臺灣博碩士論文加值系統

研究目的
全人工關節置換手術在治療嚴重關節炎的療效深獲肯定，因此被醫學界普遍公認是最具成本效益的介入治療，隨著醫療費用不斷上漲，在論病例計酬的制度下，如何兼顧醫療品質並節省醫療資源利用對臨床照護、醫院管理和保險償付更是一大課題。本研究目的在於瞭解台灣地區中兩家醫學中心施行全人工關節置換術(THR和TKR)之醫療處置行為與術後療效及資源利用情形並探討其影響因素。
方法與材料
採回溯性病歷審查方式，選擇台灣地區兩家醫學中心施行全人工髖及膝關節置換術的全部醫師作為研究醫師，以ICD-9-CM中之主手術碼為81.51(髖)及81.54(膝)，排除符合同次住院施行雙側、骨折、先前手術的併發症、骨癌、病理性骨折、感染、血友病條件後，分別為716名及1,498名接受初次全人工髖及膝關節置換的病患。資料來源包括該樣本醫院之病歷資料及住院費用申報資料檔，收集病患當次住院之病歷資料，包含病患人口學、疾病特質、醫療處置等過程指標和醫療結果療效與住院日數、醫療費用等項目，本研究係採結構式問卷作為病歷審查的工具。
研究結果
接受全人工髖關節(THR)與全人工膝關節(TKR)置換術的病患特質有些微差異。THR病患年齡明顯較低於TKR，其中THR平均年齡為55歲左右，男女分佈接近；而TKR平均年齡近70歲，女性明顯多於男性；在疾病特質變項上，BMI指數相近，入院主要診斷及致病期在兩家醫院接受處置的病患則略有差異。而專科醫師執業年數皆在12年左右無明顯不同，兩處置年度手術個案的差異，膝關節近乎是髖關節置換的兩倍。
THR與TKR的醫療處置行為在兩家醫院皆達到顯著差異， B醫院在過程面特質為選擇全身麻醉、手術時間較長，選擇一種抗生素、有復健照會及導尿管、引流管、靜脈點滴留置天數及術後第一次下床行走日數皆較晚於A醫院。在療效指標上，B醫院接受TKR併發症發生率較高，在THR中兩家醫院則無明顯差異；不論THR或TKR其再住院率和再手術率在兩家醫院沒有顯著差異，但術後因關節問題回診率則是A醫院明顯高於B醫院。
在醫療資源利用上，兩家醫院不論在THR或TKR的住院日數或醫療費用皆是B醫院明顯多於A醫院，其中THR平均住院日數A、B醫院分別為6.4天及8.3天；TKR平均住院日數分別為5.9天及8.9天，兩家醫院相差近3天，費用的差距B醫院在兩處置上皆多於A醫院約9,000元，各細項費用中除了THR在手術費和特殊材料費未達兩家醫院差異外，其餘各細項費用包含TKR在內皆達顯著差異，兩家醫院細項費用略有高低，而出院後至復健科治療的比例則以A醫院較高。
影響THR和TKR的療效中不良事件發生的影響因素各有不同，其病患的婚姻狀況為共同影響因素。另在影響住院日數長短上亦有所差異，THR和TKR共同因素為婚姻狀況、醫院別、術後輸血、靜脈點滴留置與第一次下床行走日數為影響住院日數之因子；另影響總醫療費用高低的因素上，手術年度別、麻醉術式、術後輸血、抗生素注射天數、第一次下床行走日數及住院期間復健照會等項在THR和TKR中是重要影響因子，隨著年度的增加醫療費用有下降趨勢。
結論
兩家醫院施行THR和TKR醫療處置行為及醫療資源利用存有差異性，而療效指標除了THR在出院後九十天內因關節問題回診及TKR住院期間併發症達到顯著差異外，術後療效在兩家醫院是無差異的，但住院日數與醫療費用上就有明顯不同，B醫院較A醫院其醫療資源耗用較多，建議B醫院可參考同儕醫院持續修訂臨床路徑表和選擇符合世界趨勢的照護，如抗生素注射天數，方能達到兼顧醫療品質並節省資源耗用的目標。

關鍵詞
全人工髖關節置換術、全人工膝關節置換術、醫療處置、療效、資源利用

Purpose
Total joint replacement in treating serious osteoarthritis patients in clinical outcome is good by known intervene treatment of cost-effectiveness. Under increasing medical expenditure, Clinical care, hospital management and insurance reimbursement should pay more attention on both quality of care and hospital resource saving in a prospective payment system. Therefore, the major purpose of this study was to understand the conditions in medical practical procedures, outcomes and hospital resource utilization between two medical centers in Taiwan.
Method and material
A retrospective study design was conducted by using chart reviews to choose patients who received unilateral primary total hip and knee replacement (International Classification of Diseases, Ninth Revision, Clinical Modification procedure code of 81.51 and 81.54) in two medical centers between 2001 and 2004. Patients were excluded from the study if they had had a bilateral in the same admission, fractures, previous arthroplasty surgery complication, bone cancer, pathological fractures, infection and hemophiliac. A total of 716 THR and 1,498 TKR subjects were eligible for the study among two medical centers. Data sources included medical charts and in-hospital claim files. Collect the patient in-hospital charts includes demographics, clinical characteristics, medical practical procedures of process indicators and medical outcomes, length of stay and medical charges. This study used structural formula questionnaire to take investigative means.
Result
The demographics between total hip and knee replacement patients revealed little difference. The age of THR patients was lower with comparison of TKR, and THR patient average age was fifty-five, with no difference in gender; in contrast, TKR was seventy years, and the female is higher than male gender. Clinical characteristics body mass index showed not difference. Admission diagnosis and disease duration had little difference. Specific physician practice was twelve years and was no difference in two medical centers. Acceptable surgery cases in a TKR doubled than in a THR.
THR and TKR medical practical procedures had a significant difference in two medical centers. B hospital practical procedures were general anesthesia, longer operation times, re-habilitation consultation during admission and antibiotic, catheter, drainage and intravenous drip stay days were longer in comparison with A hospital. Outcomes aspect, only TKR complication rates in B hospital were higher. Re-admission and re-operation rates in two hospitals didn’t show significant difference. Then, post-operation patients for joint question returned outpatient treatment rates were higher in A hospital than in B hospital.
In hospital resource utilization, length of stay and total hospital charges were significant higher in B hospital than in A hospital. In THR average length of stay was 6.4 days and 8.3 days in A and B hospital, respectively. In TKR were 5.9 days and 8.9 days, with gap of three days. Charges difference in B hospital is NT. 9,000 dollars higher than A hospital. The THR detailed charges beside for surgery fees and medical supply fees were not different, else detailed charges include TKR were significant differences. Two hospitals the detailed charges were difference, and discharge to rehabilitation clinical was higher in A hospital.
Adverse outcomes effective factors in THR and TKR were different. The marital status was common effective factor. Additional length of stay effective factors in THR and TKR were not consistent. THR and TKR common effective factors were martial status, hospital differences, post-operative blood transfusion, intravenous drip stay days and first get up walk days were the factors of length of stay. Then, total hospital charges effective factors were operation years, anesthesia type, post-operation blood transfusion, antibiotic injection days, first get up walk days and in-hospital rehabilitation consultation were THR and TKR important factor. Following years total hospital charges had descend.
Conclusion
The medical practical procedures and medical resources utilization in two medical centers were different between THR and TKR. Adverse outcomes besides for the THR discharge ninety days for joint question returned to OPD and the TKR in-hospital complications were significantly different. Medical adverse outcomes in two hospitals were not different. But length of stay and total hospital charge revealed statistically different. B hospital resource utilization was higher than A hospital. We suggested B hospital to revise the clinical pathways, such as antibiotic injection days, in order to achieve the object quality of care and to reduce resource utilization as well.
Key words
Total Hip Replacement, Total Knee Replacement, Medical Practical Procedures, Medical Resource Utilization

中文摘要 Ⅰ
英文摘要 Ⅲ
致謝 Ⅴ
總目錄 Ⅵ
表目錄 Ⅷ
圖目錄 Ⅸ
附錄 Ⅹ
第一章 緒論
第一節 背景與動機 1
第二節 研究目的 3
第三節 研究重要性與預期貢獻 4
第四節 名詞解釋 5
第二章 文獻探討
第一節 全人工髖及膝關節置換術之相關論述 7
第二節 全人工關節置換術醫療處置之情形 14
第三節 全人工關節置換術的療效及其影響因素之探討 17
第四節 全人工關節置換術的醫療資源利用及其影響因素之探討42
第三章 研究方法
第一節 研究架構與研究假說 57
第二節 研究設計與研究樣本 59
第三節 研究材料 61
第四節 研究變項 62
第五節 統計分析 66
第四章 研究結果
第一節 全人工關節置換術之基本特質 67
第二節 全人工關節置換術之醫療處置行為 73
第三節 全人工關節置換術之療效及其影響因素 77
第四節 全人工關節置換術之醫療資源利用及其影響因素 85
第五章 討論與建議
第一節 討論 100
第二節 研究限制 115
第二節 未來研究方向 116
第三節 建議 117
參考文獻
　　英文文獻 118
　　中文文獻 122

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15.簡麗年、吳肖琪(2003)。論病例計酬實施前後全股(髖)關節置換術病患出院後30日內的再住院情形。台灣衛誌，22(1)，69-78。
16.黃俊雄、王國照、邱亨嘉、馬漢明、張瑞根(2006)。全人工關節置換療效與醫療資源利用之探討：兩家醫學中心之比較。馬偕紀念醫院專題研究計劃(計劃編號：MMH-KMU-07)，未出版。
碩士論文
1.吳欣芳(2003)。本土及國外全人工髖關節置換術臨床路徑之比較及其對醫療資源利用與療效之影響。高雄醫學大學公共衛生學研究所碩士論文，未出版，高雄市。
2.張佳琪(1999)。論病例計酬支付制度對骨科住院醫療利用情形之影響分析：以全髖關節置換手術及全膝關節置換手術為例。國立陽明大學衛生福利研究所碩士論文，未出版，台北市。
3.許幼青(2001)。不同臨床路徑對醫療資源利用及品質之影響：以全人工髖關節置換術為例。高雄醫學大學公共衛生學研究所碩士論文，未出版，高雄市。
4.陳蘭蕙(2004)。國外臨床路徑對本土醫療資源利用與療效之影響：以某醫學中心全人工膝關節置換術為例。高雄醫學大學醫務管理在職專班碩士論文，未出版，高雄市。
5.鄭滿蕙(1999)。實施臨床路徑之影響評估：以某醫學中心人工全膝關節置換術為例。國立台灣大學碩士論文，未出版，台北市。
6.簡麗年(2002)。論病例計酬實施前後全股(髖)關節置換術醫療品質之探討。國立陽明大學衛生福利研究所碩士論文，未出版，台北市。

電子資料
1.中央健康保險局(2000)。人工股(髖)關節置換術實施論病例計酬制度後的病人醫療利用與醫療費用申報。http://www.nhi.gov.tw/information/news_detail.asp?menu=1&menu_id=&News_ID=164.
2.中央健康保險局(2005)。人工關節置換抗生素使用日數。全民健康保險專業檔案分析報告，http://www.nhi.gov.twinformation ulletin_file.
3.中央健康保險局(2005)。論病例計酬診療項目。全民健康保險醫療費用支付標準，http://www.nhi.gov.tw/information/bulletin_file/667_W0940029272-A3.doc.
4.內政部(2005)。主要國家六十五歲以上人口占總人口率。內政國際指標，http://www.moi.gov.tw/stat/

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