臺灣博碩士論文加值系統

研究目的：在論病例計酬的冠狀動脈繞道手術中，爲了監測評估心臟血流動力之功能，常採用的侵襲性血液動力學衛材分別為中央靜脈導管、肺動脈導管、光纖肺動脈導管。本研究擬探討選擇不同衛材的依據並進行臨床效果分析。
研究方法：本研究為體外循環冠狀動脈繞道手術病例調查研究，總計收集某區域教學醫院從民國89年至92年共110例之病歷記錄與健保申報資料，以及自民國87年至91年全民健康保險研究資料庫，使用SAS統計分析，比較不同衛材之患者其總住院費用、總住院天數、加護病房天數、住院死亡率及14天內再住院率。
研究結果：1.顯示三種不同血液動力學衛材在不同病患特質間之使用，無明顯相關。 2.某區域醫院放置中央靜脈導管組的病患及病患在術前有急性心肌梗塞者，確實會有較高的住院死亡風險（odds ratio分別為4.66，9.38）。3.全國年份的變化可看到肺動脈導管由1998年68.89%一路下滑至2002年的32.79%，取而帶之的卻是由中央靜脈導管及光纖肺動脈導管兩者平分（30.60% and 36.61%）。區域醫院的中央靜脈導管與肺動脈導管的住院死亡率分別為6.25%及3.57%，比醫學中心低；公立醫院的光纖肺動脈導管死亡率為3.08%，比起肺動脈導管的12.62%及中央靜脈導管的20.37%明顯的少很多（p=0.013）；財團法人醫院暨私立醫院在中央靜脈導管這組的死亡率最低，只有5.45%，光纖肺動脈導管最高有17.95%，三者的差異是有明顯差別（p=0.0179）。
結論： 由本研究資料顯示，三種血液動力學衛材皆可運用在冠狀動脈繞道手術，其選擇是由麻醉醫師和心臟血管外科醫師的專業能力及醫院整體作業環境來做決定。財團法人暨私立醫院在中央靜脈導管組的住院死亡率低，總住院費用也低，在論病例計酬下是一個好的成本效果；相對的全國公立醫院及某區域醫院在中央靜脈導管組有較高的住院死亡率，應做討論。

OBJECTIVES: The purpose of this study is to analyze the usage of three invasive hemodynamic monitoring devices in patients receiving coronary artery bypass graft (CABG), to understand the decision-making and clinical outcome in choosing among Central Venous Pressure catheter（CVP）, Pulmonary Artery Catheter（PAC）, and Fiberoptic Pulmonary Artery Catheter.
METHODS: Records of 116 CAD patients who received CABG in a regional teaching hospital from Jan. 2000 to Dec 2003, and records of 662 CABG cases from sampling of National Health Insurance Research Database were retrieved. Variables such as the demographic data, disease severity, co-morbidity, hemodynamic monitoring devices, medical cost and length of stay in each admission, length of stay in Intensive Care Unit (ICU), mortality rate during admission, and readmission rate within 14 days were analyzed.
RESULTS: In the regional hospital no significant correlation of patients attributes to the choice of monitoring device was noted, the odds ratio of death in admission were higher among patients on CVP (4.66) or with preoperative acute myocardial infarction events (9.38 ). There was a down hill trend of usage of PAC with surge in usage of both CVP and fiberoptic PAC. The private hospital perform good clinical outcome in CVP group with lower mortality and low total hospital fee in case payment CABG.
CONCLUSION: The usage of three invasive hemodynamic monitoring devices in CABG surgery is safe. It is up to the professional training background and personal preference of the anesthesiologists and cardiac surgeons. This study indicates that the regional hospital and public hospital should restrain from usage of CVP for hemodynamic monitoring in CABG till there is new evidence available to make change.

目 錄

論文授權書
論文合格通過證明
致謝 i
目錄 ii
表目錄 iv
圖目錄 vi
中文摘要 vii
英文摘要 viii
第一章 緒論 1
第一節 研究背景和動機 1
第二節 研究目的 3
第三節 預期貢獻 4
第四節 名詞解釋 6
第二章 文獻探討 9
第一節 冠狀動脈血管疾病及冠狀動脈繞道之特性及給付 9
第二節 血液動力學監視器衛材之選擇 14
第三節 臨床效率與臨床效果質評估指標 17
第四節 增加冠狀動脈繞道手術死亡率之相關因素 19
第三章 研究方法 23
第一節 研究架構和研究假說 23
第二節 研究設計和研究樣本 25
第三節 研究變項 29
第四節 統計分析方法 33
第四章 研究結果 34
第一節 某區域醫院冠狀動脈繞道手術使用三種不同侵襲性血液動力學衛材的結果 34
第二節 某區域醫院不同因素對臨床效率與臨床效果的影響 38
第三節 全國冠狀動脈繞道手術使用三種不同侵襲性血液動力學衛材的結果 40
第四節 不同特性的醫院使用三種不同侵襲性血液動力學衛材之臨床效率和效果 43
第五章 討論與建議 65
第一節 某區域醫院與全國冠狀動脈繞道手術基本特質與疾病特質之討論 65
第二節 某區域醫院影響冠狀動脈繞道手術臨床醫療品質重要因子之討論 66
第三節 不同特性的醫院使用三種不同侵襲性血液動力學衛材之臨床效率和效果之討論 70
第四節 研究限制及未來研究方向 72
第五節 結論和建議 73
附錄2-1 全民健保對冠狀動脈繞道手術給付情形 74
附錄2-2 冠狀動脈繞道手術（住院）診療項目要求表 75
附錄2-3 冠狀動脈繞道手術論病例計酬項目之「得核實申報上限額」、「得核實申報個案數比例實」 77

參考文獻 78
縮寫名詞 84


表 目 錄
表2-1 三種侵襲性血液動力學衛材的特性 21
表3-1 冠狀動脈繞道手術健保手術代碼 26
表3-2 病患特質ICD code 9-CM 27
表3-3 研究變項列表 31
表4-1-1 某區域醫院冠狀動脈繞道手術基本資料表 45
表4-1-2 某區域醫院冠狀動脈繞道手術之侵襲性血液動力學衛材在不同病患特質之分佈 46
表4-1-3 某區域醫院冠狀動脈繞道手術調整前後三種侵襲性血液動力學衛材之總住院費用、總住院天數、及加護病房天數之比較 47
表4-1-4 某區域醫院冠狀動脈繞道手術調整前後性別族群之總住費用、總住院天數、及加護病房天數之比較 48
表4-1-5 某區域醫院冠狀動脈繞道手術調整前後年齡族群之總住院
費用、總住院天數、及加護病房天數之比較 49
表4-2-1 某區域醫院侵襲性血液動力學衛材在住院死亡與十四天內再住院的比率 50
表4-2-2 某區域醫院冠狀動脈繞道手術之對數迴歸分析逐步選項不同變項對十四天內再住院發生率相對風險比 50
表4-2-3 某區域醫院冠狀動脈繞道手術之對數迴歸分析不同變項對住院死亡發生率相對風險比 51
表4-2-4 某區域醫院冠狀動脈繞道手術之對數迴歸分析逐步選項不同變項對住院死亡發生率相對風險比 52
表4-3-1 全國冠狀動脈繞道手術之基本資料 53
表4-3-2 冠狀動脈繞道手術在全國醫院分佈情形 54
表4-3-3 全國冠狀動脈繞道手術依不同年份使用侵襲性血液動力學衛材之比較 55
表4-3-4 侵襲性血液動力學衛材在全國冠狀動脈繞道手術病患人口學特質之分佈 57
表4-3-5 侵襲性血液動力學衛材在全國冠狀動脈繞道手術不同病患特質之分佈 58
表4-3-6 全國冠狀動脈繞道手術依人口學特質使用侵襲性血液動力學衛材之比較表 58
表4-3-7 全國冠狀動脈繞道手術依不同權屬別醫院使用侵襲性血液動力學衛材之比較 59
表4-3-8 全國冠狀動脈繞道手術依侵襲性血液動力學衛材之總住院費用、總住院天數 59
表4-3-9 全國冠狀動脈繞道手術依性別之總住院費用、總住院天數 60
表4-3-10 全國冠狀動脈繞道手術依年齡之總住院費用、總住院天數 60
表4-3-11 全國冠狀動脈繞道手術依醫院權屬別之總住院費用、總住院天數 61
表4-3-12 全國冠狀動脈繞道手術依醫院等級之總住院費用、總住院天數 61
表4-3-13 全國與某區域醫院冠狀動脈繞道手術依三種侵襲性血液動
力學衛材之總住院費用、總住院天數比較表 62
表4-4-1 全國使用侵襲性血液動力學衛材依權屬別醫院之住院死亡比率 63
表4-4-2 全國使用侵襲性血液動力學衛材依醫院等級之住院死亡比率 64


圖 目 錄
圖2-1 光纖肺動脈導管實際圖案 22
圖3-1 研究架構圖 24
圖4-1 冠狀動脈繞道手術在全國醫院分佈情形 54
圖4-2 侵襲性血液動力學衛材在全國不同年份百分比的變化 55
圖4-3 侵襲性血液動力學衛材在公立醫院不同年份百分比的變化 56
圖4-4 侵襲性血液動力學衛材在軍方醫院不同年份百分比的變化 56
圖4-5 侵襲性血液動力學衛材在財團法人暨私立醫院不同年份百分比的變化 57
圖4-6 住院死亡率在全國不同權屬別醫院分佈情形 64

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