(3.238.249.17) 您好!臺灣時間:2021/04/13 19:12
字體大小: 字級放大   字級縮小   預設字形  
回查詢結果

詳目顯示:::

我願授權國圖
: 
twitterline
研究生:丁毅
研究生(外文):Yih Ting
論文名稱:非創傷性糖尿病足趾截肢健保費用分析
論文名稱(外文):Application of The National Health Insurance Research Database to Analyze The Diabetes- Related Non-traumatic Toe Amputee in Taiwan
指導教授:張耀中張耀中引用關係
學位類別:碩士
校院名稱:臺北醫學大學
系所名稱:傷害防治學研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2007
畢業學年度:95
語文別:中文
論文頁數:87
中文關鍵詞:非創傷性糖尿病截肢者足趾截肢再截肢
外文關鍵詞:non-traumatic diabetic related amputeetoe amputationreamputation.
相關次數:
  • 被引用被引用:7
  • 點閱點閱:565
  • 評分評分:系統版面圖檔系統版面圖檔系統版面圖檔系統版面圖檔系統版面圖檔
  • 下載下載:0
  • 收藏至我的研究室書目清單書目收藏:0
本研究希望藉由全民健康保險研究資料庫糖尿病特定主題檔,分析台灣地區民國九十年糖尿病非創傷性截肢者的總人數、申報健康保險局之住院費用;進而連續追蹤三年查看多少存活個案發生再截肢、存活個案申報健康保險局之門診與住院費用;探討影響糖尿病非創傷性截肢者發生再截肢、醫療利用之相關因素為何?
擷取住院申報檔ICD-9 -CM編碼同時有糖尿病編碼與手術編碼為下肢足趾截肢條件者,去除因外傷原因截肢,找出中華民國九十年糖尿病非創傷性截肢者為研究對象。以SAS 8.0版軟體進行統計。先經單變項分析如性別、年齡等,找出對當次住院天數、當次住院費用、手術當次死亡、後續三年醫療利用與後續多次截肢等依變項有統計意義的變項。再以多變項廻歸及邏輯斯迴歸方法探討對以上依變項有影響之因素。
結果顯示,中華民國九十年糖尿病施行非創傷性足趾截肢共有2,202人(扣除10人性別不詳者)。男女性別分佈(1.4:1)。性別並未影響當次住院醫療費用、後續三年醫療費用與再截肢頻率。年齡愈高當次住院醫療費用、後續三年醫療費用與再截肢機會愈高,但不影響當次住院死亡。此類手術主要集中在大於50歲年長者(80.25%)。有5.86%合併接受血液透析治療。
在醫學中心施行手術者佔所有手術的45.46%,區域醫院佔35.20﹪。初次施行足趾截肢手術平均住院22.55天,平均住院費用111,458點,平均每日住院費用5,121點。手術當次住院死亡2.05%,小於30歲以下當次手術住院時無人死亡。術後三年存活者門診平均次數20.89次,中位數9次;住院平均次數2.88次,中位數2次;平均總住院天數42.25天,中位數21次。總醫療費用256,395點、總門診費用37,091點、總住院費用219,304點。存活者41.4%三年內發生再截肢,平均再截肢2.48次。
對當次住院醫療費用有影響之因素為合併接受血液透析、高血壓、腦血管阻塞、冠狀動脈粥腫樣硬化、週邊動脈血管阻塞、年齡、醫院評鑑級別。地域別及醫院評鑑級別不影響當次住院醫療費用。對後續三年醫療費用有影響因子為合併高血壓與年齡增長。
對後續三年再截肢機會有影響之因素為年齡、合併接受血液透析與合併週邊動脈血管阻塞。合併接受血液透析比無接受血液透析者有2.05倍之後續三年再截肢機會。合併週邊動脈血管阻塞比無合併週邊動脈血管阻塞有2.54倍之後續三年再截肢機會。
此研究提供臺灣地區首次有關糖尿病施行非創傷性足趾截肢之訊息,以利後續相關之研究。
We have used The National Health Insurance Research Database focusing on diabetes mellitus, which includes ambulatory care expenditures by visits and inpatient expenditures by admissions to investigate the annual number of non-traumatic diabetic-related toe amputee and their inpatient claim fee in Taiwan in the year 2001. We then followed up a three year period to realize how many patients have survived and received re-amputation along with the total claim fee (including inpatient and outpatient). Furthermore, we analyzed the factors that had influenced the claim fee and the re-amputation.
We initially selected our research subjects with ICD-9-CM code 84.11 to represent the toe amputation patients. Then, we exclude the traumatic cause by E code. The cases which received 84.11 in the year 2000 were excluded. The subjects’ data were connected to the data base between the years 2001-2004 to find out more about the survivors after three years. We exclude subjects who died during hospitalization. The Statistics used the SAS 8.0 edition to analyze the total toe amputation and re-amputation number, inpatient claim fee, outpatient claim fee along with the independent factor which influences both the fee and re-amputation. Multiple regressions and logistic regressions were used.
The result showed non-traumatic diabetic-related amputee subjects(exclude 10 non-gender patients)was 2,202 in year 2001. Male ratio was 1.4. The mean age was 62.5 years old. 80.5% of the subjects were older than 50 years old. Subjects whom received hemodialysis were 5.86%.
There were 45.46% subjects that received amputation at Medical center. Regional hospital included 35.20%. The mean of length of stay was 22.55 days. The mean inpatient claim fee was 111,458 points. The mean hospitalized fee per day was 5,121 points. 2.05% of the patients died during hospitalization. None of the patients that were younger than 30 years old died during hospitalization.
During the next 3 years; the mean and median of the survivors’ outpatient visits were 20.89 times and 9 times. The mean and median of subjects being hospitalized were 2.88 times and 2 times. The mean and the median of total hospitalization days were 42.25 days and 21 days. Total claim fee was 256,395 points (total clinic and hospitalization fee were 37,091 points and 219,304 points respectively). Survivors who had to be re-amputated were 41.4%. The mean of re-amputation was 2.48 times.
Gender hadn’t affected hospitalization claim fee or the frequency during the 3 years claim fee and re-amputation. The older the subjects the higher the hospitalization claim fee, the 3 years claim fee and re-amputation would be. But it didn’t affect death during hospitalization at that time.
Variables that affected hospitalization claim fee were hemodialysis, hypertension, cerebral vascular accident, peripheral arterial occlusive disease, coronary arterial atherosclerosis, hospital accreditation level and age. There were no regional and hospital accreditation level differences in the hospitalization claim fee.
During the 3 years both hypertension and age were variables that affected the hospitalization claim fee.
In the next 3 year’s time; age, hemodialysis and peripheral arterial occlusive disease all affects the chance of re-amputation. The odds ratio of being re-amputated, compared with the subjects who have hemodialysis and no previous history of hemodialysis, was 2.05.
Subjects who have peripheral arterial occlusive disease had 2.54 times higher the risk of being re-amputated compared with subjects with no previous history of peripheral arterial occlusive disease.
This research is the first to evaluate on The National Health Insurance Research Database about the non-traumatic diabetes-related toe amputee in Taiwan. The outcome results may provide information to the people who are interested in treating diabetes-related toe amputee.
第壹章 緒論1
第一節 研究背景與動機1
第二節 研究目的4
第貳章 文獻探討5
第一節 糖尿病足潰瘍之病理機轉5
第二節 糖尿病足部潰瘍或截肢相關之因素9
第三節 研究對象之認定14
第四節 健康保險資料庫15
第參章 材料與方法17
第一節 研究架構17
第二節 資料來源與處理20
第三節 研究變項與操作型定義23
第四節 資料分析方法25
第肆章 研究結果27
第一部份 描述性統計27
第二部份 推論性統計56
第伍章 討論74
第一節 討論74
第二節 研究限制78
第陸章 結論與建議79
第一節 結論79
第二節 研究結果之應用與建議80
第柒章 參考文獻81
1、Adler, A. I., Boyko, E. J., Ahroni, J. H., & Smith, D. G. (1999). Lower- extremity amputation in diabetes. Diabetes Care, 22 (7), 1029-1035.
2、Andersen, H., Gadeberg, P.C., Brock, B., & Jakobsen, J. (1997). Muscular atrophy in diabetic neuropathy: A stereological magnetic resonance imaging study. Diabetologia, 40(9), 1062-1069.
3、Armstrong, D.G., & Larvey, L.A.(1998). Diabetic foot ulcer: Prevention,diagnosis and classification. American Family physcan,57(6),1325-1332.
4、Beach, K.W., Bedford, G.R., Bergelin, R.O., Vandenberghe, N., Zaccardi,M., & Strandness,D.( 1988). Progression of lower-extremity arterial occlusive disease in type II diabetes mellitus. Diabetes Care, 2( 6), 464-472.
5、Bhattacharyya, S.K., & Else, B.A.(1999).Medical costs of managed care in patients with type 2 diabetes mellitus. Clin Ther,21,2131-42.
6、Boulton, A.J. (1995). Why bother educating themultidisciplinary team and the patient: the example of prevention of lower extremity amputations in diabetes. Patient Educ Couns 26,3–188.
7、Boulton A.J. (1996). The pathogenesis of diabetic foot problem: an overview. Diabetic Medicine, 13,S12-16.
8、Boulton,A.J.(2005).The global burden of diabetic foot disease. Lancet ,366(9498),719-24
9、Boyko, E. J., Ahroni, J. H., Stensel, V., Forsberg, R. C., Davignon, D. R., & Smith, D. G. (1999). A prospective study of risk factors for diabetic foot ulcer. Diabetes Care,22(7), 1036-1042.
10、Cavanagh, P.R., Ulbrecht, J.S., Caputo G.M.(2000) New developments in the biomechanics of the diabetic foot. Diabetes Metabolism Research Revew, 16,(suppl 1),S6–S1
11、Cooper D.M., Yu E.Z., &Hennesey P. (1994)Determination of endogenous cytokines in chronic wounds. Ann Surg ,219,688-692
12、Caputo,G.,M.,, Cavanagh,P.,R., Ulberecht,J.S., Gibbons,G..W., & Karchmer,A.W.(1994).Management of foot disease in patients with diabetes. New England Journal of Medicine, 331, 854-860.
13、El-Shazly, M., Abdel-Fattah, M., Scorpiglione, N., Benedetti, M. M., Capani, F.,Carinci, F., Carta, Q., Cavaliere, D., De Feo, E. M., Taboga, C., Tognoni, G., & Nicolucci,A. (1998). Risk factors for lower limb complications in diabetic patients. Journal of Diabetes and Its Complications, 12, 10-17.
14、Faglia,E., Favales,F., Quarantiello, A., Calia,P., clelia,P., Brambilla,G., Rampoldi,A., & Morabto,A.(1998). Angiographic evaluation of peripheral arterial occlusive disease and its role as a prognostic determinant for major amputation in diabetic subjectivs with foot ulcers. Diabetes Care, 23(12):1746-51
15、Gerard, K., Donaldson, C., & Maynard, A.K.(1989).The Cost of the diabetes. Diabetic Medicine ,6,64-70.
16、Hämäläinen, H., Rönnemaa, T., Halonen, J. P., & Toikka, T. (1999). Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mellitus: A populations-based 7-year follow-up study. Journal of Internal Medicine, 246, 97-103.
17、Ho,V., Wirthlin,D., Yun,H., MS , &Allison, J..(2005) Physician supply, treatment ,and amputation rates for peripheral arterial disease. Journal of Vascular Surgery ,42(1),81-7
18、Hornberger, J. (1993). The hemodialysis prescription and cost effectiveness: Renal Physicians Association Working Committee on Clinical Guidelines. Journal of American Nephrology, 4, 1021-1027.
19、Hsiao, CS. (1998). Outcome after below-knee amputation in patient of diabetic foot. Journal of plasty & Reconstuction Surgery Association, 7,27-33.
20、International Diabetes Federation. (2005). Diabetes and foot care. The International Diabetes Federation Time to Act.
21、Izumi, Y., Satterfield, K., Lee, S., & Harkless L.B.. (2005). Risk of reamputation in diabetic patients stratified by limb and level of amputation. Diabetes Care, 29 (3), 566-770.
22、Lawrence, A., Lavery, M. J. M., Armstrong,D.G., Christopher S., Wendel, R., Wunderlich, P., & Lipsky, B. A. (2006). Risk factors for foot infections in individuals with diabetes. . Diabetes Care, 29(6), 1288-1293.
23、LEA Study Group. (2000). Epidemi erica and East Asia. British Jouranal Surgery, 87, 328-337.
24、Lin,T., Chou,P., Lai,M.S. Tsai,S.Z., & Tai,T.Y.(2001). Direct costs-of-illness of patients with diabetes mellitus in Taiwan. Diabetes Reasearch and clinical practice, 54 ,supp. 1, S43-46
25、Logerfo, F.W., Gibbons G.W., Pomposelli,Jr, F.B., Campbell, D.R., Miller A. Freeman, D.V., & Quist W.C.(1992). Trends in the care of the diabetic foot: Expanded role of arterial reconstruction. Arch Surg, 127,17-21
26、Loots, M.A., Lamme, E.N., Mekkes, J.R., Bos, J.D., & Middelkoop, E. (1999). Cultured fibroblasts from chronic diabetic wounds on the lower extremity (non-insulin-dependent diabetes mellitus) show disturbed proliferation. Arch Dermatol Res, 291, 93-99.
27、Mayfield, J. A., Reiber, G. E., Nelson, R. G., & Greene, T. (1996). A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care, 19(7),704-709.
28、Most , R., & Sinnock, P. (1983). The epidemiology of lower extremity amputations in diabetic individuals. Diabetes Care, 6, 87-91.
29、Ohsawa,S., Inamori,Y., Fukuda,K., & Hirotuiji,M.( 2001). Lower limb amputation for diabetic foot.. Arch Orthop Trauma Surg,121,(4):186-190
30、O’Hare, A. M., Bacchetti, P., Segal, M., Hsu, C.Y., & Johansen, K.L. (2003). Factors associated with future amputation among patients undergoing hemodialysis: results from the Dialysis Morbidity and Mortality Study Waves 3 and 4. American Journal of Kidney Disease, 41, 162-170.
31、Reiber, G.E., Vileikyte, L., Boyko, E.J., del Agulia, M., Smith, D.G., Lavery, L.A., & Bouton, A.J.(1999). Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care, 22(1),157-162
32、Reiber, G.E., Smith, D.G., Wallace, C., Sullivan, K., Hayes, S., Vath, C., Maciejewski, M.L., Yu, O, Heagerty, P.J., & LeMaster, J. (2002). Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. Journal of American Medical Association, 287(19),2552-8
33、Saltzberg,S.S, Pomposelli, Jr, F.B., Belfiel, A.K., Sheahan, M.G., Campbell, D.R., Skillman, J.J., LoGerfo,F.W. &, Hamdan,A.D..(2003). Outcome of lower-extremity revascularization in patients younger than 40 years in a predominantly diabetic population. Journal of Vascular Surgery,38(5),1056-9
34、Schaper, N. C., Nabuurs-Franssen, M. H., & Huijbert MS (2000). Peripheral vascular disease and type 2 diabetes mellitus. Diabetes Metabolism Research Review,16, supp 1:S11-15.
35、Schaper, N. C., & Nabuurs-Franssen, M. H., (2002). Pathogenesis and evaluation of the diabetic foot. Seminars in Vascular Medicine, 2(2), 221-228.
36、Sheahan, M.G., Hamdan, A.D., Veraldi, J.R., McArthur, C.S., Skillman, J.J., Campbell, D.R. , Scovell, S.D., LoGerfo, F.W. & Pomposelli, Jr, F.B.(2005). Lower extremity minor amputations: The roles of diabetes mellitus and timing of revascularization. Journal of vscular surgery ,42(3),476-80
37、Selby, J. V., & Zhang, D. (1995). Risk factors for lower extremity amputation in persons with diabetes. Diabetes Care, 18(4), 509-51
38、Singh N., & Armstrong D.G. (2005). Preventing foot ulcers in patients with diabetes. Journal of American Medical Association, 293, 217-218.
39、Slovenkai, M. P. (1998). Foot problems in diabetes. Medical Clinics of North America, 82(4), 949-971.
40、Speckman, R. A. F., Roman L., D., Eggers, S. H., & Bedinger,P. W. (2004). Diabetes is the strongest risk factor for lower-extremity amputation in new hemodialysis patients. Diabetes Care, 27(9), 2198-2203.
41、Tegner, R.(1985). The effect of skin temperature on vibratory sensitivity in polyneuropathy. Journal of Neurology Psychiatry ,48(2),176-178.
42、Tseng, C.H., Chang C.J., Fu C.C., Chen M.S., Kao, C.S., Wu, H.P., Chuang L.M., & Tai,T.Y.(1990)A comparision of diabetic control status between urban and rural diabetic patients in Taiwan. Journal of Formosa Medical Association, 89(8),666-71
43、Tseng, C.H. Tseng, C.H., Tai, T.Y., Chen C.J., & Lin, B.J.(1994). Ten-year clinical analysis of diabetic leg amputees. Journal of Formosa Medical Association, 93(5), 388-392
44、Viswanathan, V., Madhavan, S., Rajasekar, S., Chamukuttan, S.,& Ambady, R.(2006).Urban-rural difference in the prevalence of foot complications in South-Indian diabetic patients. Diabetes Care, 29(3),70-3
45、Wrobel, J.S., Mayfield, D. A.,& Reiber, M.(2001). Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population. Diabetes Care, 24,860–864
46、Wang, C.L., Wang, M., Lin M.C., Chien K.L., Huang, Y.C.,& Lee, Y.T.(2000). Foot complications in people with diabetes: A community-based study in Taiwan. Journal of Formosa Medical Association, 99(1),5-10
47、Young, M. J., Breddy, J. L., Veves, A., & Boulton, A. J. M. (1994). The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. Diabetes Care, 17(6), 557-560.
48、Zangaro,G.A.,& Hull,M.M.(1999). Diabetic neuropathy : Pathophysiology and prevention of foot ulcers. Clinical Nurse Specialist, 13(2), 57-68.
49、衛生署. ( 2006). 衛生統計
50、林正清(2003).臺灣全民健康保險臺灣資料庫有關之研究 國立臺灣大學公共衛生學院研究所 碩士論文
51、林信成(2005).應用全民健康保險臺灣資料庫分析臺灣地區糖尿病患者之醫療利用 國立交通大學管理學院 碩士在職專班經營管理組
52、中央健康保險局(2005). 醫療品質
53、陳健仁(2003). 高血糖盛行率調查 國民健康局
54、李美璇、潘文涵、張新儀(2003). 糖尿病盛行率調查 國民健康局
55、郭清輝 (1995). 糖尿病人的足部問題. 臨床醫學, 36(4), 240-242.
QRCODE
 
 
 
 
 
                                                                                                                                                                                                                                                                                                                                                                                                               
第一頁 上一頁 下一頁 最後一頁 top
系統版面圖檔 系統版面圖檔