臺灣博碩士論文加值系統

背景與目的：國內急診就醫人次逐年增加，造成大型醫院急診壅塞，延長病人於急診之滯留時間。國外研究指出，急診滯留時間長短可能與住院病人之照護費用及臨床結果相關，惟台灣尚缺乏此類研究。本研究探討急診滯留時間長短對住院醫療利用及死亡風險之影響。
方法：採回溯性設計，利用中部某醫學中心之臨床資料庫，擷取2012年至2016年急診且住院之病人共59,073人次(42,139人)為研究對象。使用廣義估計方程式(Generalized estimating equation, GEE)校調人次樣本屬性重覆之問題，以分析住院天數及住院費用之差異。以邏輯斯迴歸(Logistic regression)探討急診病人住院後之死亡風險。分析之其他相關因素包括人口學特質、檢傷級數、到院方式、共病、醫師年資及科別、來診時間。統計以SPSS 22.0進行分析。
結果：急診病人平均住院天數9.84天，平均住院費用77,370元，住院後死亡率12.3%。廣義估計方程式分析結果顯示，在控制其他變項後，住院天數隨著急診滯留時間增加而增加；相較於急診滯留時間≤2小時患者，滯留24-48小時之患者多2.27天住院天數(P<0.001)，滯留≥48小時之患者則多3.22天(P<0.001)。校正後邏輯斯迴歸分析結果顯示，相較於急診滯留時間≤2小時者，急診滯留時間24-48小時(OR=1.73, P<0.001)及≥48小時(OR=2.23, P<0.001)的病患皆呈現顯著較高死亡風險。
結論：急診滯留時間長短與住院天數及死亡風險皆相關。政府衛生單位及醫療機構宜參考本研究發現，持續以降低急診病人滯留超過24小時之比率為關鍵策略，以減少住院醫療資源的耗用，保障適時完善的緊急醫療供應，以提升急診處置效率及醫療品質。

Purpose: The number of emergency department visits in Taiwan has been increasing yearly, leading to overcrowding in the emergency departments (EDs) of large-scale hospitals and prolonging the length of stay (LOS) in ED. Previous studies have indicated that LOS in ED was related to the medical costs and clinical outcomes of inpatient care. However, such studies are still lacking in Taiwan. This study investigated the effects of length of stay in ED on inpatient utilization and mortality.
Method: This retrospective study used the clinical database of a medical center in central Taiwan. A total of 59,073 person-times (42,139 patients) with ED visit and subsequent hospitalization were identified. Generalized estimating equations (GEE) were used to adjust repeated characteristics of the study sample in analyzing the differences in length of hospital stay and inpatient costs. Logistic regression examined the mortality after admission to the hospital from the ED. Other analyzed factors included demographic characteristics, triage level, ED arrival mode, comorbidity, physician seniority, clinical department, and ED visit period. Statistics were analyzed with SPSS 22.0.
Results: The average length of hospital stay was 9.84 days. Inpatient costs averaged NT$77,370. The mortality after hospitalization was 12.3%. GEE analysis revealed that, after controlling for all other covariates, inpatient LOS increased with each increment of LOS in ED. Compared with LOS in ED ≤2 hours, patients with LOS in ED between 24-48 hours and ≥48 hours received 2.29 days and 3.24 days of inpatient LOS, respectively (P<0.001). Adjusted logistic regression results indicated that, compared with LOS in ED ≤2 hours, patients with LOS in ED for 24-48 hours (OR=1.73, P<0.001) and LOS in ED ≥48 hours (OR=2.23, P<0.001) were significantly associated with higher odds of mortality.
Conclusion: Length of stay in emergency department was closely related to inpatient length of stay and mortality. According to the study findings, health authorities and institutions should continue to use length of stay in emergency department less than 24 hours as a key performance indicator. Efforts should be made to reduce the ratio of length of stay in emergency department longer than 24 hours, in an attempt to ensure the timely provision of quality emergency care and improve the efficiency of emergency treatment and medical quality.

誌謝 i
摘要 ii
Abstract iv
目錄 vi
表目錄 ix
圖目錄 x
第一章、緒論 1
第一節 研究背景與動機 1
第二節 研究重要性 5
第三節 研究假設 5
第四節 研究目的 5
第二章、文獻探討 6
第一節 急診滯留時間的定義 6
第二節 急診滯留時間長短對住院醫療利用之影響 8
第三節 急診滯留時間長短與死亡風險之相關性 9
第四節 影響住院醫療利用及死亡風險之其他相關因素 11
第五節 文獻小結 17
第三章、研究方法 18
第一節 研究設計與架構 18
第二節 研究對象與資料來源 20
第三節 分析工具 21
第四節 研究變項操作型定義 21
第五節 分析方法 24
第四章、研究結果 25
第一節 研究樣本之描述性統計 25
第二節 共線性診斷 31
第三節 急診滯留時間長短對住院醫療利用之廣義估計方程式分析 32
第四節 急診滯留時間長短與死亡風險之邏輯斯迴歸分析 40
第伍章、討論 46
第一節 急診滯留時間長短與住院醫療利用相關之原因探討 46
第二節 急診滯留時間長短與死亡風險相關之原因探討 49
第三節 其他相關因素之影響 50
第陸章、結論與建議 54
第一節 結論 54
第二節 建議 56
第三節 研究限制 58
參考文獻 59

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