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研究生:曹淑雲
研究生(外文):TSAO ,SHU-YUN
論文名稱:腎臟移植手術執行量與醫療品質及醫療資源耗用相關性探討
論文名稱(外文):The Relationship between Surgical Volume and Qualityof Care and Utilization in Kidney Transplantaion
指導教授:李偉強李偉強引用關係
指導教授(外文):Lee,Wui-Chiang
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:74
中文關鍵詞:腎臟移植手術執行量醫療結果醫療資源耗用
外文關鍵詞:kidney transplantationsurgical volumequality of careutilization of medical resource
相關次數:
  • 被引用被引用:1
  • 點閱點閱:238
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  • 下載下載:0
  • 收藏至我的研究室書目清單書目收藏:4
手術執行量與醫療結果及醫療資源耗費相關性在國外許多文獻被廣泛探討。根據2008年美國USRDS(United States Renal Data System)統計,我國的末期腎衰竭無論在發生率或盛行率皆居全球首位,為國人面臨的重要健康問題。而末期腎衰竭的替代療法中,無論在生活品質或醫療資源耗費,腎臟移植都被視為是最佳之選擇。本研究主要目的為以本國腎臟移植為例,探討移植醫院之腎臟移植手術執行量與醫療結果及醫療耗用之相關性。
研究設計採回溯性之次級資料分析,資料來源為國家衛生研究院「全民健保學術研究資料庫」。研究對象為1996年至2003年,全國所有向健保局申報腎臟移植之病患(手術碼55.69或處置碼76020B),排除二次換腎及小於18歲之非成年病患,共計1,060例。利用SPSS15.0套裝軟體,進行描述性及推論性統計。
移植醫院依研究期間腎臟移植手術執行量以群集分析分為高執行量醫院(≧72例)及低執行量醫院(≦72例),移植病患則依其接受腎臟移植之醫療院所分別歸入二組醫院。研究經人口學、術前疾病特質及疾病嚴重度校正,醫院手術執行量為影響病患及腎臟存活的重要因素,結果顯示:(一)年齡與性別是影響病患三年存活的重要因素,對於腎臟存活則不具關聯性;而疾病特質與醫療結果亦不具相關性。(二) 腎臟移植高執行量醫院有較低的當次手術死亡率、細菌感染及CMV感染率。(三)腎臟移植高執行量醫院有較佳的三年病患及腎臟存活率。(四) 腎臟移植高執行量醫院有較低的手術當次住院天數及手術當次醫療資源耗費。以上皆具統計差異。
依據研究結果分別對衛生主管機關、醫療院所及未來研究者提出下列建議:(一)對衛生主管機關:本研究印證腎臟移植手術執行量與醫療品質及醫療資源耗費具有正相關性,建議衛生主管機關重視重點醫療(例如器官移植)設置與規模之輔導並加強醫療品質的監測管理。(二)對醫事機構︰投置各項醫療專長時,應以實證資料為佐,詳細評估其可行,方為提升醫療品質及改善醫院經營體質之上策。(三)對未來研究者︰分析國內移植醫院執行腎臟移植手術之學習曲線定義threshold volume,以作為衛生主管機關或移植醫院執行業務之參考依據。
The relationship between surgical volume, quality of care and utilization is well discussed in many documentations abroad. End stage renal disease is a major health problem in Taiwan because its incidence and prevalence are both highest around in the world according to the report of USRDS(United States Renal Data System) in 2008. Kidney transplantation is the best choice of renal replacement therapy for end stage renal , no mater in quality of life or utilization of medical resource. Our study is using data of kidney transplantation in Taiwan to evaluate the relationship between surgical volume, quality of care and medical resource utilization.
The study design is retrograde by analyzing secondary data from academic research data bank of national health insurance which is provided by National Health Research Institutes. We collect 1,060 patients who declare kidney transplantation to Bureau of National Health Insurance from 1996 to 2003, patients who received secondary transplantation and aged below 18 years old were excluded. Statistics is calculated by SPSS 15.0.
We divided these hospitals, according to their surgical volume of performing kidney transplantation, as high-volume hospitals (over 72 cases) and low-volume hospitals (less than 72 cases), all patients were fit into these two groups. After adjusted with demography, predisposing disease characters and severity of disease, we found that surgical volume of performing kidney transplantation is the most important factor associated with survival rate of patient and graft. Age and gender are also major factors associated with three years patients survival , but not graft survival. The characters of disease are not associated with future outcome. Those hospitals have higher surgical volume resulted in lower surgical mortality and both bacterial and viral infection rate. The three years patient and graft survival rate are also higher. Additionally, the length of hospital stay and expenditure are both lower in these hospitals with high surgical volume . Above results are all reach statistical significance.
So we suggest that firstly the health authority should put more attention counsel the set-up scale of each hospital for organ transplant and reinforce monitoring of the quality of medical care, because the surgical volume of kidney transplantation positively related with quality of care and utilization of medical resource. Secondly, a medical institutions should use evidence-based data to evaluate the feasibility of building protocol as kidney transplantation, not only improve self quality of patients care but also management. The third, we hope forecoming researchers can analyze the threshold volume of kidney transplantation in each hospital, providing reference to our health authority and other medical institutions to reach their best benefits.
第一章 緒論............................................1
第一節 研究背景與動機..................................1
第二節 研究目的及重要性................................3
第三節 研究貢獻........................................4
第二章 文獻探討........................................5
第一節 腎臟移植的歷史回顧..............................5
第二節 腎臟移植概述....................................6
第三節 影響腎臟移植病患及腎臟存活的相關因素............7
第三章 研究方法.......................................13
第一節 研究架構與假說.................................13
第二節 研究對象與資料來源.............................15
第三節 研究變項與操作型定義...........................17
第四節 資料處理及統計分析.............................19
第四章 研究結果.......................................23
第一節 基本特質.......................................23
第二節 當次醫療結果及醫療資源耗費分析.................26
第三節 長期醫療結果及醫療資源耗費分析.................29
第四節 影響醫療結果因素分析...........................30
第五章 討論...........................................42
第一節 腎臟移植病患基本特質討論.......................42
第二節 腎臟移植病患醫療品質與醫療資源耗費討論.........42
第三節 研究限制.......................................49
第六章 結論與建議.....................................52
第一節 結論...........................................52
第二節 建議...........................................52
參考文獻..............................................55
附錄..................................................60
參考文獻
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