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研究生:康建文
研究生(外文):Chien-Wen Kang
論文名稱:使用Fluoroquinolones作為經驗療法對成人重症社區性肺炎的臨床效益分析
論文名稱(外文):Impact of Fluoroquinolones as Initial Antibiotic Choice on the Clinical Outcomes of Severe Community-Acquired Pneumonia in Adults
指導教授:陳美美陳美美引用關係
學位類別:碩士
校院名稱:長榮大學
系所名稱:醫務管理學系(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:2012
畢業學年度:100
語文別:中文
論文頁數:79
中文關鍵詞:重症社區性肺炎經驗性抗生素
外文關鍵詞:TW-DRGsFluorouinolones
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研究背景:全民健保於2002年實施醫院總額制度後,延宕10年的TW-DRGs(台灣論病計酬支付制),才自2010年1月1日起分年分項導入住院支付制度。定額支付的方式,給予醫療提供者財務誘因和承擔風險之責任,促使醫院轉向思考如何藉由臨床指引建置臨床路徑,以提升住院照護品質並兼顧成本管控,也成為本研究論文的起因。
依文獻探討,在內科加護病房使用抗生素佔其費用比例高達40%,而肺炎是內科常見疾病,並自2008年列居台灣地區十大死因的第4位。因此,研究抗生素的選擇對於改善疾病治療與費用支出有其重要性。
研究目的:分析選用不同經驗性抗生素治療重症社區性肺炎患者對醫療品質與費用的影響。
研究方法:採回溯性之類實驗研究法。資料來源為南部某地區醫院加護病房重症肺炎患者的就醫紀錄。藉由條件限制,篩選出2007年7月至2009年6月由急診入住之重症社區性肺炎患者共183人次,並依經驗性抗生素的選擇,將患者分為使用Fluoroquinolones(FQs)的實驗組和未選擇Fluoroquinolones(FQs)的對照組。分析兩組之間在住院天數、出院結果與醫療費用的差異。統計方法採單變量的t檢定、卡方檢定、ANOVA,與多變量的複線性迴歸分析及羅吉斯迴歸分析。
研究結果:實驗組與對照組在患者的年齡、性別、疾病嚴重度上沒有顯著性差異。而選用不同經驗性抗生素的影響如下:
一、使用Fluoroquinolones之患者,平均住院總天數少1.68天,在複線性迴歸分析裡,同樣顯示使用Fluoroquinolones會有較少住院總天數,但統計檢定上皆未達顯著差異。
二、使用Fluoroquinolones之患者,平均ICU住院天數少0.82天,而複線性迴歸
分析,同樣發現使用Fluoroquinolones能減少住ICU天數,但兩者在統計上均未達顯著差異。
三、使用Fluoroquinolones的患者有較佳的出院結果(病情穩定比例75%:63.6%),在羅吉斯迴歸分析亦顯示使用Fluoroquinolones有較佳的治療效果,但統計上均未達顯著差異。
四、使用Fluoroquinolones之患者,ICU抗生素費用多$1,223,在複線性迴歸分析也發現,使用Fluoroquinolones者其住ICU抗生素費用相對較高,但統計上皆無顯著差異。
五、使用Fluoroquinolones之患者,平均住院總費用少$21,663,在複線性迴歸分析裡,顯示使用Fluoroquinolones相對有較少住院費用的支出,但皆未達統計上的顯著差異。
研究結論:本研究結果呈現,在使用Fluoroquinolones作為經驗療法對成人重症社區性肺炎的臨床效益上,無論是總住院費用、住院天數甚至於治療結果的風險值皆略低於對照組。但兩組之間未達統計上的顯著差異,無法證實其臨床效益優於未使用Fluoroquinolones者。其可能原因在於潛在疾病的影響與用藥組合的不同。因此,必須進一步釐清疾病的特性與用藥史(劑量、療程),並分析與臨床治療結果之相關性。

Abstracts
Background:After the National Health Insurance of Global Budget System for the medical institutes implemented in 2002,a prospective payment system of the "Taiwan diagnosis-related groups" (Tw-DRGs) finally started in January, 2010. For the health providers,the fixed payment gives an intensive to increase income and than they must have been to taken the responsibility for handing the risk. Therefore,thinking how to build clinical path by clinical guidelines to control the cost and up-grade the quality of care for hospitalized patients is my reason for this study.
Base on literature review,the use of antibiotics on medical ward especially on intensive care unit,the expenditure is up to 40% of annual admission drug cost. While pneumonia is a common medical disease and forth on top ten causes of death in Taiwan from 2008,so it is important to research the relationship about the choice of empirical antibiotics with treatment and expenditure of medical resources.

Purpose:Base on the different choice of empirical antibiotics,this study tries to analysis the impact on quality of care and cost for severe community acquired pneumonia.

Method:This study uses retrospective of quasi-experimental method.The resources from medical record of Southern Regional Hospital of Taiwan and through limitation to select hospitalized patients which sample size is 183 with severe community acquired pneumonia of intensive from July 1, 2007 to June 30, 2009. By the variance of choosing the empirical therapy,the patient’s separated into using Fluoroquinolones(FQs) and non using Fluoroquinolones(FQs) and analyzed by covariance software of the SPSS 12 Versions through independent sample t-test、Chi-square test、ANOVA Analysis and Multiple Regression Analysis and Logistic Regression Analysis to the influence in length of stay、the condition of discharged and health cost.

Result:The results as follows,no matter in age、gender and disease severity, there is non significant difference between the two groups.
1、 In the group of using Fluoroquinolones(FQs) than non using,the total average
length of stays decreased 1.68 days and on Multiple Regression Analysis also revealed less days,but non obviously significance.
2、 In the group of using Fluoroquinolones(FQs) than non using,the average length of stays in Intensive Care Unit decreased 0.82 days,and on Multiple Regression Analysis also revealed less days,but non obviously significance.
3、 In the group of using Fluoroquinolones(FQs) than non using had better result of discharged (the percentage of clinical stable in using Fluoroquinolones(FQs) and non using is 75%:63.6%),and on Logistic Regression Analysis also revealed better condition,but non obviously significance.
4、 In the group of using Fluoroquinolones(FQs) than non using,the average cost of antibiotics in Intensive Care Unit increased NT$1,223,and on Multiple Regression Analysis also revealed higher,but non obviously significance.
5、 In the group of using Fluoroquinolones(FQs) than non using,the total average medical expenditure decreased NT$21,663,and on Multiple Regression Analysis also revealed litter,but non obviously significance.

Conclusion:The results presented in this study about the clinical benefit of choosing Fluoroquinolones as empirical therapy for adults with severe community acquired pneumonia,regardless of the total hospital costs、length of stay and even the risk of treatment results are slightly lower than the non using group. Because of the outcome had no statistically obviously significant on the two groups,it could not confirm the clinical benefits better than non-using Fluoroquinolones. The underline disease and drugs regimen may be the one reason of influencing the outcome, therefore,we must further clarify the characteristics of the disease and medication history about dose、regimen and duration , and analyze the correlations with clinical treatment.

誌謝I
中文摘要II
英文摘要IV
論文目錄VII
圖目錄IX
表目錄X
附錄目錄XI
第壹章 緒論1
第一節 研究背景與動機1
第二節 研究目的3
第三節 名詞定義3
第貳章 文獻探討5
第一節 DRG制度對醫院營運的影響5
第二節 肺炎與治療準則11
第三節 臨床路徑與實證效益22
第參章 研究方法31
第一節 研究架構31
第二節 研究假說32
第三節 研究對象與資料來源33
第四節 變項定義35
第五節 資料處理與分析方法38
第肆章 研究結果42
第一節 重症社區性肺炎住院病患基本特性分析42
第二節 影響醫療品質之單變量分析43
第三節 影響醫療費用之單變量分析46
第四節 使用Fluoroquinolones與否對醫療品質影響之多變量分析47
第五節 使用Fluoroquinolones與否對醫療費用影響之多變量分析50
第伍章 討論52
第一節 說明使用Fluoroquinolones對醫療品質之影響52
第二節 說明使用Fluoroquinolones對醫療費用之影響53
第三節 其他自變項對醫療品質與費用之影響-55
第四節 研究限制56
第六章 結論與建議58
第一節 結論58
第二節 研究建議59
參考文獻61


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