鍾國彪Chung, Kuo-Piao臺灣大學:醫療機構管理研究所陳孟渝Chen, Meng-YuMeng-YuChen2010-05-052018-06-292010-05-052018-06-292009U0001-0508200912114900http://ntur.lib.ntu.edu.tw//handle/246246/180836背景與目的：台灣於2001年推出五大疾病論質計酬，其中糖尿病論質計酬於2007年開始依醫療院所照護病人結果面指標作為獎勵條件，跨出真正論「質」的第一步。國外已有許多調查醫師對於論質計酬的認知與態度的研究，用以評估計畫的成效及了解現況，然而國內的研究仍付之闕如。因此本研究將針對參與糖尿病論質計酬的醫師進行調查，了解其對於論質計酬的態度，並探討其與醫師認知、個人特質及醫療院所特質的相關性。究方法：本研究引用國外學者Meterko等人發展之「Provider Attitudes toward Incentives」問卷，並依研究目的增加題項。透過三位專家學者進行效度檢測及八位醫師進行前測，對部分題項進行修擬後完成定稿。本研究為橫斷性研究，對象為全台參與糖尿病醫療給付改善方案院所之醫師，以立意取樣的方式進行。問卷發放期間為2009年4月24日至6月3日，共發放585份問卷，回收有效問卷207份，有效問卷回收率為35.38%。究結果：研究結果顯示醫師對於論質計酬支付制度的理念大多持有正面的看，有83.6%的醫師認為當醫師達到較好的照護品質時，健保局應給予財務獎amp;#63871;，75.4%的醫師相信給予財務獎勵是增進醫療照護品質的有效方法，並有71%醫師認為財務獎勵相較於非財務獎勵，為較佳的獎勵方式。多數的醫師認同糖病論質計酬的「預期效果」，但對於「組織支持」的認同較低，特別是在財務持的部份，有40.6%的醫師不同意「糖尿病醫療給付改善方案」給付的金額，以補償達到品質指標獎勵目標。本研究結果亦得到醫師個人特質中的最高學歷機構特質與醫師對於論質計酬的認知會影響醫師對於論質計酬的態度。其中當醫師對於國內論質計酬的自評了解越高、對論質計酬的財務分配越了解，對於論質計酬的態度越呈正向關係；此外，機構中領導者的鼓勵也能提升醫師對於論質計酬正面的態度。議：對於未來研究的建議包括：可增加質性的部份，補強機構特質在執行質計酬時的差異與影響，以及了解院所對於財務獎勵的分配方式；探討態度與為的關連；可從護理人員、營養師、衛教師，甚至病患的角度來加以分析比較；研究對象擴大到其他論質計酬方案進行探究。Background and Objectives: In 2001, the pay-for-performance programs was applied in 5 main diseases in Taiwan. Among them, the program for diabetes mellitus firstly adopted clinical outcome indicators as the reward basic. That was the real first step in rewarding the “performance.” Studies from foreign countries have investigated physicians’ knowledge and attitudes toward the pay-for-performance system in order to understand the implementation conditions and evaluate its effectiveness. However, local studies related to this issue are limited. This study aimed at understanding the knowledge and attitudes toward the pay-for-performance among physicians who participated in the diabetes mellitus pay-for-performance program. In addition, the relationships among physician’s attitudes, knowledge, personal characteristics, and characteristics of healthcare institutions were examined.ethods: The investigation instrument in this study was based on the “Provider Attitudes toward Incentives” questionnaire developed by Meterko and his colleagues. Additional questions were added to fit the research purposes. According to the validity test by three experts and a pilot test for 8 physicians, several questions were revised. This was a cross-sectional study focusing on physicians participated in the diabetes mellitus pay-for-performance program in Taiwan. A purposive sampling method was adopted. 585 questionnaires were distributed between April 24th and June 3rd, 2009 and 207 valid questionnaires were returned. The valid response rate was 35.38%.esults: Study results showed that most of the physicians held a positive attitude toward the pay-for-performance mechanism. 83.6% of the physicians thought that the Bureau of National Health Insurance should provide financial incentives to a physician when his/ her services achieved a better quality. 75.4% of the physicians believed that the financial incentive was an effective approach to improving quality of health care. 71% of the physicians suggested that financial incentives were better than non-financial incentives. Most of the physicians applauded the “anticipated outcome” under the diabetes mellitus pay-for-performance program, while they approved with the “organizational support” less. This situation was especially significant with respect to the “financial support”, that 40.6% of the physicians did not think the amount of eimbursement under the “Medical Benefit Improvement Project in Diabetes Mellitus” could compensate the effort they spent to fulfill the goal. This study also found that physician’s education level, characteristics of the healthcare institution, and physician’s knowledge of the program could impact the physician’s attitudes toward the program. Through the self-administered questionnaires, those who understood the program and the financial distribution more were more likely to have a positive attitude toward the pay-for-performance program. Furthermore, the encouragement from the chief of an institution could contribute to physician’s positive attitudes toward the program.uggestions: Suggestions for future study include: using the qualitative method to strengthen the healthcare institution aspect to understand its impact on the implementation of the pay-for-performance program and the distribution of financial incentives within an institution; exploring the relationship between attitudes and behavior; broaden the investigation targets to include nurses, nutrition consultants, health education practitioners, and even patients; studying the effect of this program in other diseases.誌謝……………………………………………………………………………….….....i文摘要………………………………………………………………………………..ii文摘要………………………………………………………………………………..iii目錄……………………………………………………………………………….....vii目錄……………………………………………………………………………….....ix一章 緒論……………………………………………………………………… …1 一節 研究背景與動機………………………………………………………...1 二節 研究目的………………………………………………………………...3 二章 文獻探討………………………………………………………………….…4一節 論質計酬支付制度介紹………………………………………….…..4二節 影響醫師認知態度之相關因素探討…………………………….…..9三節 醫師對於論質計酬的態度面向………………………………….…13四節 醫師對於論質計酬認知與態度之實證研究…………………….…16五節 糖尿病醫療給付改善方案………………………………………… 23六節 文獻總結…………………………………………………………….28三章 研究方法………………………………………………………………….29一節 研究流程…………………………………………………………….29二節 研究架構…………………………………………………………….30三節 研究假說…………………………………………………………….31四節 研究設計與資料來源……………………………………………….32五節 研究工具…………………………………………………………….33六節 資料處理與分析方法……………………………………………….42四章 研究結果………………………………………………………………….43一節 問卷回收情形………………………………………………………...43二節 共同方法變異檢定…………………………………………………...43三節 因素分析與信度…………………………………………………… ..43四節 描述性統計分析…………………………………………………… ..49五節 雙變項分析………………………………………………………… ..66六節 多變項分析……………………………………………………….85五章 研究討論……………………………………………………………..101一節 醫師參與「糖尿病醫療給付改善方案」情形………………..101二節 描述性結果討論………………………………………………..103三節 研究假說驗證………………………………………………… .106四節 影響醫師對於論質計酬態度的相關因素結果探討…………..110五節 研究限制……………………………………………………… .112六章 結論與建議…………………………………………………………..114一節 結論……………………………………………………………..114二節 建議……………………………………………………………..115考文獻…………………………………………………………………………117 英文文獻……………………………………………………………………117 中文文獻……………………………………………………………………121錄一 專家效度名單…………………………………………………………123錄二 研究問卷………………………………………………………………124錄三 填答之「診所醫師」描述性分析……………………………………130錄四 填答之「醫院醫師」描述性分析……………………………………138application/pdf703886 bytesapplication/pdfen-US論質計酬糖尿病醫療給付改善方案醫師態度醫師認知Pay-for-performanceMedical Benefit Improvement Project in Diabetes MellitusPhysician’s attitudePhysician’s knowledge[SDGs]SDG3thesishttp://ntur.lib.ntu.edu.tw/bitstream/246246/180836/1/ntu-98-R96843014-1.pdf