目的：
本研究將以總額給付制度導入為一主要研究重點，探討政策實施前後對腦中風病患之照護品
質及預後之影響，其評估指標為再住院及併發症狀況，進一步分析在不同居住地、年齡層、
性別及醫療層級上是否有所差異。並且分析此政策介入對腦中風病患再住院狀況及費用上實
質擴散程度為何；以此檢視總額給付制度是否發揮其有效運用醫療資源之初衷，並衡量其影
響病患醫療照護的程度，進而達到控制成本和提升照護的醫療品質。
方法：
本研究採用中央健保局委託國衛院所統整出具全國代表性的資料庫－全民健康保險資料庫中
的醫事機構基本資料檔（HOSB）及住院醫療費用清單明細檔（DD），研究期間為民國88 年
到89 年及民國93 年到94 年，共計4 年的整體趨勢分析與討論。依據本研究目的，將總額實
施前後的腦中風老年病患之病人特性構面中的年齡、性別及分布區域等自變項，以及醫事機
構特性中的評鑑等級、所有權及教學與否等自變項進行描述性統計分析，欲於全國性的次級
資料檔案分析中得知總額制度實施前後，台灣腦中風病患老年病患之分布趨勢，進一步使用
線性迴歸模式及邏輯式迴歸模式分析依變項與自變項之關係並加以討論。並根據病患之
icd9-cm 之主診斷碼定義腦中風病患以及其伴隨之charlson comorbidity index，用以評估病患
之疾病嚴重程度。
結果：
台灣整體四年來的腦中風老年病患於總額前後之再住院及併發症的表現上，感染的狀況呈現
顯著成長的趨勢，而在醫療費用的部分，總額後也有較高的成長率；在醫療機構層級的部分，
感染的狀況在法人醫院、醫院中心、地區醫院、教學及非教學醫院皆呈現顯著之成長；而在
研究族群部分，男性、女性、70-74 歲、南部及東部等，其感染部分呈現顯著成長。
結論：
本研究針對總額制度的介入，分析老年病患常見的腦中風疾病於制度前後的再住院及併發症
狀況，進而對其進行數據解讀，延伸探究總額制度對於台灣整體醫療照護體系的潛在警示，
並提供政府以及相關衛生決策機構對於政策制定與疾病衛教推廣的明確方向，以提供相關疾
病病人於醫療照護上得到更完善的照護品質。

Objective：
The purpose of this research is to explore the influences of the global budget implementation on the
older stroke patient's outcome and medical quality. In further analysis, this study compared the
differences of the older stroke patient's rehospitalization and complication across age groups,
genders, regions, and the hospital’s characters. Analysis of the real extent of the Global budget
policy on the readmission of patients was focused on stroke-related outcomes and costs. This study
also reviewed the Global budget policy on whether it has effective control of medical
resources, and measured its impact on medical care of patients, thus to control costs and
improve quality of care.
Method：
The data were derived from the National Health Insurance database and the Taiwan census data.
The study periods were 1999-2000 and 2004-2005. In this research, descriptive analysis was used
to examine the older stroke patient's outcome and medical quality. T -test and chi-square was used
to investigate the outcome and medical quality differences between medical institutions and
personal characteristics. Logistic regression and linear regression model were used to detect and
describes data trends.
Results:
Regarding Taiwan's overall four years of the older stroke patient's rehospitalization and
complication, the status of infection and medical expenses showed significant growth
trend after the Global budget policy implementation. For the medical institutions characteristics,
the infection status of the non-for-profit hospital, medical center hospital, district hospital,
teaching and non-teaching hospital were showing significant growth. For the personal
characteristics, the infection status of male, female, aged 70-74, south and east regional were
with significant growth.
Conclusion：
According to the study results, we found that the Global budget policy implemented in Taiwan was
still need to be improved. We suggest the policy makers
and the hospitals may use the 「Global budget policy implemented」as an indicator to monitor the
quality of care and the outpatient care quality in Taiwan’s healthcare system. Thus not only can
reduce the unnecessary expenditure, but also can offer the general public better quality of
healthcare and improve their quality of life.

論文審定書 ...................................................................................................................................... i
致謝 ................................................................................................................................................. ii
摘要 ................................................................................................................................................ iii
Abstract ......................................................................................................................................... iv
目錄 ................................................................................................................................................. v
表目錄 ............................................................................................................................................ vi
圖目錄 ........................................................................................................................................... vii
第一章 緒論 ................................................................................................................................. 1
第一節 研究背景與動機 ..................................................................................................... 1
第二節 研究目的 ................................................................................................................. 2
第二章 文獻探討 ......................................................................................................................... 4
第一節 總額給付制度 ......................................................................................................... 4
第二節 總額給付制度帶來的影響 ................................................................................... 10
第三節 腦中風患者醫療品質及預後之狀況 ................................................................... 15
第四節 文獻總結 ............................................................................................................... 21
第三章 研究方法 ....................................................................................................................... 22
第一節 研究設計和架構 ................................................................................................... 22
第二節 研究變項 ............................................................................................................... 24
第三節 研究問題 ............................................................................................................... 26
第四節 研究假設 ............................................................................................................... 28
第五節 資料來源及研究對象 ........................................................................................... 30
第六節 統計分析 ............................................................................................................... 31
第四章 結果 ............................................................................................................................... 32
第一節 總額前後腦中風的再住院、併發症及費用控制之趨勢................................... 32
第二節 各醫療機構總額前後之病患再住院、併發症及費用....................................... 39
第三節 各研究族群特性在總額前後之再住院、併發症及費用................................... 53
第四節 病人、醫院特性、總額實施對研究對象預後、醫療品質及費用之影響 ...... 67
第五章 結論與討論 ................................................................................................................... 86
第一節 討論 ....................................................................................................................... 86
第二節 結論 ....................................................................................................................... 88
第四節 研究限制 ............................................................................................................... 89
第五節 建議 ....................................................................................................................... 90
參考文獻 ....................................................................................................................................... 91

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