研究目的
過去已有研究顯示就醫時段與急性心肌梗塞病患之治療結果與醫療資源耗用有顯著相關，仍鮮少有研究探討不同的就醫時段下，醫院權屬別與治療方式及治療結果間的關係是否有所不同，擬藉由本研究探討此問題
研究方法
本研究採回溯性研究。資料來源為2003-2006年全民健保資料庫。研究對象為2004年初次因急性心肌梗塞就醫，且接受血栓溶解劑(recombinant tissue-type plasminogen activator-rt-PA)或緊急冠狀動脈氣球擴張術(primary PCI-pPCI)治療者。自變項為醫院權屬別(公、私立)與治療方式(pPCI vs rt-PA)。依變項為病人當次住院死亡率、兩年內再住院率與心血管疾病相關急診次數、住院天數與醫療費用。控制變項包括性別、年齡、Charlson comorbidity index、醫院層級與病人居住地之都市化程度。在多變項分析中，分別使用Logistic regression與Generalized linear model分析在不同就醫時段下(假日 vs 非假日)，醫院權屬別與治療方式對於病人治療結果預後與醫療資源耗用之影響。

研究結果
在假日就醫的情況下，於公立醫院就醫之病人的死亡風險較私立醫院者高(OR=3.26,p<0.01)，但非假日則無此現象。而治療方式與死亡風險之關係無論是否假日就醫，皆無顯著相關。而無論假日或非假日，接受pPCI治療者之再住院風險均較使用rt-PA者低(假日：OR=0.69,p=0.02；非假日：OR=0.78,p=0.01)。在假日就醫的情況下，接受pPCI治療者之急診次數較使用rt-PA者低(exp(β)=0.77,p=0.03)，但非假日則無此現象；至於住院天數及醫療費用，則是與醫院權屬別及治療方式均無相關，且無論假日或非假日皆如此。
結論
本研究結果顯示，就醫時段的不同，在醫院權屬別與死亡風險、治療方式與再住院或急診次數之關係上呈現不同現象。未來應著力於假日時段公私立醫院及治療方式間醫療水準的一致性與提升整體pPCI治療比率，有效縮短D2B time。
關鍵字：急性心肌梗塞、就醫時段、醫院權屬別、死亡率、再住院率、醫療資源耗用

Background
Over the past period of time,many studies has been shown that time of presentation significantly related to the outcomes and medical resource utilization of acute myocardial infarction, but still there are few studies about whether hospital ownership under different presentation time of acute myocardial infarction(AMI) influence the care and outcomes and medical resource utilization.Our study will focus on these issue.
Methods
This study retrospectively reviewed the data for the 2003-2006 National Health Insurance research database(NHIRD). Subjects presented with first-episode AMI in 2004 and had received either thrombolytic agent (recombinant tissue type plasminogen activator-rt-PA) or primary percutaneous coronary intervention (primary PCI-pPCI) therapy. The independent variables were hospital ownership (public, private) and treatment (pPCI vs rt-PA). The dependent variables were hospitalization mortality, readmission rate within two years, and cardiovascular disease-related emergency department visits, hospitalization and medical expenses. Control variables included gender, age, Charlson comorbidity index, hospital level and the degree of urbanization of residence of patients. In multivariate analysis, we used Logistic regression and Generalized linear model to analyse the effects of hospital ownership under different presentation time (holiday vs non-holiday) and different treatment(pPCI vs rt-PA) on the patient outcomes and consumption of medical resources within two years.
Results
Treatment for AMI in case of holidays, the patient's risk of death were higher in the public hospital than private hospitals (OR = 3.26, p &lt;0.01), but in case of non-holidays, there were no such phenomenon. There was no significant difference about risk of death between two kinds of treatment (pPCI vs rt-PA),whether or not holiday. The rate of readmission was lower in patients accepting pPCI therapy than those who accepting rt-PA therapy, regardless of holidays or non-holiday, (Holiday: OR = 0.69, p = 0.02; non-holiday: OR = 0.78, p = 0.01). The frequency of cardiovascular disease-related emergency department visits was lower in patients accepting pPCI therapy than those who accepting rt-PA therapy in case of holidays(exp (β) = 0.77, p = 0.03), but in in case of non-holidays, there were no such phenomenon; The length of hospital stays and medical expenses were not correlated to hospital ownership or treatment, whether or not holiday.
Conclusions
The results of this study show that under different time of presentation,the relationship between hospital ownership and risk of death and the correlation between different treatment and the rates of readmission & cardiovascular disease-related emergency department visits rendered the different phenomenon. In the future,we should promote the use and timing of invasive cardiac procedures(pPCI) and should focus on the consistency of emergent treatment of AMI between the public and private hospitals in the holiday.
Keywords: acute myocardial infarction,time of presentation, hospital ownership, mortality, readmission rate, medical resource utilization

目 錄
誌謝………………………………………………………………………………. i
中文摘要………………………………………………………………………… iii
英文摘要………………………………………………………………………. v
目錄…………………………………………………………………………… vii
圖目錄…………………………………………………………………………… x
表目錄…………………………………………………………………………… xi
第一章 緒論
第一節 研究背景…………………………………………………1
第二節 研究動機 ………………………………………………2
第三節 研究目的………………………………………………..3
第二章 文獻探討
第一節 急性心肌梗塞的定義……………………………………5
第二節 冠狀動脈心臟病及急性心肌梗塞的流行病學探討……5
第三節 冠心病與急性心肌梗塞的危險因子……………………7
第四節 冠狀動脈心臟病及的成因及病理機轉………………11
第五節 急性心肌梗塞症的診斷…………………………………13
第六節 急性心肌梗塞症的治療……………………….....……16
第七節 國內外實證研究-Door to balloon time(D2B time)…23
第八節 國內外實證研究-假日效應……………………..………27
第九節 國內外實證研究-醫院權屬別…………………………29
第十節 醫療資源耗用……………………………………………35
第三章 研究方法
第一節 研究設計與架構……………………………………....…37
第二節 研究變項說明………………………………………….....38
第三節 研究變項操作型定義………………………………….…42
第四節 研究假說…………………………………………….……44
第五節 資料來源…………………………………………….……44
第六節 資料處理與統計分析方法………..................……..……44
第四章 研究結果
第一節 描述性統計…………….…………………………………47
第二節 推論性統計…………………….…………………………58
第三節 研究結果摘要………………………………………62
第四節 研究假設驗證……………………………………………65

第五章 討論
第一節 影響不同時段公私立醫院治療方式與結果的
干擾因子………………………………………………. ….67
第二節 國內對於急性心肌梗塞症治療之成效…………….……68
第三節 台灣公私立醫院對於急性心肌梗塞症治療方式
與結果之差異………………………………….……….…70
第四節 急性心肌梗塞症醫療資源耗用之差異……………….…72
第六章 結論與建議
第一節 結論……………………………………………………..…74
第二節 建議 ………………………………………………….……75
第三節 研究限制……………………………………..……………79
參考文獻
英文文獻………………………………………………………………..80
中文文獻………………………………………………………………86

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中文文獻 :
1.施華菁，錢慶文；假日就醫對醫療結果與預後醫療資源耗用是否有影響?-以急性心肌梗塞疾患為例；國立陽明大學醫務管理研究所碩士論文 2007。
2.洪世育；台灣地區2000-2004年冠心病疾病率分析。慈濟大學公共衛生研究所碩士論文 2008-07-18。
3. 彭徐毅；Gender differences in medical utilization and 30-day fatality in Taiwanese patients with acute myocardial infarction. 慈濟大學 2009-08-26。
4. 張樂心；不同權屬別醫院之經濟行為研究；國立臺灣大學衛生政策與管理研究所。
5. 李怡真；醫院權屬別及層級別與醫院照護品質產出相關性之研究─以院內死亡、14天及30天內再入院為例 2008。
6. 許碩芬，楊雅玲，范碧純；台灣健保醫療費用時間序列預測模型；風險管理學報 第七卷 第三期 2005 年11 月。
7. 陳寬政，林子瑜，邱毅潔，紀筱涵；人口老化、疾病擴張、與健保醫療費用；人口學刊第39 期，2009 年12月，頁59-83。