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研究生:鍾寬智
研究生(外文):Kuan-Chih Chung
論文名稱:全膝關節置換術麻醉方式及術後結果之探討
論文名稱(外文):Anesthesia preferences and post-operative outcomes in Taiwanese patients having total knee replacement
指導教授:張菊惠張菊惠引用關係
指導教授(外文):Chu-Hui Chang
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:68
中文關鍵詞:全膝關節置換術麻醉決策麻醉負荷量
外文關鍵詞:total knee replacementanesthetic decision-makinganesthetic load
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膝關節疾病好發於老年人,且全膝關節置換術是公認極具效益的常規治療方法。鑑於各機構對於全膝關節置換術所選擇麻醉方式之差異,缺乏國內相關研究。因此本研究將了解全膝關節置換術病人,接受全身麻醉或半身麻醉的情形,進而探討決定麻醉方式的影響因子、及術後結果之間的相關性。
採橫斷式研究設計,利用全民健康保險研究資料庫2004年至2006年百萬歸人檔,選取接受全膝關節置換術之住院病人為研究對象。串連住院醫療費用清單明細檔、住院醫療費用醫令清單明細檔、醫事機構基本資料檔、及醫事人員基本資料檔,以卡方檢定比較不同病人屬性與醫院因素之麻醉施行率,並在控制病人因素後,以結構方程式釐清影響手術麻醉決策為醫院因素或醫師因素。
共計1602位病人,以女性為多(73.9%),年齡集中於65至75歲(52.9%),就醫地點醫學中心佔39.5%、地區醫院其次(33.7%)。研究發現66.4%採行半身麻醉,隨病患年齡愈高半身麻醉比例愈高(p<0.0001),性別間無差異。與醫院層級呈顯著相關性,地區醫院之半麻比例高達85.9%,其次為醫學中心之63.8%,區域醫院最低為45.3%(P<0.0001)。醫療區域(地區)方面呈顯著相關性,台北分局之半麻率最高(81.0%)最低為高屏分局(47.7%)(P<0.0001)。醫院權屬方面,公立醫學院附設醫院之半麻率最高(91.4%),最低為財團法人醫院(39.9%)(P<0.001)。與手術醫師專科年資無關。麻醉負荷量的增加,半身麻醉比例呈現顯著差異的下降。術後結果方面,不同的麻醉方式對術後的住院天數影響不大。
從結果推測台灣全膝關節置換術的麻醉方式,在選擇上受到醫院層級、醫療區域等因素影響明顯大於醫師行為因素;而麻醉方式的不同並不會影響到病患的住院天數。希冀能藉由本研究的資訊,提供一適當的麻醉決策指引,帶給病患更好的醫療品質。


Knee arthropathy often occurs in elderly people, and total knee replacement (TKR) is the choice of treatment that is recognized as being highly effective. While there are differences in the choice of anesthetic method in TKR between the various institutions, there is a lack of relevant research in Taiwan. In this study, we therefore wanted to gain an understanding of circumstances in relation to general and regional anesthesia in TKR patients, in order to explore the factors that influence the anesthetic choices and the correlation between anesthetic method and surgery outcome.
We performed a cross-sectional study, using millions of data files from 2004 to 2006 from the National Health Insurance Research Database. Subjects consisted of hospitalized patients who received TKR. We used the chi-square test to compare anesthetic methods in relation to patient attributes and hospital factors. After controlling patient-related factors, we used structural equation modeling to determine whether decision-making in anesthesia is influenced by hospital-related or physician-related factors.
There were a total of 1602 patients, the majority of which consisted of female patients, mostly aged between 65-75. The location of medical treatment consisted for a large part of medical center. We found that regional anesthesia was applied in 66.4% of the cases, and the ratio of regional anesthesia was increased as patients got older. No difference was found between the genders. The significant correlations were found with the hospital level, medical care region, hospitals affiliated, and anesthetic load. No correlation was found with the seniority of the surgeon. With regard to surgery outcomes it can be said that different anesthetic methods had no big effect on the length of postoperative hospitalization.

The results suggest that in Taiwan, the choice of anesthetic method in TKR is influenced more by factors related to the hospital level and medical care region than by factors related to physicians’ behavior. Moreover, different anesthetic methods do not affect the length of hospitalization. We hope that the results of this study can serve as a guide for adequate decision-making in anesthesia, so that patients can be received better quality of care.


目錄
致謝…………..………………………………………...........……………….........Ⅰ
中文摘要……..………………………………………...........……………….........Ⅱ
英文摘要……..………………………………………...........……………….........Ⅲ
目錄…………..………………………………………...........……………….........Ⅴ
表目錄………..…………………………………………...........……………….....Ⅵ
圖目錄………..…………………………………………...........……………….....Ⅶ
第一章 緒論..........................................................................................1
第一節 研究背景和動機...................................................................…1
第二節 研究目的................................................................................3
第二章 文獻探討....................................................................................4
第一節 病人之麻醉安全.......................................................................4
第二節 全膝關節置換術之麻醉.............................................................9
第三節 醫療決策之訂定.....................................................................16
第三章 研究方法...................................................................................25
第一節 研究架構...............................................................................25
第二節 研究對象與資料來源...............................................................26
第三節 研究變項之操作型定義............................................................30
第四節 描述資料處理與分析方法.........................................................33
第四章 研究結果...................................................................................34
第一節 施行全膝關節置換術之現況......................................................34
第二節 施行全膝關節置換術後結果之分析............................................40
第三節 施行全膝關節置換術麻醉方式之分析.........................................43
第五章 討論與建議................................................................................52
第一節 結論......................................................................................52
第二節 討論......................................................................................54
第三節 建議......................................................................................61
英文參考文獻.........................................................................................63
中文參考文獻.........................................................................................67


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