臺灣博碩士論文加值系統

摘要
研究背景及目的：全民健保支付制度由論量計酬逐漸轉變為前瞻性支付制度，以節制費用並維持適當的品質，對醫院管理者造成莫大的衝擊；在總額預算即將實施的時刻，以實證研究找出影響住院日的相關因素，作為醫療管理的方向甚為重要。本研究旨在探討急性期梗塞性腦中風病人之住院日，及影響住院日之因素，為發展臨床路徑之前驅研究。
研究方法：本研究為前瞻性設計，以南台灣某醫學中心神經內科病房，自民國87年8月至90年7月三年間實施出院準備服務之915位個案為對象。病人住院期間，由個案管理者以自行發展之「出院準備服務個案評估單」，收集住院過程可能影響住院日之「醫療因素」及「非醫療因素」，包括生理、心理、社會等層面之資料，及所提供的服務為自變項。
結果：按解剖學分類，梗塞性腦中風可分為前腦循環系統、後腦循環系統、及小洞梗塞三類，前腦循環系統梗塞之平均住院日為11.0±6.5日(N=449)，影響住院日之因素有病情不穩、併發症、ADL較差、醫師因素、等待床位或檢查、決定是否轉長期照護機構、住院中缺乏照顧人力七個變項，可解釋54%之變異量；後腦循環系統梗塞之平均住院日為13.6±8.7日 (N=375) ，影響住院日之因素有病情不穩、併發症、ADL較差、由加護病房轉入四個變項，可解釋39%之變異量；小洞梗塞之平均住院日為10.4±4.9日 (N=91) ，影響住院日之因素有病情不穩、併發症、ADL較差、由加護病房轉入、教育程度、社服需求、決定是否轉長期照護機構七個變項，可解釋59%之變異量。
結論：本研究結果為發展梗塞性腦中風臨床路徑分類，及其住院日之重要依據；並可提供醫療機構規劃腦中風病房之規模的決策依據，諸如：病床週轉率、神經科與復健科病床數之比例、相關專業人員之編配、後續照護機構之建構、及照護模式等。

Abstract
Background and purpose：The purposes of this study were to analyze the length of stay (LOS) among the cerebral infarct patients and the factors affecting LOS. Methods：This research prospectively studied cerebral infarct patients admitted to the neurological ward in a medical center from 1st August 1998 to 31 July 2001. Under the discharge-planning program, the case manager went through the medical and non-medical factors affecting LOS. The services to meet the patient’s needs were also delivered and evaluated.
Results：According to the anatomy，915 cerebral infarct patients were divided into three groups：1).449 were anterior cerebral infarction with an average length of stay (ALOS) of 11.0±6.5days. Seven variables explained 54% of variance of the model. Medical factors affecting LOS were unstable condition, complication, and poorer activities of daily living (ADL). Non-medical factors were waiting for consultation, waiting for rehabilitate bed, deciding transfer to long-term care facilities (LTC), and the problem of caregiver. 2).375 were posterior cerebral infarction with ALOS of 13.6±8.7days. Four variables explained 39% of variance of the model. Medical factors affecting LOS were unstable condition, complication, from intensive care unit, and poorer ADL. 3).91 were lacunars infarction with ALOS of 10.4±4.9days.Seven variables explained 59% of variance of the model. Medical factors affecting LOS were unstable condition, complication, from intensive care unit, and poorer ADL. Non-medical factors were lower education level, social service needs, and deciding transfer to LTC.
Conclusions：The results of study offer the evidences and information：1).To create the clinical pathway of cerebral infarction；2).To design a stroke unit such as scale, care model, and professional man power et al.

致謝 I
目錄 II
表目錄 IV
圖目錄 V
中文摘要 VI
英文摘要 VII
第一章 緒論
第一節 研究背景與動機 1
第二節 重要性與預期成效 3
第三節 研究目的 5
第四節 名詞解釋 6
第五節 各章節之安排 7
第二章 文獻查證
第一節 腦中風及其分類 8
第二節 腦中風病人的住院日數 11
第三節 影響腦中風病人住院日數的因素 13
第四節 有效降低住院日數之實證研究 18
第五節 本章摘要 21
第三章 材料與方法
第一節 研究架構與設計 33
第二節 研究假設 35
第三節 研究樣本與資料收集 36
第四節 研究工具 37
第五節 測量變項 38
第六節 資料處理與統計方法 40
第四章 研究結果
第一節 描述性統計 41
第二節 研究工具之信度與效度 44
第三節 住院日數 45
第四節 影響住院日數之因素 46
第五節 本章摘要 48
第五章 討論與結論
第一節 梗塞性腦中風病人之住院日數 56
第二節 醫療因素對後腦循環系統梗塞病人住院日之影響 61
第三節 非醫療因素對後腦循環系統梗塞病人住院日之影響 64
第四節 結論 69
第五節 建議 71
第六節 研究限制與未來研究方向 73
參考文獻
中文參考文獻 74
英文參考文獻 75
附錄 出院準備服務個案評估單 79
表目錄
表2-1 腦中風病人住院日數相關研究 26
表2-2 影響腦中風病人住院日數之醫療因素的相關研究 28
表2-3 影響腦中風病人住院日數之非醫療因素的相關研究 30
表2-4 縮短住院日數之相關研究 32
表4-1 主要診斷 50
表4-2 主要與次要診斷 51
表4-3 描述性統計 52
表4-4 不同年度、不同梗塞部位腦中風病人住院日CV值比較 53
表4-5 不同部位梗塞性腦中風病人住院日之變異分析 53
表4-6 前腦循環梗塞病人住院日之複迴歸分析 54
表4-7 後腦循環梗塞病人住院日之複迴歸分析 55
表4-8 小洞梗塞病人住院日之複迴歸分析 56
表4-9 研究假設之驗證摘要 57
圖目錄
圖3-1 梗塞性腦中風病人住院日影響因素之概念架構 34

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