| 摘要: | 目的：在高齡化的人口結構中，慢性病社區管理是地區醫院發展社區醫療最重要的方式。本研究即以地區醫院為基礎，以出院準備服運用個案管理模式，設定以糖尿病、腦中風、高血壓慢性疾病，在不同照護管理模式之間成效差異。並探討影響糖尿病、腦中風、高血壓病患，在出院後6個月內，急診醫療利用與再住院醫療利用相關因素。 方法：本研究主要針對某地區醫院，在2002年1月1日到2003年2月29日，以糖尿病、腦中風、高血壓為研究對象，以實施個案管理照護模式為介入措施，區分為傳統照護組與個案管理組。以回溯性調查方式，進行個案資料收集。並以描述性統計分析，不同照護模式組別中，在個人基本特性、社會支持系統，與醫療結果上的分佈情形。並以羅吉斯迴歸(Logistic regression analysis )探討影響糖尿病、腦中風、高血壓慢性病患，在出院後6個月內，急診醫療利用與再住院醫療利用之相關素。 結果： 在醫療結果指標中，個案管理模式組糖尿病病患，比傳統照護組糖尿病病患，在平均住院天數、門診醫療使用、急診醫療利用次數、糖化血色素改善程度、出院後1-6個月內是否急診醫療利用有顯著效果；腦中風病患中，個案管理模式組比傳統照護組，在平均住院天數、門診醫療使用、總巴氏量表改善程度、膽固醇改善程度上有顯著效果。高血壓病患在個案管理模式組，比傳統照護組，在出院後1-3個月門診醫療使用、第一次收縮壓改善程度、總舒張壓改善程度、三酸肝油脂改善程度上有顯效果。 以羅吉斯迴歸分析在控制其它變項後，在糖尿病患者中有無實施個案管理模式，是影響糖尿病病患急診利用主要因素。血糖因素則是影響糖尿病病患，再住院醫療使用最重要因素。腦中風患者中，獨居、安養護機構及腦中風患者合併肺循環疾病，是影響腦中風患者在出院後6個月內急診利用主要因素；而腦中風患者合併肺循環疾病，是主要影響腦中風病患再住院醫療使用之主要原因。高血壓患者在出院後1-6個月內，影響急診醫療利用與再住院醫療使用，在統計結果上無顯著影響。 結論與建議：1.以出院準備服運用個案管理模式，對慢性病管理照護是有效果，可作為發展社區化慢性病照護管理策略。2.針對複雜且變異性高的疾病，應結合不同管理模式之優點，發展最適合病患的照護模式。; patients is one of the most important services for developing and expanding services for district hospitals. This study is based on a district hospital’s discharge planning. Different outcomes under different managements were compared for DM patients, CVA patients and HT patients. The frequencies of emergency call and re-admission to hospital were correlated among those patients within 6 months from discharge. Methods: The subjects were selected as patients of DM, CVA and HTN from a district hospital from Jan. 01 2002 to Feb. 29 2003. The study group was divided into 2 groups: a control group and a case management model group. Each group carried out respective duties and took records and characteristics among those patients within 6 months after discharge. Then data were sorted out and analyzed. Under descriptive statistical analysis, different management methods, individual characteristics, social supports and results of medical cares were distributed. The logistic regression analysis was used to be the statistical tools. Results: DM patients under discharge planning had marked improvement compared to a control group in length of hospital stay, frequencies of OPD consultation, emergency call and HbA1C level within 6 months after discharge. CVA patients under discharge planning had remarkably improved in length of hospital stay, frequencies of OPD consultation, Barthel IADL scale, and cholesterol level compared to control group. HTN patients under discharge planning had fewer visits to OPD consultation, improved in systolic and diastolic pressure control as well as triglycerides level compared to control group. After analyzing data with logistic regression analysis, it found that the main factor for DM patient calling ER after 6 months from discharge was a lack of case management model. Blood sugar level was a main factor for re-admission to hospital among DM patients. Among CVA patients, living alone, geriatric institutions and associated pulmonary diseases were the main factors for calling ER or readmission within 6 months from discharge. And combined CVA with pulmonary disease was main factor for readmission among HTN patients. No remarkable factor was noted for HTN patients calling ER or readmission within 6 months from discharge. Conclusion and recommendations: (1) The discharge planning has effective improvements of health care for chronic ill patients. And it can be a device and tactic for the developing and expanding services of a district hospital. (2) Combining different managements method is an advantage for complicated and fragile chronic ill patients and it can expand further to meet the needs of the patients. Key words: Case management, Discharge planning, Diabetes mellitus, Cerebrovascular accident, Hypertension |
