目的:本研究主旨在於探討國內心臟衰竭病人其診斷初期連續性照護程度是否會影響醫療照護的品質，並以心臟衰竭之可避免住院及急診作為指標檢視其相關性。

方法:本研究為橫斷式研究，資料來源為國家衛生研究院全民健保資料庫，以回溯性方式收集2009~2012年之次級資料為，主要分析對象為2010年40歲以上新診斷的心臟衰竭病患共2388人，2010~2011年測量其連續性照護指標且分為低、中、高三組，並檢視其2012年可避免住院及急診利用情形，並以t檢定、ANOVA分析、卡分檢定、邏輯斯迴歸分析、負二項式迴歸分析並探討心臟衰竭病患其連續性照護與可避免住院及急診之相關性。

結果: 邏輯斯迴歸結果呈現，在急診方面，連續性照護指標(COCI、UPC)，連續性照護分布於中間者與分布於高者，其發生急診的機率呈現較低的趨勢(P<0.001)；在可避免住院方面，連續性照護指標(COCI、UPC)分布於中間者與分布於高者，其發生可避免住院的機率呈現較低的趨勢(中:P<0.05；高: P<0.001)，但UPC分布於中間者未達統計上顯著差異。負二項式迴歸結果呈現，在急診次數方面，連續性照護指標(COCI、UPC)，於中間者與分布於高者，其使用急診的次數有減少的趨勢(中：P<0.05；高:P<0.001)；在可避免住院次數方面，連續性照護分布於中間者與分布於高者，其使用可避免住院的次數有減少的趨勢(COCI高：P<0.01；UPC高：P<0.001)，但兩種連續性照護指標分布於中間者皆未達統計上顯著差異。

結論:
本研究結果顯示，初次診斷後的心臟疾病患者，其門診連續性照護越高，能夠避免病情惡化減少急診及可避免住院的使用，可得知在針對日益專業化和缺乏基層醫療照護及轉診制度的台灣，連續性照護為維護醫療品質的一項重要指標，提供照護者監控其照護是否能夠維持有效的疾病管理，以達到早期治療、降低病情惡化風險並減少醫療資源的使用之目的。

關鍵字：心臟衰竭、連續性照護、可避免住院、急診

Background: From 2007, cardiovascular disease has become the second leading cause of death in Taiwan and heart failure is one of the most cost-intensive chronic diseases and the most common cause of hospitalization and emergency visit . However, hospital admissions due to heart failure are considered to be potentially avoidable through effective and continuous ambulatory care. Our aim is to examine whether continuity in ambulatory care is associated with preventable hospitalizations and emergency visit due to heart failure.
Methods: Using National Health Insurance Research Database (NHIRD), we selected patients with a first time diagnosis of heart failure from 2009-2012. And defined two measures of continuity of care: Continuity of Care Index (COCI), Usual Provider Index (UPC) . We analyzed whether these measures are associated with preventable hospitalizations and emergency visit due to heart failure by using logistic regression models and Negative Binomial Regression Model. We controlled for a wide range of covariates such as sex, age and the Charlson comorbidity index,and we also controlled the accessibility of healthcare(including hospital level and urban-rural location)
Results: Data of 2388 heart failure elder patients were included in the analyses. Index values of COCI range from 0.77 to 0.83. Results of logistic regression analyses indicate that the continuity indices COCI, UPC are negatively associated with preventable hospitalizations and emergency visit.
Conclusion: The results indicate that the greate continuity in the ambulatory sector is associated with less use of preventable hospitalizations and emergency visit.This approach would enhance the continuity in ambulatory care and encourage the patients to visit a fixed location and physicians for medical treatment to maintain a fixed relationship between doctors and patients; an established relationship would promote medical services with high continuity in ambulatory care.

Keywords：Heart failure , Continuity in ambulatory care, Preventable hospitalizations, Emergency visit

摘　要 ii
Abstract iv
目　錄 v
圖　次 vii
表　次 viii
第壹章 緒論 1
第一節 研究背景動機 1
第二節 研究目的 2
第貳章 文獻探討 3
第一節 心臟衰竭疾病介紹與相關研究文獻探討 3
第二節 可避免住院文獻探討 6
第三節 連續性照護文獻探討 10
第四節 連續性照護與可避免住院相關文獻探討 17
第五節 文獻小結 19
第參章 研究設計與方法 21
第一節 研究架構與假設 21
第二節 研究對象與資料來源 22
第三節 研究變項與操作型定義 30
第四節 統計分析方法 35
第肆章 研究結果 36
第一節 樣本特性與變項分布情形 36
第二節 連續性照護指標與自變項分布情況 41
第三節 研究變項與醫療照護結果之相關性分析 51
第四節 多變項分析 61
第五節 研究假設驗證 87
第伍章 研究討論與建議 88
第一節 討論 88
第二節 研究限制與建議 92
第三節 結論 93
參考文獻 94
附　錄 107

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