| 摘要: | 台灣地區自實施全民健康保險以來，醫療費用逐年升高，許多致力於醫療制度改革者，遂提出以「論人計酬」(capitation)為主軸，類似健康維護組織(Health Maintenance Organization，HMO)的健康守門員(gatekeeper)制度，由於HMO的制度除了能減少醫療資源的浪費及抑制醫療費用的上漲外，也非常注重基層醫療照護的品質，因此學者們強調新制度的醫療水準及服務品質不該低於目前制度。所以在新醫療給付制度實施前應先瞭解目前基層醫療照護品質，做為未來新制度實施後對基層醫療照護品質改善或維持的參考依據。 本研究目的為參考「國際生活品質評估計劃」(The International Quality of Life Assessment Project，IQOLA)所建立翻譯量表的研究流程，將美國約翰霍普金斯基層醫療照護政策中心(Johns Hopkins Primary Care Policy Center)所發展的基層醫療照護品質評估工具(Primary Care Assessment Tool)發展成適合台灣地區的基層醫療照護品質評估工具，並進行該測量工具之信、效度評估。 研究流程分為二個階段，第一個階段是以定性與定量的方法來評估和改善翻譯問卷概念的相等性及接受度。定性的部分包括原版問卷的翻譯與反翻譯，定量的部分則包含醫師的調查與民眾的調查；第二階段是藉由民眾的調查進行實際資料收集，經由資料分析測試問卷量表假設檢定及其信、效度評估。 研究結果顯示，此測量工具所包含的五個構面為「第一線接觸」、「進行中照護」、「照護協調性」、「綜合性服務」、「社區導向服務」，其內部一致性(Cronbach’s a)介於0.65~0.96之間。在效度方面，因素效度分析結果能明顯的區分出測量工具中的五個構面；在臨床效度方面，亦能看出不同醫療照護提供者的社區融合程度、民眾健康狀態和滿意度與基層醫療照護品質有顯著的不同。 本研究所發展之中文版「基層醫療照護品質評估工具」是一具備相當良好信、效度之測量工具，將可廣泛的使用於基層醫療照護品質之測量與監測，還可提供臨床醫師改善基層醫療照護品質的參考。在未來的研究方向，可嘗試使用於不同特質的醫師、不同的醫療照護機構或醫療體系，以了解其基層醫療照護品質的差異；並可探討病人的遵醫性與醫療照護品質的關係，以及前瞻性追踪民眾健康狀態的轉變與基層醫療照護品質改變的相關。; Since the costs of medical care increase dramatically after implementation of National Health Insurance in Taiwan, there is an urgent need for health care reform. Many scholars recommended that capitation be favorable type of payment for practitioners and health care be provided by organized groups of health professionals on a prepayment basic, known as health maintenance organizations (HMOs). Several forms of HMO plans require primary care physicians to act as gatekeepers for their patients. Under this condition, it’s important to monitor the performance of current health system’s performance to assure its quality of care. This task, however, won’t be achieved if there won’t be a reliable and valid instrument measuring quality of primary care. Thus, the main goal of the current study is to develop the Chinese-version Primary Care Assessment Tool (PCAT) measuring quality of primary care. The development of Chinese-version PCAT following the guidelines proposed by The International Quality of Life Assessment Project (IAOLA) for cross-cultural adaptation by translating English-version one, which was developed by Johns Hopkins Primary Care Policy Center. This proposed study consists of two stages. In the first stage, preliminary Chinese versions were obtained through translation procedure including back translations under the consideration of conceptual equivalence. In addition, the survey of the attitude of primary care physicians toward the importance of the items and pretest of the general population were conducted to examine PCAT’s acceptance. The second stage was to validate the Chinese-version PCAT to provide estimates of reliability and validity among residents of general population. Our study results show that Cronbach’s a for scales of First-Contact, Ongoing Care, Coordination of Care, Comprehensiveness of Care, and Community-Oriented Primary Care ranged from 0.65 to 0.96. Validation by factor analysis yielded results remarkably similar to those proposed by the authors who developed PCAT. The results of construct validity based upon theoretical relationships shows that significant differences of primary care quality were observed among subjects with different practitioner-patient relationship, health status, and satisfaction of medical care. The Chinese Version of PCAT appears to be an acceptable and sound assessment tool of primary care quality. It should be used by doctors as reference to improve the primary medical care quality. To future research, it could be applied either in monitoring quality of care of different training of practitioners or clinical settings, or exploring the relationship between medical care quality and patient’s compliance, and the longitudinal relationship between health transition and change of care quality. |
