| Summary: | 碩士 === 長榮大學 === 醫務管理學系(所) === 100 === Background
A Global Budget System (GBS) is intended to prevent the waste of medical resources paid for by health insurance; however, after implementation, the effect of the GBS on medical resources is noteworthy. Pneumonia is one of the top ten causes of fatality and morbidity in children, not only in Taiwan, but also around the word. We therefore chose children (?18 years old) with pneumonia as our study population. Different from previous studies, we are focused on the total disease course of the patients, but not on the particular events of each clinical visit.
Object
To investigate the effect of a GBS on healthcare quality and the use of medical resources for childhood pneumonia before and after implementing a GBS.
Methods
We used a non-random experimental- and control-group study. The experimental group were children who visited hospitals as inpatients and outpatients; the control group were children who visited local clinics. The study period was 6 months before and after July 1, 2002, the date on which the GBS was implemented. The database is from the Taiwan National Health Research Institutes. The clinical course of every patients’ pneumonia was 100% before or 100% after the date of the implementation of the GBS. The medical code used to identify appropriate patients in the database corresponded to pneumonia. There were 198 pre-GBS and 149 post-GBS patients; there were 93 pre-GBS and 71 post-GBS controls. SPSS 12.0 for Windows was used for ?2 tests, t-tests, multivariate logistic regression analysis, and covariance analysis.
Results
Before and after the GBS was implemented, there were no significant differences in the types of medical institutions and in the specialties of the attending physicians that the experimental group children visited. Most children in the experimental group were residents of central and northern Taiwan. Most of the hospitals they visited were regional (multi-district) hospitals, and then district (local or city) hospitals. Most were private medical foundation hospitals. In the experimental group, most of the attending physicians were pediatricians with a mean of 5.5 years’ experience. In the control group, there were no differences in the locations of the clinics or in the specialties of the attending physicians before and after the GBS was implemented.
The quantity of healthcare provided
1. Implementing the GBS had no effect on admitting children with pneumonia to the hospital; however, the length of hospital stays rose from 4.15 days (SD = 2.32) to 5.69 days (SD = 5.07) (t = ?2.384, df = 129, p = 0.019). An analysis of covariance indicated that the length of hospital stays significantly (p < 0.05) increased in medical centers (the largest hospitals in Taiwan).
2. Implementing the GBS significantly (p < 0.05) decreased the number of visits to out-patient clinics in the experimental group from 4.43 (SD = 2.80) to 3.81; however, the length of hospital stays were not significantly different. There was no significant difference in the control group. The analyses of covariance showed only that the length of hospital stays recommended by medical center pediatricians increased.
Medical costs
1. The costs per patient in the experimental group for antibiotics, non-antibiotic medications, chest X-rays, co-payments, and total medical fees were not different before or after implementing the GBS.
2. The cost for chest X-rays in outpatient clinics in the experimental group was significantly lower 68% (t = 2.827, df = 345, p = 0.005); however, the costs for antibiotics, non-antibiotic medications, and co-payments were not significantly different. In the control group, the costs for antibiotics, non-antibiotic medications, and co-payments were not significantly different.
3. Before and after the GBS was implemented, the medical costs for antibiotics, non-antibiotic medications, chest X-rays, and medical payments from Taiwan’s National Health Insurance (NHI) claims were not significantly different in either the experimental or the control group. An analysis of covariance showed that the GBS affected medical payments for antibiotics and non-antibiotic medications only in medical center clinics.
Healthcare quality
1. After the GBS had been implemented, the number of inpatient and outpatient children in the experimental group given chest X-rays, based on the hospital’s clinical guidelines, dropped from 60.6% to 44.3% (?2 = 9.095, df = 1, p = 0.003). However, after adjustments by the hospital type and the attending physician’s medical specialties, the odds ratio was significantly lower: 50%. In the control group, the difference was not significant.
2. In the experimental group, the proportion of sputum examinations was not significantly different. In the control group, no sputum examinations were done.
3. In the experimental group, the hospital’s clinical guidelines did not change the antibiotics prescribed for pneumonia, nor did they change in the control group.
Conclusion
Implementing the GBS caused the length of hospitalization and medical costs for children in the medical center to increase, but had no effect on medical costs for children in non-medical- center hospitals. These findings highlight that the GBS did not reduce total healthcare costs for children with pneumonia. Although the number of chest X-rays taken has been significantly reduced, it is possible that this economy has had a negative effect on healthcare quality.
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