated that after the implementation of the VBAC casepayment, the VBAC rate incr eased 6.06% (p<0.001). The findings of logistic regression analysis showed that the VBAC ca sepayment, major clinical diagnosis, seniorityof physicians, average delivery performed by ph ysicians, gender and age of physicians, convenience of C-section assumed by physicians, mate rnal age and planned hospitalization for delivery were significant predictors of physicians’ ope rating VBAC.

Based on the findings, there were three recommendations to BNHI ： 1. Establish strict clinic

al guidelines of performing primary and repeat C-section; 2. Set up peer-review mechanism of

C-section cases; and 3. Use the risk-adjustment cesaerean section rate to monitor the C-section

situations of hospitals.