臺灣博碩士論文加值系統

背景：臺灣的精神疾病盛行率為53‰，醫院的急性精神病房與慢性精神病房中大部分為精神分裂症病人。由於精神分裂症是慢性且長期的疾病，常反覆發作，對社會及醫療資源是很大的負擔。
目的：本研究旨在探討國內精神分裂症病人出院後一年之再住院率，以及其相關影響因素。期能有助於精神分裂症病人照護內容的規劃，以預防病情再復發，進一步降低醫療及社會成本的耗費。
方法：本研究資料來自國家衛生研究院發行的全民健康保險研究資料庫，擷取2007年住院且出院之精神分裂症病人，排除出院時未滿18歲者，所得研究對象共5,284人。以Kaplan-Meier方法估計存活函數，並以Cox比例危險模型（Cox proportional hazards regression model）檢驗可能顯著影響再住院風險的因子。資料處理採用SAS 9.2 統計軟體執行。
結果：國內精神分裂症病人出院後一年再住院率為57.5%，再住院的平均間隔時間為218.39天（標準誤=2.028）。精神分裂症病人出院時的年齡越高，一年內再住院的風險越低（HR=0.994，95% CI=0.990-0.997）。相較於一般公/民營事業的受雇者，精神分裂症病人若為農、漁民（HR=1.290，95% CI=1.034-1.609）、低收入戶（HR=1.545，95% CI=1.261-1.893）、由鄉鎮市區公所投保之地區人口（HR=1.385，95% CI=1.146-1.674）或無工作之眷屬（HR=1.335，95% CI=1.090-1.634），有較高的風險會在出院後一年內再住院。相較於高度都市化市鎮，精神分裂症病人投保地區的若為一般鄉鎮市區（HR=1.147，95% CI=1.003-1.313）或高齡化市鎮（HR=1.446，95% CI=1.144-1.828），有較高的風險會在出院後一年內再住院。精神分裂症病人過去因精神疾病住院的次數若達3次以上，則有較高的再住院風險（HR=1.563，95% CI=1.426-1.714）；若過去因精神疾病住院的天數超過21天，則再住院風險亦會隨住院天數增加。
結論：國內精神分裂症病人出院後一年再住院風險的預測因子包含身份類別、投保地區都市化程度、過去三年精神科住院次數與天數等。建議醫療院所可參考這些風險因子，加強精神分裂症病人的社交技巧訓練、家庭支持與後續追蹤；醫療政策制定者可加強對精神疾病的社會支持。

Background: The prevalence rate of psychiatric disorders was 53‰ in Taiwan. Both in the acute psychiatric ward or chronic psychiatric ward, most patients were schizophrenia. In acute psychiatric ward, 58% patients were schizophrenia. In chronic psychiatric ward, 80% patients were schizophrenia. Schizophrenia was a chronic and lifelong mental illness. As patients with schizophrenia often relapse, it consumed a lot of social and medical resources.
Objectives: The purpose of this study was to investigate the risk factors affecting the rehospitalization in patients with schizophrenia within one year after discharged. In the present study, it was hoped to be a reference for caregivers making better care plans in order to prevent relapse and rehospitalization for patients with schizophrenia.
Methods: The study cohort was retrieved from the National Health Insurance Research Database published by the National Health Research Institutes, and it was composed by 5,284 schizophrenic patients who admitted and discharged in 2007. Patients who was younger than 18 years old were excluded from the study. Rehospitalization was considered as the primary outcome variable in this study. In the present study, it used the Kaplan-Meier method to estimate the Survival curve and the multivariate Cox proportional hazards regression model to identify risk factors. Data was analyzed with SAS version 9.2 for Windows.
Results: The one-year rehospitalization rate was estimated at 57.49%, and the mean time to rehospitalization was 218.39 days (SE= 2.028 ). The present study found the risk of rehospitalization reduced with age (HR=0.994, 95% CI=0.990-0.997). Compared to employees of public or private enterprises or institutions, there were significantly higher risks of rehospitalization, which included farmer or fishermen(HR=1.290, 95% CI=1.034-1.609), low income households(HR=1.545, 95% CI=1.261-1.893) and who were unemployed and qualify as dependents(HR=1.335, 95% CI=1.090-1.634) or insured by administrative office in the village, township, city or area(HR=1.385, 95% CI=1.146-1.674). Compared to patients lived in highly urbanized town, those lived in ordinary town (HR=1.147, 95% CI=1.003-1.313) or in aging town (HR=1.446, 95% CI=1.144-1.828) had higher risk of rehospitalization. Additionally, there were significantly higher risks of rehospitalization, if the number of previous hospitalizations for psychiatric was over 2 times (HR=1.563, 95% CI=1.426-1.714). Furthermore, the risk of rehospitalization also increased with the cumulative days of previous hospitalizations for psychiatric.
Conclusions: The present study found risk factors of affecting the rehospitalization in patients with schizophrenia included type of identity, urbanization stratification, the number of previous hospitalizations for psychiatric, and the cumulative days of previous hospitalizations for psychiatric. The present study suggested that caregivers should enhance the patients’ social skill training and the support from families. The present study also suggested that the health policy makers should make people acquainted with psychiatric.

目錄
中文摘要 I
ABSTRACT III
目錄 VI
表目錄 VIII
圖目錄 IX
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的與研究問題 3
第三節 研究重要性與貢獻 3
第二章 文獻探討 5
第一節 精神分裂症概述 5
第二節 精神分裂症之流行病學 7
第三節 精神分裂症病人復發與再住院之相關研究 9
第四節 精神分裂症病人再住院之相關因素探討 14
第三章 研究方法 20
第一節 研究設計及架構 20
第二節 資料來源與研究對象 22
第三節 研究變項及定義 28
第四節 資料分析方法 39
第四章 研究結果 41
第一節 研究對象之描述性統計 41
第二節 精神分裂症病人出院後一年內再住院率 47
第三節 精神分裂症病人出院後一年內發生再住院之間隔時間 60
第四節 精神分裂症病人出院後一年內再住院之預測因子分析 66
第五章 討論與建議 72
第一節 研究重要結果及討論 72
第二節 研究限制 80
第三節 建議 81
參考文獻 85
附表　全民健康保險研究資料庫之地區代碼與都市化程度分類對照表 92

中文部分
內政部（2012）。內政部統計通報101年6月底身心障礙之慢性精神病患統計。瀏覽日期：2012年10月29日。網址：http://sowf.moi.gov.tw/stat/week/week10134.doc
孔繁鐘（2006）。DSM-IV精神疾病診斷與統計。台北市：合記。
全民健康保險爭議審議委員會（2008）。精神科急性病房超長住院之爭議案利。醫療爭議審議報導，32，12-18。
吳肖琪（2010）。全國精神醫療資源需求調查－兼論未來發展策略。行政院衛生署委託科技研究計畫（編號： DOH98-TD-M-113-97004），未出版。
沈淑華（2007）。精神分裂症患者出院後一年內再住院之因素探討（未出版之碩士論文）。國立成功大學，臺南市。
林潔欣、陳正宗、王興耀、林世棋、陳明招、林清華（2008）。影響漢臺灣族精神分裂症病人再住院時間的因子。高雄醫誌，24（8），408-414。
胡海國（1997a）。全國一年中再住院精神分裂症患者之個人、家庭與病程之分析。當代醫學，24（5），435-438。
胡海國（1997b）。全國一年再住院精神分裂症患者之臨床與住院歷程分析。當代醫學，24（7），606-609。
胡海國（1997c）。全國精神分裂一年中住院患者再住院次數分析。當代醫學，24（1），68-74。
胡海國（1999）。精神分裂症：描述性精神病理。台北市：橘井文化。
胡海國（2002）。精神分裂症之社區流行病學。當代醫學29（9），717-727。
國家衛生研究院（2004）。全民健保精神疾病住院病患歸人檔。瀏覽日期：2011年11月5日。網址：http://w3.nhri.org.tw/nhird/file_talk/psy_document.pdf
國家衛生研究院（無日期）。全民健康保險研究資料庫-使用注意事項。瀏覽日期：2012年11月6日。網址：http://nhird.nhri.org.tw/talk_01_1.htm
張作貞、宋麗玉、吳秀蘭（2010）。影響台灣精神疾病患者未持續或中斷就醫之風險因素探討：以精神分裂症及情感性精神病爲例。醫護科技期刊，12（4），265-279。
張銀波、代光智（2012）成都市社區精神分裂症患者再入院的相關因素。上海精神醫學，24（1），34-41。
黃宗正、劉智民、劉震鐘、謝明憲、簡意玲、胡海國（2011）。精神分裂症的臨床與精神病理。臺灣醫學，15（4），365-374。
黃鼎鈞（2004）。臺灣精神疾病跨區住院比例的變遷－1997與2001（未出版之碩士論文）。亞洲大學，臺中市。
楊逸鴻、葉英堃、胡海國（2012）。社區中精神分裂症、雙極性疾患、憂鬱症在臺灣與其他國家的盛行率。臺灣精神醫學，26（2），77-87。
葉玲玲、藍忠孚、鄭若瑟（2003）。台灣精神分裂症患者精神醫療利用與費用之分析探討。臺灣公共衛生雜誌，22（3），194-203。
劉介宇、洪永泰、陳怡如、劉季鑫、莊義利、翁文舜、梁賡義（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，4（1），1-22。
鄭茉莉（主編）（1999）。ICD-9-CM分類規則彙編。臺北市：病歷管理協會。
謝佳容、蕭淑貞（2006）。台灣社區精神復健機構的服務現況與展望。精神衛生護理雜誌,，1（2），41-50。
簡以嘉（2004）。台灣全民健保精神疾病盛行率、醫療利用及費用分析研究（未出版之博士論文）。國立陽明大學，臺北市。

英文部分
Addington, D. E., Beck, C., Wang, J., Adams, B., Pryce, C., Zhu, H., et al. (2010). Predictors of admission in first-episode psychosis: developing a risk adjustment model for service comparisons. Psychiatric Services, 61(5), 483-488.
Almond, S., Knapp, M., Francois, C., Toumi, M., & Brugha, T. (2004). Relapse in schizophrenia: costs, clinical outcomes and quality of life. The British Journal Of Psychiatry: The Journal Of Mental Science, 184, 346-351.
an der Heiden, W., & Häfner, H. (2000). The epidemiology of onset and course of schizophrenia. European Archives of Psychiatry & Clinical Neuroscience, 250(6), 292.
Ascher-Svanum, H., Baojin, Z., Faries, D. E., Salkever, D., Slade, E. P., Xiaomei, P., et al. (2010). The cost of relapse and the predictors of relapse in the treatment of schizophrenia. BMC Psychiatry, 10, 1-7.
Centers for Disease Control and Prevention(2012). Classification of Diseases, Functioning, and Disability . Retrieved November 6, 2012, from: http://www.cdc.gov/nchs/icd.htm
Chabungbam, G., Avasthi, A., & Sharan, P. (2007). Sociodemographic and clinical factors associated with relapse in schizophrenia. Psychiatry And Clinical Neurosciences, 61(6), 587-593.
Chien, I. C., Chou, Y. J., Lin, C. H., Bih, S. H., Chou, P., & Chang, H. J. (2004). Prevalence and incidence of schizophrenia among national health insurance enrollees in Taiwan, 1996–2001. Psychiatry & Clinical Neurosciences, 58(6), 611-618.
Csernansky, J. G., & Schuchart, E. K. (2002). Relapse and rehospitalisation rates in patients with schizophrenia: effects of second generation antipsychotics. CNS Drugs, 16(7), 473-484.
Gbiri, C. A., Badru, F. A., Ladapo, H. T. O., & Gbiri, A. A. (2011). Socio-economic correlates of relapsed patients admitted in a Nigerian mental health institution. International Journal Of Psychiatry In Clinical Practice, 15(1), 19-26.
Grinshpoon, A., Abramowitz, M. Z., Lerner, Y., & Zilber, N. (2007). Re-hospitalization of first-in-life admitted schizophrenic patients before and after rehabilitation legislation: a comparison of two national cohorts. Social Psychiatry And Psychiatric Epidemiology, 42(5), 355-359.
Killaspy, H. (2006). From the asylum to community care: learning from experience. British Medical Bulletin, 79-80, 245-258.
Lin, C. H., Chen, W. L., Lin, C. M., Lee, M. D., Ko, M. C., & Li, C. Y. (2010). Predictors of psychiatric readmissions in the short- and long-term: a population-based study in Taiwan. Clinics (São Paulo, Brazil), 65(5), 481-489.
Lin, H. C., Tian, W. H., Chen, C. S., Liu, T. C., Tsai, S. Y., & Lee, H. C.(2006). The association between readmission rates and length of stay for schizophrenia: A 3-year population-based study. Schizophrenia Research, 83(2-3), 211-214.
Marom, S., Munitz, H., Jones, P. B., Weizman, A., & Hermesh, H. (2005). Expressed emotion: relevance to rehospitalization in schizophrenia over 7 years. Schizophrenia Bulletin, 31(3), 751-758.
McGrath, J., Saha, S., Chant, D., & Welham, J. (2008). Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiologic Reviews, 30, 67-76.
Morken, G., Widen, J. H., & Grawe, R. W. (2008). Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC Psychiatry, 8, 1-7.
Niehaus, D. J. H., Koen, L., Galal, U., Dhansay, K., Oosthuizen, P. P., Emsley, R. A., et al. (2008). Crisis discharges and readmission risk in acute psychiatric male inpatients. BMC Psychiatry, 8, 44-44.
Prince, J. D., Akincigil, A., Kalay, E., Walkup, J. T., Hoover, D. R., Lucas, J., et al. (2008). Psychiatric rehospitalization among elderly persons in the United States. Psychiatric Services,59(9), 1038-1045.
Schmidt-Kraepelin, C., Janssen, B., & Gaebel, W. (2009). Prevention of rehospitalization in schizophrenia: results of an integrated care project in Germany. European Archives of Psychiatry & Clinical Neuroscience, 259, 205-212.
Uçok, A., Polat, A., Cakir, S., & Genç, A. (2006). One year outcome in first episode schizophrenia. Predictors of relapse. European Archives Of Psychiatry And Clinical Neuroscience, 256(1), 37-43.
World Health Organization (1997). Gender differences in the epidemiology of affective disorders and schizophrenia. Retrieved from http://www.who.int/mental_health/publications/gender_schizophrenia/en/
World Health Organization (2012a). Mental health: Schizophrenia. Retrieved November 1, 2012, from: http://www.who.int/mental_health/management/schizophrenia/en/
World Health Organization (2012b). Health topics: Schizophrenia. Retrieved November 1, 2012, from: http://www.who.int/topics/schizophrenia/en/
Yoshimasu, K., Kiyohara, C., & Ohkuma, K. (2002). Efficacy of day care treatment against readmission in patients with schizophrenia: A comparison between out-patients with and without day care treatment. Psychiatry And Clinical Neurosciences, 56(4), 397-401.