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研究生:蘇倍玉
研究生(外文):Pei-Yu Su
論文名稱:人工膝關節置換術前老年人口門診醫療利用分析
論文名稱(外文):Ambulatory Health Services Utilization Before Undergoing Total Knee Replacement—A Nationwide Study among the Elderly in Taiwan
指導教授:陳曾基陳曾基引用關係
指導教授(外文):Tzeng-Ji Chen
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:醫務管理研究所
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
論文頁數:109
中文關鍵詞:膝關節炎葡萄糖胺止痛藥關節內注射玻尿酸復健針灸
外文關鍵詞:Knee osteoarthritisGlucosamineAnalgesicsIntraarticular Hyaluronate InjectionRehabilitationAcupuncture
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研究背景與目的:
骨關節炎目前是各國盛行率快速成長的慢性疾病之一,以60歲以上老年人口發生率最高,其中又以膝部關節炎為主要導致老年人行動不便之疾病,不但對老年人生活產生影響也將耗用大量的醫療資源,尤其當疾病嚴重度較重之病患對接受人工膝關節置換術存有疑慮之時,可能導致於病患尋求更多門診治療,以消除對於侵入性手術之風險疑慮和焦慮感,故本研究目的為探討接受人工膝關節置換術之老年人口使用情形並回溯其術前之門診醫療利用與使用治療方式情形及其影響因素。

資料來源與研究對象:
本研究以國家衛生研究院之健保資料庫100萬人承保抽樣歸人檔(LHID2005),選取於2005年初次接受人工膝關節置換術(Toal Knee Replacement,TKR)之65歲以上老年人口且其前五年也未接受TKR者,並回溯其術前兩年門診醫療利用和其門診開令處方用藥或診療項目之情形。

研究方法:
本研究以軟體SAS 9.1版進行資料庫處理與統計分析,推論性分析主要以T檢定、變異數分析、Kruskal-Wallis無母數檢定、卡方檢定、poisson迴歸、邏輯斯迴歸,分析各相關因素變項對於不同治療方法及門診醫療利用情形與其影響因素。在共病症指標測量預測醫療利用及治療方式之情形,本研究以Deyo’s CCI與Elixhauser作為共病症測量指標。

研究結果:
接受人工膝關節置換術者共有353人,以女性居多、且平均接受手術年齡為72.9歲,且接受手術多於醫學中心、財團法人機構接受手術比例最高。
術前兩年門診就醫記錄之病患共有344人,其性別年齡分布皆與接受手術者相似,以女性居多、多分布於70至74歲者比例最高;以需部份負擔者為主:投保金額以15,841至22,800元者比例最高;兩共病症指標(Deyo’s CCI與Elixhauser)皆以無共病症者比例最高,若以個別共病症來看,以罹患有高血壓、心血管疾病和消化性潰瘍之共病症比例較高,在醫療機構屬性方面,門診求診於基層診所、私立醫療機構為最多。術前兩年門診紀錄中其平均就醫次數為12.77次、且以65至69歲者、共病症數為四項者、主要就診於基層診所和財團法人醫療機構者其平均就醫次數較高:就醫醫療機構家數方面,以女性、65至69歲、有三項共病症者、免部分負擔、投保金額以15,841至22,800元者之病患其平均就醫醫療機構數較高。
術前門診紀錄中有開立處方明細者為341人,其中於本研究主要探討之五種治療方式中,使用一種治療方式者比例最高,其中又以使用止痛藥最多為132人(38.71%)。個別治療方式而言,曾使用止痛藥者佔88.27%、葡萄糖胺者為31.96%、注射玻尿酸者為24.34%、復健為22.29%、針灸傷科為1.47%。
利用Poisson回歸檢定結果得知,年齡、共病症、是否免部分負擔與門診累計就醫次數有統計上顯著意義:在累計就醫醫療機數方面,與年齡、共病症有顯著關係。
在不同治療方式之邏輯斯回歸結果中,以有無使用Acetaminophen情形而言與性別、共病症有顯著關係;cox-2 inhibitor(選擇性COX-2抑制劑)則以性別、共病症、醫療機構權屬別有顯著關係;傳統NSAID(非選擇性NSAID)與共病症有顯著關係;有無使用葡萄糖胺之情形與年齡、共病症、是否免部分負擔有顯著關係;注射玻尿酸與共病症、是否免部分負擔者有顯著關係;復健與性別、共病症、是否免部分負擔者有顯著關係。

結論與建議:
由本研究結果顯示,初次接受人工膝關節置換術前其門診有高度醫療利用之情形,且其接受不同治療方式皆多以共病症或疾病嚴重度因素影響最多,故可針對高醫療利用或高診次之病患介入關懷,以了解其影響因素,並建立預測醫療利用或是否為潛在須接受手術之病患模型,以利發展疾病管理、並避免有逛醫院之情形產生。
Background and Objective
Osteoarthritis is one of the most prevalent chronic diseases in many countries. Elderly who aged 60 or older have the highest incidence rate of osteoarthritis.Knee osteoarthritis mainly causes disability in the elderly, and usually leads to a dramatic impact to their daily lives.Patients with severe condition tend to seek consultations of having Total Knee Replacement (TKR) and request for more outpatient services to reduce their uncertainty and anxiety, which cause greater health expenditure. The aim of this study is to discuss the relationship analyse between medical utilization before having TKR, treatment type in the elderly receving TKR and the related factors.
Subjects
This research used a one million population-based National Health Insurance database (LHID2005) of 2005 provided by the National Health Research Institute. We identified study subjects who aged 65 or older, with first TKR treatment in 2005 and have no TKR history in the past five years. A retrospective method was used to investigate their medical utilization, outpatient prescription and received treatments in the past two years.
Methods
All statistical analyses were performed using SAS 9.1. The T test, analysis of variance, Kruskal-Wallis test, Chi-square test, Poisson regression analysis and logistic regression model were used for inferential statistics to reveal association between different treatment types and outpatient services within each variable. We used Deyo’s Charlson Comobidity Index (CCI )& Elixhauser’s co-morbidity indicator to predict the level of medical utilization and received treatments in this study.
Results
In 353 patients who received TKR, most patients were female and received TKR in medical center or legal foundation. The average age of patients of having TKR was 72.9.
For 344 patients from the record of two years before TKR treatment, most patients were female and aged 70 to 74, corresponding with the result in the patients received TKR. Other characteristics in this group were that most patients were requiring co-payment individuals with higher rates in the insurance amount group 15,841~22,800, and higher rates in no co-morbidity. But for individuals with co-morbidity, there were higher percentages in hypertension, cardiovascular disease and digestive ulcer. Patients had outpatient services and TKR were compared with respect to the type of medical facility they visited. Patients mostly had outpatient treatment at clinics and private medical institutes, which for the patients with TKR treatment showed a different result in our study. The average visit of record of two years before TKR treatment was 12.77, most patients were aged 65 to 69, combining three diseases, no co-payment individuals, and in the insurance amount group 15,841~22,800.
In 341 patients having prescription before operation, most of these patients received only one treatment and took analgesics. Among these patients, 88.27% had analgesics, 31.96% had glucosamine, 24.34% had intraarticular hyaluronate injection, 22.29% took rehabilitation and 1.47% had acupuncture and manual therapy.
Poisson regression test showed statistically significant in age, co-morbidity, co-payment and total medical visits.
In comparison with different treatment by logistic regression model, age and co-morbidity have significant difference in using acetaminophen or not; gender, co-morbidity and type of medical facility have significant difference in cox-2 inhibitor; co-morbidity has significant difference in unselective NSAID; age, co-morbidity and co-payment have significant difference in using glucosamine; co-morbidity and co-payment have significant difference in intra articular hyaluronate injection; gender, co-morbidity and co-payment have significant difference in rehabilitation.
Conslusions and Suggestions
There was a marked increase in outpatient medical utilization for those who had the first TKR. Patients with co-morbidity or more severe condition tended to have several kind of treatment. Intervention should be made for patients with high medical utilization and visits to avoid doctor shopping behavior;developing disease management, and understanding possible factors by building models for predicting medical utilization and detecting potential TKR patients.
目 錄
致謝 I
中文摘要 II
英文摘要 IV
目錄 VI
表目錄 VII
圖目錄 VIII

第一章 緒論 1
第一節 研究背景 1
第二節 研究動機 2
第三節 研究目的 4
第二章 文獻探討 5
第一節 骨關節炎及其治療 5
第二節 老年人口醫療利用 12
第三節 共病症之影響 14
第四節 術前就醫行為 17
第三節 研究設計 19
第一節 研究架構 19
第二節 研究流程 20
第三節 研究假說 21
第四節 資料來源與研究對象 22
第五節 研究變項與操作型定義 24
第六節 資料處理與分析方法 29
第四章 研究結果 34
第一節 描述性統計 34
第二節 推論性統計 57
第五章 討論 85
第一節 研究結果之討論 85
第二節 研究方法之討論 91
第三節 假說驗證 93
第四節 研究限制 96
第六章 結論 97
第一節 結論 97
第二節 建議 100
參考文獻 101
附錄 107
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