臺灣博碩士論文加值系統

由資料庫中篩選出1-18歲首次取得重大傷病證明之三類型先天性心臟病共計1,202人，分別為發紺型先天性心臟病155人占例12.90%、非發紺型先天性心臟病966人占例80.36%、阻塞性先天性心臟病81人占例6.74%，平均年齡為5.05
歲，其中女性616人占例51.25%，男女平均住院次數分別為2.23次、1.90次；
平均住院天數分別為18.21天、13.56天；平均住院醫療費用分別為213,123元、166,146元，在平均住院次數、天數及醫療費用方面變異數分析男女均有顯著差異。男女平均門診人次分別為54.47人次、52.47人次；男女平均門診醫療費用分別為38,990元、36,993元，在平均門診人次及醫療費用方面男女性變異數分析並無顯著差異；在不同年齡層以住院天數及門診醫療費用有顯著差異，以幼兒的平均住院天數、門診人次及門、住診醫療費用都明顯高於其他年齡層。特約類別之住院天數及住院醫療費用醫學中心高於其他層級別，並有顯著差異；門診人次以基層診所最高、門診醫療費用則以醫學中心高於其他層級別，且有顯著差異。
討論：
本研究之結果與研究假設大致吻合，男性門、住診及總醫療費用均高於女性，年齡別以幼兒（1至3歲）醫療資源耗用最多，有合併症及有手術之發紺型先天性心臟病住院天數及住院醫療費用高於非發紺型及阻塞性先天性心臟病，社經地位及城鄉差距之醫療資源用則無顯著差異，顯示全民健康保險普及性。本研究對三類型先天性心臟病患者醫療資源耗用情形有詳盡描述外，並建議對醫院權屬別進行DRGs之疾病嚴重度分析，又該病患持續追蹤治療情形為未來研究方向。

Background and Purpose:
Congenital heart disease is one of the congenital diseases commonly found in children, and is caused mostly by cardiac structural malformations that children are born with. Most of its symptoms appear early, and is the primary heart disease that occurs in childhood. Of the children heart diseases, congenital heart disease accounts for quite a high percentage, with about 8-10 out of every 1000 newborn infants suffering from this disease in Taiwan, an attack rate of about 0.8-1%.This study aimed to analyze the factors in medical resources consumption among children with congenital heart disease who acquired the National Health Insurance for the first time in major injuries

Purpose:
1. Analyze the situation of medical resource utilization among children aged 1 to 18 with different types (cyanosis, non-cyanotic, and obstructive) of congenital heart diseases.
2 . Discuss the impact of individual (gender, age, surgery, complications, and socioeconomic status) and environmental (hospital region,
level, ownership, and urban-rural gap) related factors on medical resources utilization of different types of congenital heart diseases.
3. Analyze above differences and correlation and make recommendations for early screening and early treatment, in order to conserve health care resources and provide a reference for preventive medicine and genetic health.

Materials and methods:
The sources of analysis data for this study came from the secondary database of the Department of Health's Central Health Insurance Bureau, namely "catastrophic illness detailed file", "out-patient prescription and treatment detailed file", "Inpatient expenses detailed file", "basic medical data file of institutions", and "underwriting data file". From the "catastrophic illness detail file", patients with congenital heart disease aged between 1-18 years old who received certification of serious diseases for the first time in 2003 were captured,

then details on these patients' outpatient prescriptions, treatments, and hospitalization medical expenses between 2003 and 2005 were collected, followed by descriptive and inferential analysis of medical resources consumption on individual (gender, age, surgery, complications, and socioeconomic status) and environmental (hospital region, level, ownership, and urban-rural gap) related factors of patients with different types of congenital heart diseases.

Results:
A total of 1,202 patients with the three types of congenital heart disease aged between 1-18 years of age who received certification of serious diseases for the first time were selected from the database, which consisted of 155 patients with cyanotic congenital heart disease (12.90%), 966 patients with non-cyanotic congenital heart disease (80.36%), and 81 patients with obstructive congenital heart disease (6.74%). The average age was 5.05 years, of which 616 were women accounted for 51.25%. The average number of hospital stay for male and female patients were 2.23 times and 1.90 times respectively; the average length of hospital stay were 18.21 days and 13.56 days respectively; the average hospitalization cost were NT 213,123 yuan and NT166,146 yuan respectively. ANOVA showed a significant difference between male and female patients in terms of the average number of hospital stay, days of hospital stay, and medical costs.
The average number of clinical visits for male and female patients were 54.47 times and 52.47 times respectively; the average outpatient medical expenses for male and female patients were NT38,990 yuan and NT36,993 yuan respectively, and ANOVA showed no significant difference between male and female in terms of the average number of clinical visit and out-patient medical expenses; significant differences existed between different age groups in terms of hospital days and outpatient medical costs, where the average hospital days, clinical visits, inpatient and outpatient medical costs of young children were significantly higher than other age groups.Special category hospital days and inpatient medical costs of medical centers were higher than other levels with a significant difference; highest outpatient visits was found in primary care and medical centres have the highest outpatient medical costs than other levels, and there were significant differences.

Discussion
The results of this study were roughly consistent with the hypothesis, where inpatient and total medical costs of male were higher than female, the highest consumption of medical resources was found in young children (1-3 years), hospital days and hospital costs of patients with congenital cyanosis heart disease complications or surgery were higher than those with non-cyanotic or obstructive congenital heart disease, and no significant difference was found in socioeconomic status and urban-rural gap in terms of consumption of medical resources, indicating the universalness of the national health insurance.Detailed descriptions on the consumption of medical resources by patients with the three types of congenital heart disease were presented in this study. It is recommended that future research should pursue separate DRGs disease severity analysis on different hospital ownership and track patient treatment as the future research directions.

論文電子檔著作權授權書-------------------------------- i
論文審定同意書--------------------------------------- ii
誌謝------------------------------------------------- iii
中文摘要---------------------------------------------- iv
英文摘要---------------------------------------------- vi
目錄------------------------------------------------- ix
圖目錄------------------------------------------------ xi
表目錄--------------------------------------------- xii
第一章 緒論 -------------------------------------- 1
第一節 研究背景及動機---------------------------- 1
第二節 研究問題---------------------------------- 3
第三節 研究目的---------------------------------- 4
第四節 研究重要性-------------------------------- 5
第二章 文獻探討----------------------------------- 6
第一節 先天性心臟病介紹-------------------------- 6
第二節 先天性心臟病之罹病率與病型--------------- 18
第三節 先天性心臟病與重大傷病相關性------------- 20
第四節 先天性心臟病醫療資源耗用及影響因素------- 22
第三章 研究設計與方法---------------------------- 24
第一節 研究架構--------------------------------- 24第二節 研究假設--------------------------------- 25
第三節 研究對象及材料--------------------------- 26
第四節 研究變項操作型定義----------------------- 28
第五節 資料處理與分析方法----------------------- 33

第四章 研究結果---------------------------------- 35
第一節 描述性統計------------------------------- 35
第二節 樣本依變數描述及變異數分析--------------- 40
第三節 推論性統計------------------------------- 83
第五章 討論與研究限制---------------------------- 97
第一節 兒童先天性心臟病之重大傷病討論----------- 97
第二節 兒童先天性心臟病醫療資源耗用討論--------- 98
第三節 研究限制-------------------------------- 103
第六章 結論與建議------------------------------- 104
參考文獻--------------------------------------------- 105
附錄------------------------------------------------- 110

中文部份

李淑莉、陳月枝（2001），兒童經歷開心手術治療過程母親的壓力源及因應行為.護理研究，Vol.9,No.2，172-182.
呂鴻基、洪啟仁、吳美環、侯守賢、朱樹勳、連文彬（1993），台灣的先天性心臟病.台灣醫學雜誌，92（附冊1），1-12.
行政院衛生署（2008），台灣地區少年主要死亡原因.取自http：//www.doh.gov.tw/statistic/data/衛生統計叢書2/96/記者會專區/表3.xls.
林竹川（2007），先天性心臟病患者論病例計酬給付制度之醫療資源耗用分析.國立中山大學醫務管理研究所碩士論文.
張耀輝（2006），兒童心臟病.健康情報，32.
朱樹勳（2002）淺談心臟開刀（2）先天性心臟病的開刀治療（一）.健康世界，Vol.72,No.07，26-33.
朱樹勳（2003）淺談心臟開刀（3）先天性心臟病的開刀治療（二）.健康世界，Vol.72,No.08，39-43.
朱樹勳（2004）淺談心臟開刀（4）先天性心臟病的開刀治療（三）.健康世界，Vol.72,No.09，46-50.
陳永忠（1996），易被忽略的先天性心臟病-心房中膈缺損，台灣醫界，Vol.39,No.12，33-36.
陳永忠（1996），最常見之先天性心臟病-心室中膈缺損，台灣醫界，Vol.39,No.7，60-64.
邱舜男（2006），常見先天性心臟病，國立台灣大學醫學院附設醫院雲林分院院訊，2月刊，8-10.
鍾宏濤（2008），幼兒先天性心臟病之診斷與治療，育兒生活，221版，159-160.
陳豐霖、陳家玉、謝凱生（1999），無心臟雜音的先天性心臟病-全肺靜脈回流異常，中華民國新生兒醫學會會刊，Vol.8,No.2，14-17.
孫麗娟、吳恩婷、黃書健、柯文哲、王主科、吳美環（2007），單一心室循環的先天性心臟病的心衰竭，中華民國重症醫學雜誌，Vol.8,No.4，184-191.
陳月枝（2007），實用兒科護理（第五版），華杏出版股份有限公司.
蕭聖謀（2002），國立台灣大學附設醫院先天性心臟病之產前診斷.國立台灣大學醫學院臨床醫學研究所碩士論文.
呂鴻基、陳烱明、許瑞雲、陳烱霖（1976），中國人先天性心臟病罹病率與病型之研究.台灣醫誌，75；53-59.
孟春昌、黃碧桃（1980），先天性心臟病在台灣.臨床醫學，230-231.
呂鴻基、洪啟仁、吳美環等（1993），台灣的先天性心臟病.台灣醫誌，92卷附冊1.
趙治中、張嘉侃、潘文中、吳玉樹等（1984），台灣地區先天性心臟病兒童生長發育之研究.中兒醫誌，25：286-390.
簡文彥（2008），最常見的先天性異常-早期發現小兒先天性心臟病，媽媽寶寶，254期，219-221.
翁仁崇（2006），胸腔內視鏡手術治療先天性心臟病之現況.臨床醫學，57，419-422.
吳琦森 （2007），心臟導管在兒童心臟病之應用.北市醫學雜誌，Vol.4,No.7附冊，611-617.
吳玉村、趙治中、張嘉侃（1985），先天性心臟病兒童矯正手術對生長之影響.中兒醫誌，Vol.27,No.3，246-250.
孫懿英、王如華、黃碧桃、白鷺（2001），學齡前期先天性心臟病童與一般兒童之氣質、母親教養方式比較.護理研究，Vol.4,No.1，39-52.
許國正（2005），先天性心臟病患童父母於開心手術前後需求之探討.慈濟護理雜誌，Vol.4,No.4，40-49.
全民健康保險保險對象免自行負擔費用辦法.
全民健康保險保險重大傷病範圍.
陳建仁、林莉華（1997），健康保險資料庫之學術應用：重大傷病證明資料檔分析之經驗.中華衛誌，Vol.16,No.6，513-520.
盧瑞芬、李佳琳、莊逸洲（1999），全民健康保險保險重大傷病患者住院醫療資源使用. 中華衛誌，Vol.18,No.4，283-292.
劉介宇、洪永泰、莊義利、陳怡如等（2006），台灣地區鄉鎮市區發展類型應用於大型健康調查抽樣設計之研究.健康管理學刊，Vol.4 No.1，1-22
張朝琴（2007），貧窮與健康-社經地位與原住民族健康問題探析.國立嘉義大學通識學報（第六期），461-486
洪宜盈（2006），跨國婚姻婦女所生育子女之健康狀況及相關因素分析.澄清醫護管理雜誌，Vol.2 No.2，17-23.

英文部份

Bayer LM, Robison SJ,（1960）Growth history of children with congenital heart defects.size according to sex, age decade, surgical status,and diagnostics category. American Journal of Diseases of Children,117（5）,564-72.
Carianne L.Verheugt,Cuno S.P.M.Uiterwaal,Enno T. et al（2008）Gender and outcome in adult congenital heart disease.Journal of the American Heart Association.Circulation.118；26-32.
Chang LK, Lin SL, Ueng KC et al（1994），Comparison of transthoracic and transesophageal echocardiography in the detection of congenital heart disease in adults.Acta Cardiol Sin,174-178.
Connor JA,Gauvreau K,Jenkine KJ.（2005），Factors associated with increased Resource utilization for congenital heart disease. pediatrics,166（3）,689-695.
Garson A, Allen HD, Gersony WM.et al（1994）The cost of congenital
heart disease in children and adults.A model for multicenter assessment of pricr and practice variation.Archives of pediatrics & adolescent medicine,148（10）,1039-1045.
Hsieh KS, Lin CC, Lin WS, Chen FL（1996）,Dynamic three-dimensional display of common congenital cardiac defect from reconstruction of two-dimensional echocardiography images. Acta Paed Sin,37（1）,27-30.
Jean Anne Connor,Kimberlee Gaurvreau and Kathy J.Jenkins（2009）Factors associated with increased resoure utilization for congenital heart disease.American Academy of Pediatrics,116；689-695.

Lai FC, Wei HJ, Wang CC（2001），Partial sternotomy for simple congenital heart disease.Formosan J Surg,34：122-125.
Laura E.Yount and William T.Mahle（2004）Economic analysis of palivizumab in infants with congenital heart disease.
Pediatrics,114；1606-1611.
Lin CC, Hsieh KS, et al（2004）,Evaluation of complex congenital heart disease with real-time three-dimensional chocardiography.Acta Cardiol Sin,20：21-23.
Lin JF, Chen YY, Lin CC et al（2005），Detection of major congenital heart disease with detailed fetal echocardiography.Clinical Neonatology,12（2）,60-63.
Rothman KJ, Fyler DC,（1976）Sex, birth order, and maternal age characteristics of infants with congenital heart defects. American Journal of Epidemiology,104（5）,527-34.
Ungerleider MR,Bengur AR,Kessenich AL. et al（1997），Risk factors
for higher cost in congenital heart operations.The Annals of Thoracic Surgery,64（1）,44-8.
Wu MH, et al（2010），Prevalence of congenital heart disease at live birth in Taiwan.The Journal of Pediatrics. www.jpeds.com.
Yang HL, Chen YC, Mao HC, et al（2004）Effect of a systematic discharge nursing plan on mothers’knowledge and confidence in caring for infants with congenital heart disease at home.J Formos Med Assoc,103（1）,47-52.