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研究生:顏秀紅
研究生(外文):Hsiu-Hung Yen
論文名稱:中風後復健早期介入效果是否更好?
論文名稱(外文):Is the Effect of Early Rehabilitation on Treatment Outcome and Medical Cost for Stroke Patients Better?
指導教授:錢慶文錢慶文引用關係
指導教授(外文):Ching-Wen Chien
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:113
中文關鍵詞:腦中風合併症費用全民健保復健
外文關鍵詞:ComplicationsNational Health InsuranceRehabilitationStrokeUtilization
相關次數:
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  • 下載下載:176
  • 收藏至我的研究室書目清單書目收藏:4
研究目的 復健在中風倖存者的功能恢復扮演一個重要角色,目前「最佳開始復健的時間」仍未成定論。國內外均建議,在醫師確定病人診斷為急性腦中風且病情穩定,即應該盡快開始中風復健,但仍常見病人延後開始復健。本研究擬探討「早期復健對中風病人療效和醫療資源耗用的影響」。

研究方法 採用「全民健康保險研究資料庫」2003至2006年資料,篩選出2005年初次因腦中風住院,出院後於同一年度內門住診有復健代碼記錄之病人為研究對象,共計19,949人。 依「中風後初次復健時間早晚」,將研究對象分成(1)「住院時復健組」 、 (2)「出院後7日內復健組」 、 (3)「出院後8至31日復健組」 、 (4)「出院後超過31日復健組」,共4組。用邏輯斯迴歸來分析病人死亡和合併症發生之風險,並採用線性迴歸分析醫療總費用,復健總費用和復健總費用A(排除語言治療A﹝即一般性語言治療﹞的費用)、復健總費用B(排除語言治療A和職能治療B﹝即副木﹞的費用)、復健總費用C(吞嚥治療的費用)、復健總費用D(副木的費用)。控制變量包括性別、年齡、中風類型、中風主要危險因子(高血壓、糖尿病、心臟病)和醫療資源(復健次數、初次腦中風住院之醫院層級)。

研究結果 結果顯示:超過31日復健組患者的死亡風險高於住院時復健組(但未達統計上顯著的差異),在褥瘡、尿路感染、深靜脈血栓形成和肺炎,則達統計上顯著差異(1.76-2.65倍) 。至於醫療總費用,出院後開始復健患者是住院時復健組的2.98 -3.01倍(皆達統計上顯著差異)。

結論 總括而言,由本研究結果顯示:(1)「住院時復健組」:合併症發生率最低
(深層靜脈血栓症除外),醫療總費用也最低(1年平均49,984元)。多項復健次數最少。(2)「出院後七日內復健組(最年輕)」最多的項目,有:(半年內、一年內)之所有類型的復健次數,復健總費用(1年平均32,157元)。最少的項目,有復健總費用C(吞嚥)。(3)「出院後超過31日復健組」:4種合併症發生率、醫療總費用(1年平均113,323元)、年齡、半年至1年間之物理、職能B和總復健的復健次數均為最高,最少的項目有復健總費用(1年平均23,627元)等。(4)4組復健組別醫療總費用均為其復健總費用之至少1.5倍以上,甚至接近5倍。
Purpose Rehabilitation plays an important role of functional recovery in stroke survivors, however, optimal timing of rehabilitation after stroke remains controversial. In general, it is suggested to begin rehabilitation as soon as possible after the patient diagnosed as stroke and the condition is stable, though it is common to be postponed the beginning of stroke rehabilitation. The current research examined the effects of early rehabilitation on treatment outcome and medical cost for stroke patients.
Method Data from Taiwan National Health Insurance (NHI) database during 2003-2006 was used in this retrospective study, drawing 19, 949 stroke subjects. Subjects were divided into four categories depending on when they started rehabilitation: 1) during hospitalization, 2) 7 days after discharge, 3) 7-31 days after discharge, and 4) exceeding 31 days after discharge. Logistic regression was used to analyse patient mortality rate and comorbidity rate to examine the outcomes, and linear regression was used to analyse total medical cost, total rehabilitation cost, rehabilitation cost A (eliminate speech therapy costs) and rehabilitation cost B (eliminate speech therapy costs and splinting costs), rehabilitation cost C (swallowing therapy costs) and rehabilitation cost D (splinting costs of occupational therapy ﹝called as OT(B) in this thesis﹞). Control variables included sex, age, types of stroke, hypertension, diabetes, cardiovascular disease, frequency of rehabilitation within one year after stroke, and accreditation level of hospital.
Result Results showed that patients who received rehabilitation exceeding 31 days after discharge had mortality rate higher than patients who started rehabilitation during hospitalization (but stastistically not significant), and their comorbidity rates for bed sores, urinary infections, deep vein thrombosis and pneumonia were stastistically significant higher(1.76-2.65 times). As for medical cost, patients who received rehabilitation after discharge were 2.98 -3.01 times higher (also stastistically significant) than those receiving rehabilitation during hospitalization.
Conclusion Results indicated that early rehabilitation could reduce comorbidity rate of stroke patients as well as the medical cost. In summary, this findings demonstrated (1) “start rehabilitation during hospitalization group”: The rate of complications (except deep vein thrombosis) and the total medical cost (mean annual cost: 49,984 NT dollars) were lowest. Many items of frequency of different rehabilitative therapy were least. (2) “start rehabilitation 7 days after discharge group (youngest)”: the frequency of different rehabilitative therapy (in a half year, one year) and total rehabilitation cost (mean annual cost: 32,157 NT dollars) were highest. The rehabilitation cost C (to swallow) was lowest. (3) “start rehabilitation exceeding 31 days after discharge group”: the frequency of 4 kinds of complication, the frequency of 3 kinds of rehabilitation (including physical therapy, occupational therapy B, and total rehabilitation) from a half year to during 1 year, and medical cost (mean annual cost: 113,323 NT dollars) were highest, and age was oldest; total rehabilitation cost (mean annual cost: 23,627 NT dollars), rehabilitation cost A and rehabilitation cost B were lowest. (4) 4 groups of medical cost are at least 1.5 times and even close 5 times above their’s total rehabilitation cost.
論文電子檔著作權授權書 …………………………………………… i

論文審定同意書 ……………………………………………………… ii

誌謝 ..………………………………………………………………iii

中文摘要 .…………………………………………………………… iv

英文摘要 ……………………………………………………………… vi

目錄 …………………………………………………………………… ix

圖目錄 ……………………………………………………………… xii

表目錄 ……………………………………………………………… xiii






目 錄

第一章 緒 論 --------------------------------------------- 1
第一節 研究背景與動機 ------------------------------------ 1
第二節 研究重要性 ---------------------------------------- 2
第三節 研究問題 ----------------------------------------- 3

第二章 文獻探討 ------------------------------------------ 5
第一節 腦中風與併發症 ------------------------------------ 5
第二節 併發症與不動 (immobilization, immobility) 的關係 -- 7
第三節 強調早期(復健)活動(early mobilization, early rehabilitation, early training) ------------------------- 7
第四節 早期(復健)活動與併發症 -----------------------------8
第五節 腦中風病房或單位(stroke ward or unit)(跨科別整合療法) -------------- 8

第三章 研究設計與方法 ---------------------------------- 10
第一節 研究架構與研究假設 ------------------------------- 10
第二節 資料來源與資料擷取過程 --------------------------- 12
第三節 研究變項之操作型定義 ----------------------------- 14
第四節 統計軟體與統計分析方法 --------------------------- 18

第四章 研究結果 --------------------------------------- 21
第一節 描述性統計分析 ----------------------------------- 21
第二節 分層分析 ----------------------------------------- 38
第三節 推論性統計 ----------------------------------------77

第五章 討 論 -------------------------------------------- 86
第一節 研究樣本的討論 ----------------------------------- 86
第二節 研究假設驗證的討論 ------------------------------- 87
第三節 重要文獻的比較 ----------------------------------- 91

第六章 結論與建議 --------------------------------------- 93
第一節 重要研究發現 ------------------------------------- 93
第二節 建議 -------------------------------------------- 101
第三節 研究限制 ---------------------------------------- 104

參考文獻 ----------------------------------------------- 105
中文部分
高文文(民91)。中風患者門診療程物理治療資源利用型態及功能改善狀況之研究。國立臺灣大學醫療機構管理研究所碩士論文,台北市。
高木榮、蔡美文、林茂榮、林銘川、王亭貴與賴金鑫(1999)。北區全民健康保險後復健醫療費用成長分析研究。中華民國復健醫學會雜誌,27(2),37-45。
張榕浚(民91)。全面性照護之缺血性腦中風臨床路徑發展與評估。中國醫藥學院醫務管理研究所碩士論文,台北市。
畢柳鶯與連倚南(1997)。全民健保制度與復健醫療發展-以台灣中區為例看復健醫療資源分佈及其未來走向。中華民國復健醫學會雜誌,25(1),65-72。
傅士豪(民96)。台灣腦中風病人病發一年內之門診復健利用及其相關因素探討. 國立陽明大學物理治療暨輔助科技學系碩士論文,台北市。
蔡宜秀、孫明輝、洪麗珍與郭憲文(2008)。影響某區域醫院缺血性腦中風初患病患住院醫療費用之相關因素。 Mid-Taiwan Journal of Medicne, 13(3), 143-151。

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