臺灣博碩士論文加值系統

研究背景：台灣腦中風發生率為每十萬中30.3人，其中約70%為缺血性中風，約30%為出血性中風，缺血性中風約15-26%病人入住加護病房，一年內死亡則高達40%。
目的：探討不同類型的腦中風病人之死亡率、加護病房住院天數的影響相關因素，同時比較加護病房住院天數與長短期死亡率的相關性。
方法：採用衛生福利部資料科學中心的2005-2016年之「兩百萬人抽樣檔」，以全民健康保險申報資料進行分析，本研究住院主診斷為腦中風且入住加護病房之病人為研究對象，共8,634位病人納入分析。本研究採用Kaplan-Meier分析不同類型的腦中風病人在加護病房、住院期間及出院後一年內存活情形；以廣義估計式(Generalized estimating equations, GEE)分析病人其加護病房、住院期間死亡之影響因素，以及Cox Proportional Hazard Regression分析病人出院後一年內死亡之相關因素。
結果：腦中風病人短期死亡因素皆受年齡、住院期間使用呼吸器、重度中風影響，但缺血性中風病人有心房顫動病史住院期間死亡風險較低(OR:0.74；95% CI: 0.60-0.93)，而出血性中風病人就醫層級為醫學中心(OR:0.45；95% CI: 0.30-0.69)及區域醫院就醫(OR:0.66；95% CI: 0.50-0.87)住院期間死亡風險較低。
腦中風病人出院後一年死亡因素皆受到年齡、共病症、復健及醫院所在低都市化地區影響，但缺血性中風病人住院期間使用rt-PA(HR:0.32；95% CI: 0.14-0.72)出院後一年內死亡風險較低。
結論：腦中風病人短期死亡受到中風嚴重度影響較大，以出血性中風死亡率較高，但當住院天數超過80天則以缺血性中風較高，其中出血性中風病人地區醫院就醫影響顯著，而缺血性中風病人則受到心房顫動病史死亡風險反而較低；腦中風病人長期死亡皆受到年齡、共病症及復健影響較大，另外兩種中風類型皆容易受到醫院所在都市化程度影響；加護病房住院天數受到年齡較大、共病症較多、重度中風、使用呼吸器、私立醫院、醫院所在市化程度的影響。

Background: The incidence rate of stroke in Taiwan was 30.3 pre 100,000 person. Among them, 70% patients were ischemic stroke (IS) and 30% patients were hemorrhagic stroke (HS). Other study showed that about 15-26% of IS patients are admitted to the intensive care unit (ICU) during hospitalization and 40% of them were died within 1-year after stroke.
Objectives: The aim of the study is to investigate the impact factors of ICU length of stay and the mortality of ischemic or hemorrhagic stroke patients, and to estimate the influence of ICU length of stay toward the long-term and short-term mortality of stroke patients.
Methods: Date was obtained from the longitudinal National Health Insurance Research Database (LHID) during 2005-2016. Stroke patients were identified by the primary diagnosis at admission and those who admitted to the ICU. Total 8,634 patients were included in the analysis. The Kaplan-Meier method was used to estimate the ICU mortality, in-hospital mortality and 1-year mortality after stroke discharge. We used generalized estimating equation (GEE) to estimate the impact factors of ICU mortality and in-hospital mortality. The Cox proportion hazard regression was used to estimate the impact factors of 1-year mortality after stroke discharge.
Results: Stroke patients’ age, using mechanical ventilation(MV) during hospitalization and sever severity have significantly higher risk of short-term mortality.IS patient who had history atrial fibrillation(OR:0.74；95% CI: 0.60-0.93) had significantly lower risk of in-hospital mortality and HS patients admitted in medical center(OR:0.45；95% CI: 0.30-0.69) and regional hospital(OR:0.66；95% CI: 0.50-0.87) had significantly lower risk of in-hospital mortality. Stroke patients’ age, comorbidity, received rehabilitation and admitting in lower urbanization area had significantly impact of 1 year mortality after stroke discharge. IS patients used rt-PA during hospitalization (HR:0.32；95% CI: 0.14-0.72) had significantly lower risk of 1- year mortality after stroke discharge.
Conclusions: The severity of stroke has significant impact on short-term mortality of stroke patients. HS patients have higher mortality than IS patients; however, the mortality of IS patients would be higher than HS patients after 80 days of hospitalization. Patient’s age, CCI score, received rehabilitation and admitting in lower urbanization area have significant impact on the long-term mortality of stroke patients. Elderly, with comorbidities, sever severity, using MV during hospitalization , admitted in private or local hospital would have longer ICU length of stay.

目錄
致謝 II
中文摘要 III
Abstract V
目錄 VII
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 3
第二章 文獻探討 4
第一節 腦中風流行病學 4
第二節 腦中風病人的短期及長期死亡之相關因素 6
第三節 加護病房病人死亡相關因素 14
第四節 小結 23
第三章 研究設計與方法 24
第一節 研究架構與假說 24
第二節 資料來源與研究對象 27
第三節 研究變項與操作型定義 30
第四節 統計分析 36
第四章 研究結果 37
第一節 腦中風病人特質分布 37
第二節 腦中風病人死亡情形之雙變量分析 42
第三節 加護病房死亡多變量分析 62
第四節 住院期間死亡多變量分析 68
第五節 出院後一年內死亡情形之存活分析 74
第六節 加護病房住院天數之影響因素 81
第五章 討論 85
第一節 加護病房死亡情形 85
第二節 住院期間死亡 87
第三節 出院後一年內死亡情形 90
第四節 加護病房住院天數影響因素 93
第五節 研究限制 95
第六章 結論與建議 96
第一節 結論 96
第二節 建議 98


表目錄
表2-1：影響中風病人死亡因素相關研究彙整……………………………………. 10
表2-2：中風病人死亡相關研究彙整……………………………………………….. 12
表2-3：影響加護病房死亡因素相關研究…………………………………….. 19
表2-4：加護病房病人死亡相關研究彙整………………………………...…...…...21
表3：研究變項定義…………………………………………......................................35
表4：腦中風病人特質之分布情形…………………………......................................40
表5-1：不同中風類型加護病房死亡之卡方檢定………….......................................45
表5-2：不同中風類型住院期間死亡之卡方檢定………….......................................51
表5-3：不同中風類型出院後一年內死亡之卡方檢定…….......................................58
表6-1：不同中風類型住院病人加護病房死亡之GEE分析.....................................66
表6-2：不同中風類型住院病人住院期間死亡之GEE 分析....................................72
表7-1：不同中風類型病人出院後一年內死亡之存活分析.......................................79
表8：不同中風類型病人加護病房住院天數複線性迴歸..........................................83

圖目錄
圖1：研究架構ㄧ……………………………………………………………………25
圖2：研究架構二……………………………………………………………………26
圖3：選樣流程圖……………………………………………………………………29
圖4：缺血性中風及出血性中風加護病房住院期間存活曲線圖.………………...65
圖5：缺血性中風及出血性中風住院期間存活曲線圖.................………………...71
圖6：缺血性中風及出血性中風出院後一年內存活曲線圖.........………………...74

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