2010-2014台灣醫院整合醫療主治醫師之特徵、趨勢與臨床表現

Abstract

Introduction: The emergence of hospitalist has dramatically changed the face of hospital care in the US, and has distributed to Taiwan since early 2000. This study aims to investigate the background of hospitalist care in Taiwan, including demographics and characteristics of hospitalists who cared for hospitalized patients in Taiwan from 2010 to 2014, and also the clinical performances of hospitalists in caring for hospitalized general medicine patients. Methods: This study is conducted with a retrospective design using National Health Insurance (NHI) whole-population claims data from the Collaboration Center of Health Information Application(CCHIA), Ministry of Health and Welfare in Taiwan. We defined that a physician who had at least 100 evaluation-and-management codes in a given year and carried inpatient claim amount for ≧80% of their total inpatient and outpatient claims in a given year, except for practicing as an intensivist, was a hospitalist. Trend and characteristics of hospitalists from 2010 to 2014 were analyzed. The main care outcomes included hospital mortality , length of stay, hospitalization cost and post-discharge 30-day mortality. Outcomes of hospitalized patients with pneumonia, urinary tract infection (UTI), chronic obstructive pulmonary disease (COPD) and upper gastrointestinal bleeding (UGIB), cared by hospitalists were compared to the non-hospitalist group. To deal with repeated admission and clustering of patients under physicians, generalized estimating equations (GEE) was constructed on which in-hospital outcomes and post-discharge outcomes were used as the endpoint variables. Statistical significance was set at a two-sided P<0.05 Results: A total of 13207 internal medicine, family medicine and neurology specialists were identified. The distribution showed that the number and percentage of specialists decreased gradually from 0-9% to 90-100%. the number of hospitalists declined from 108 in 2010, to 84 in 2014. Most hospitalists were male (more than 70%). The average age of hospitalists were 40-45. Over 80% of hospitalists were internal medicine specialists. Hospitalists tended to practice in metropolitan areas of Taiwan, and a trend toward affiliation to medical centers. After controlling for patient-level and institutional factors, multivariate regression analysis showed that hospitalized patients with pneumonia handled by hospitalists had lower hospital mortality, while patients with UTI, COPD and UGIB had no statistical difference in hospital mortality compared to those handled by non-hospitalist. Adjusted LOS of patients with pneumonia, UTI and COPD were similar, but LOS of patients with UGIB was longer when cared by hospitalists compared that of non-hospitalists. Adjusted hospitalization costs were lower for hospitalists in pneumonia and UTI, but insignificant difference in COPD and UGIB. Post-discharge 30-day morality was lower for UTI patients handled by hospitalists, while no significant difference in the other three diseases. Conclusion: The background and practice pattern of hospitalists in Taiwan were similar with the US, but the growth trend was not evident from 2010 to 2014. The performance of hospitalists showed favorable survival benefit and cost saving in caring for pneumonia and UTI patients. However, LOS of hospitalists care was not uniformly shortened. These findings suggested that hospitalist care in Taiwan has potential to improve survival and save cost, but the efficiency in throughput warrant further study.