臺灣博碩士論文加值系統

糖尿病人口逐年增加，對醫療耗用之影響亦持續加重，尤其是住院費用。糖尿病患有較多特定感染與死亡機會，然而客觀數據指出其敗血症住院個案死亡率卻較低。有必要針對糖尿病對敗血症住院患者存活與醫療耗用的影響進行深入探討。
本研究採用樣本醫院西元2009年初迄2010年底之住院登錄資料，以同一次住院期間有處置血液細菌培養及處方抗生素為醫師臨床判定敗血症、以ICD-9-CM code定義糖尿病與敗血症相關疾病，據以分析病患因素與醫療提供者因素對敗血症存活與醫療耗用的影響。研究變項包含性別、年齡、Charlson Index、感染部位、血液菌種、糖尿病、科別、醫師年資、存活狀態、存活天數、住院總醫療費用、住院日均醫療費用。資料整合與分析採用描述性統計、卡方檢定、變異數分析、Cox迴歸模型、存活曲線分析與廣義線性模式。
研究結果顯示糖尿病患者比非糖尿病患者敗血症住院死亡率較低且日均費用較少，但是存活個案住院天數與總費用不具統計顯著差異。此外，發現其他影響敗血症存活的因子有年齡、感染部位、血液菌種、Charlson index、內外科屬性。
醫療可近性與降血糖藥物潛在抗發炎作用可能與糖尿病患者相對死亡率較低有關。就有限的醫療資源而言，糖尿病病患之治療及就醫行為之遵從性，乃為醫療負荷之關鍵要素。

The increasing population of diabetes continued to increase medical consumptions, especially inpatient costs. Diabetes patients were linked to more infections and deaths of which were associated with high demands of inpatient care. However, literatures have revealed that diabetes patients were found with lower fatality in sepsis care. Further investigations on the association between diabetes and survival and medical consumptions among hospitalized patients with sepsis are warranted.
The study data were collected from medical chart and claim database of the sample hospital during 2009-2010. Sepsis was defined by the results of blood cultures and prescription of antibiotics. ICD-9-CM code extracted from medical chart was used to define diabetes and sepsis-related diseases. The study variables include gender, age, Charlson Index, infection site, blood-stream bacteria, diabetes, medical division, physician seniority. Data were integrated and analyzed with statistical methods including description, chi-square analysis, One-way ANOVA, Cox regression, Kaplan-Meier survival curve, and Generalized Linear Model.
The results showed that sepsis patients with diabetes had lower fatality and lower average daily medical cost than those who without diabetes. No statistical significance were found between diabetes and non-diabetes patients on the hospital length of stay among survivors and overal medical costs. The study has found factors, including age, infections, blood-stream bacteria, Charlson index, and specialties, were associated with sepsis survival.
Medical care accessibility and the potential anti-inflammatory effects of anti-diabetic agents may be associated with lower fatality among sepsis patients with diabetes. From the perspectives of limited medical resources, it is important to view the treatment protocol and patient's compliance as critical factors to reduce burden of diseases in the future.

目 錄
指導教授推薦書
口試委員會審定書
電子檔案上網授權書…iii
授權書…iv
誌謝…v
中文摘要…vi
英文摘要…vii
目錄…ix
圖表目錄…xi
第一章 緒論…1
第一節 研究背景…1
第二節 研究動機與目的…3
第二章 文獻探討…4
第一節 敗血症…4
第二節 糖尿病…10
第三節 糖尿病與敗血症…16
第三章 材料與方法…20
第一節 研究架構與研究假說…20
第二節 敗血症、血液細菌培養與感染部位…22
第三節 病患疾病複雜度指標(Charlson co-morbidity Index)…24
第四節變項操作型定義…26
第五節 資料整合與統計方法…28
第四章 研究結果…29
第一節 樣本背景資料…29
第二節 病患存活因子分析…35
第三節 存活分析…39
第四節 重要存活風險因子對存活天數、總費用與日均費用的影響…43
第五章 討論…48
第一節 背景資料分析探討…48
第二節 存活因子分析結果探討…51
第三節 糖尿病與重要存活風險因子對病患存活的影響…53
第四節 糖尿病藥物對敗血症存活的可能影響…54
第五節 糖尿病等存活因子對存活天數、總費用與日均費用的影響…57
第六節 研究限制…59
第六章 結論與建議…60
第一節 研究結論…60
第二節 建議…61
參考文獻…63
附錄…72
 
圖表目錄
圖3-1 研究架構圖…21
表4-1-1基本人口學資料…33
表4-2-1病患存活因子分析…37
表4-2-2病患存活因子分層分析(7-99歲)…38
圖4-3-1 有無糖尿病的存活曲線…39
圖4-3-2 有無明確感染部位(A)及其與有無糖尿病(B)的存活曲線…40
表4-3-2糖尿病與有無明確感染部位對敗血症存活之影響 40
圖4-3-3 有無血液菌種(A)及其與有無糖尿病(B)的存活曲線…41
表4-3-3糖尿病與血液有無菌種對敗血症存活之影響…41
圖4-3-4 是否內科病患(A)及其與有無糖尿病(B)的存活曲線…42
表4-3-4 糖尿病與是否為內科病患對敗血症存活之影響…42
表4-4-1重要存活風險因子對存活個案住院天數、總費用與日均費用的廣義線性模型分析…46
表4-4-2重要存活風險因子對存活個案住院天數、總費用與日均費用的廣義線性模型分析(7-99歲)…47

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