臺灣博碩士論文加值系統

目的：
台灣已邁入高齡化社會，骨質疏鬆症已成為近幾年來重要的公共衛生議題，且骨質疏鬆性骨折對患者來說，其所造成的疼痛及活動受限將嚴重影響病患的生活品質，而其所引起之後續醫療支出與生活品質之惡化，無論對於病患、病患家屬，甚至對整個社會而言都是一個沉重的負擔，因此目前需要有關骨質疏鬆性骨折的相關知識，來評估骨質疏鬆性骨折對整個社會所造成的影響，並找出高危險族群，幫助相關政策制定者可依此分配相關資源。本研究使用量化的分析方式來探討台灣骨質疏鬆性骨折病患再入院的影響因子，及其相關醫療資源使用之情形，並期望本研究之研究結果可增加國人對於台灣中老年人骨質疏鬆性骨折的了解，促使有關單位發展全國性的預防措施，並同時提升台灣整體的醫療照護品質。

方法：
本研究利用國家衛生研究院全民健康保險資料庫2001年至2007年的資料，採用回溯性研究法來針對50歲以上之骨質疏鬆性骨折病患進行次級資料分析，並將骨質疏鬆性骨折病患依其再入院發生情況進行分組，分析人口學變項(包含年齡、性別)、醫療機構特性(包括醫療機構層級、醫療機構權屬別、教學醫院與否、城鄉分布)及共病分數等變項對於骨質疏鬆性骨折病患再入院的影響，及其相關之醫療資源使用情形。

結果：
共有5483名骨質疏鬆性骨折的住院病患，其中有4179名(76.22%)病患發生再入院情況，有1304名(23.78%)則沒有發生任何再入院，經過首次入院後，有3432名(82.13%)病患是因為主診斷碼為骨質疏鬆性骨折而再入院，而有1331名(31.8%)病患發生主診斷碼為骨質疏鬆性骨折之六個月內再入院。在醫療資源使用方面，有發生再入院的骨質疏鬆性骨折病患其無論是住院次數、住院天數、總藥費與總住院費用皆顯著較高於沒有發生再入院的病患，而年齡與Charlson分數都與骨質疏鬆性骨折病患的再入院機率有顯著的相關。

結論：
從衛生政策的觀點，骨質疏鬆性骨折此議題的重要性在未來會日益增加，本研究提供相關衛生單位與各醫療機構對於政策制定及衛教推動的明確方向，讓骨質疏鬆性骨折病患能得到更完善之醫療照護品質，同時也能減少醫療資源之浪費。

Research Objectives:
Osteoporosis has become a significant public health problem in recent years, especially with the growth of the elderly population. Osteoporotic fractures exact a terrible toll on the population with respect to morbidity, cost, and to a lesser extent mortality. These effects can lead to psychological problems, social consequences, functional limitations, and poor quality of life. Thus, knowledge regarding osteoporotic fractures is needed to evaluate the impact of osteoporotic fractures on society, to identify high-risk populations, and to help policymakers to allocate resources accordingly. This study aims to investigate the influence factors of hospital readmissions among osteoporotic fractures patients in Taiwan, and the study results are expected to increase our understanding of the magnitude of the elderly population suffering from osteoporotic fractures and to urge policymakers to develop effective national prevention strategies.

Study Design:
Using Taiwan’s National Health Insurance database, we identified elderly patients with a hospitalization for osteoporotic fractures between 2001 and 2007. We divided readmissions into different groups (14-day, 30-day, 180-day and over 180-day) and evaluated each group’s demographic, hospital characteristics, and Charlson Comorbidity Index. The claims data are also used to calculate the health services utilization of osteoporotic fractures among those elderly patients with or without readmission of osteoporotic fractures. The data analyses were carried out by Chi-square test, t test, multiple linear regression and multivariate logistic regression.

Population Studied:
Patients aged 50 or older with osteoporotic fractures were identified based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

Principle Findings:
Among 5483 osteoporotic fractures patients, 6.9% of them were readmitted within 14 days, 34.7% were readmitted within 30 days and 13.9% were readmitted within 180 days. The medical resource utilizations were significantly higher in patients with readmissions than those without readmission. Age and Charlson Comorbidity Index were significantly affected the probabilities of readmissions.

Conclusion:
From the perspective of health policy, the issue of osteoporotic fractures will become increasingly important in the future. This national study will help raise awareness of osteoporotic fractures and hopefully motivate public health policy makers to develop effective national prevention strategies against osteoporosis to prevent osteoporotic fractures.

論文審定書 I
誌謝 II
中文摘要 III
ABSTRACT V
目錄 VII
圖次 VIII
表次 IX
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究方法與目的 3
第二章 文獻探討 4
第一節 骨質疏鬆症之介紹 4
第二節 流行病學、再入院與共病及醫療資源使用概況 10
第三節 文獻總結 18
第三章 研究方法 19
第一節 研究設計與架構 19
第二節 研究問題與假設 21
第三節 研究樣本及資料蒐集 22
第四節 研究變項之操作型定義 27
第五節 研究資料之處理與分析 30
第六節 資料分析方法 32
第四章 研究分析與結果 33
第一節 描述性統計分析 33
第二節 推論性統計分析 42
第五章 研究討論 63
第一節 研究結果討論 63
第二節 研究假設驗證 66
第六章 研究建議 67
第一節 研究限制 67
第二節 研究建議 67
第三節 研究貢獻 68
參考文獻 69

壹、中文文獻：

內政部統計處(民101年8月7日)。內政統計通報。取自
http://sowf.moi.gov.tw/stat/week/list.htm

中華民國骨質疏鬆症學會(民100)。台灣成人骨質疏鬆症防治之共識及指引。取自
http://www.toa1997.org.tw/index.php?page_id=9bf31c7ff062936a96d3c8bd1f8f2ff3

中華民國骨質疏鬆症學會(民101年8月7日)。FRAX世界衛生組織骨折風險評估
工具。取自http://www.shef.ac.uk/FRAX/tool.jsp?country=26

行政院衛生署國民健康局、財團法人國家衛生研究院、中華民國骨質疏鬆症學會(民
100)。骨質疏鬆症臨床治療指引。新北市：行政院衛生署國民健康局

沈雅雯(民100年10月20日)。抗骨質疏鬆 台灣每年花費40億。奇摩新聞。取自
http://tw.news.yahoo.com/

李瑋君、韓岳津、吳英黛、曹昭懿(民96)。骨質疏鬆相關骨折住院病患之健保申報
分析。台灣醫學，11，22-8。

侯君翰(民99年11月8日)。骨質疏鬆症-你應該知道的事。臺大醫院網站。取自
http://health.ntuh.gov.tw/health/new/5961.htm  

洪瑞國(民99)。老年人發生第二次對側髖骨骨折之保護及危險因子之分析及探討
(未出版之碩士論文)。國立陽明大學，台北市。

國家衛生研究院(民100)。全民健康保險研究資料庫譯碼簿。取自
http://nhird.nhri.org.tw/UNACD/date_2.htm

趙育箴、陳全裕、吳俊鋒、張秦松、郭柏秀、張軒睿…吳至行(民99)。偏遠社區老
年女性骨質疏鬆症盛行率與相關危險因子之研究。台灣家醫誌，2，64-73。

劉介宇、洪永泰、莊義利、陳怡如、翁文舜、劉季鑫、梁賡義(民95)。台灣地區鄉
鎮市區發展類型應用於大型健康調查抽樣設計之研究。健康管理學刊，4(1)，
1-22。

貳、英文文獻：

Becker, D. J., Yun, H., Kilgore, M. L., Curtis, J. R., Delzell, E., Gary, L. C., …Morrisey,
M. A. (2010). Health services utilization after fractures: evidence from Medicare. J Gerontol A Biol Sci Med Sci, 65(9), 1012-1020. doi: 10.1093/gerona/glq093

Blume, S. W., &; Curtis, J. R. (2011). Medical costs of osteoporosis in the elderly
Medicare population. Osteoporos Int, 22(6), 1835-1844. doi:10.1007/s00198-010-1419-7

Boockvar, K. S., Halm, E. A., Litke, A., Silberzweig, S. B., McLaughlin, M., Penrod, J.
D., …Siu, A. L. (2003). Hospital readmissions after hospital discharge for hip fracture: surgical and nonsurgical causes and effect on outcomes. J Am Geriatr Soc, 51(3), 399-403.

Borgstrom, F., Zethraeus, N., Johnell, O., Lidgren, L., Ponzer, S., Svensson,
O., …Jonsson, B. (2006). Costs and quality of life associated with osteoporosis-related fractures in Sweden.Osteoporos Int, 17(5), 637-650. doi: 10.1007/s00198-005-0015-8

Bouza, C., Lopez, T., Palma, M., &; Amate, J. M. (2007). Hospitalised osteoporotic
vertebral fractures in Spain: analysis of the national hospital discharge registry.
Osteoporos Int, 18(5), 649-657. doi: 10.1007/s00198-006-0292-x

Budhia, S., Mikyas, Y., Tang, M., &; Badamgarav, E. (2012). Osteoporotic Fractures- A
Systematic Review of US Healthcare Costs and Resource Utilization. Pharmacoeconomics, 30(2), 147-170.

Burge, R., Puleo, E., Gehlbach, S., Worley, D., &; Klar, J. (2002). Inpatient hospital and
post-acute care for vertebral fractures in women. Value Health, 5(4), 301-311. doi:
10.1046/j.1524-4733.2002.54126.x

Charlson, M. E., Pompei, P., Ales, K. L., &; MacKenzie, C. R. (1987). A new method of
classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases, 40(5), 373-383.

Chen, H. F., Ho, C. A., &; Li, C. Y. (2008). Increased Risks of Hip Fracture in Diabetic
Patients of Taiwan. Diabetes Care, 31(1), 75-80. doi: 10.2337/dc07-

Dai, K., Zhang, Q., Fan, T., &; Sen, S. S. (2007). Estimation of resource utilization
associated with osteoporotic hip fracture and level of post-acute care in China. Curr Med Res Opin, 23(12), 2937-2943. doi: 10.1185/030079907X233061

Dai, Y. T., Wu, S. C., &; Weng, R. (2002). Unplanned hospital readmission and its predictors in patients with chronic conditions. Journal of the Formosan Medical Association, 101(11), 779-785.

Deyo, R. A., Cherkin, D. C., &; Ciol, M. A. (1992). Adapting a clinical comorbidity
index for use with ICD-9-CM administrative databases. Journal of Clinical Epidemiology, 45(6), 613-619.

Dimai, H. P., Redlich, K., Peretz, M., Borgstrom, F., Siebert, U., &; Mahlich, J. (2012).
Economic Burden of Osteoporotic Fractures in Austria. Health Econ Rev, 2(1), 12. doi: 10.1186/2191-1991-2-12

French, D. D., Bass, E., Bradham, D. D., Campbell, R. R., &; Rubenstein, L. Z. (2008).
Rehospitalization after hip fracture: predictors and prognosis from a national veterans study. J Am Geriatr Soc, 56(4), 705-710. doi: 10.1111/j.1532-5415.2007.01479.x

Gehlbach, S. H., Burge, R. T., Puleo, E., &; Klar, J. (2003). Hospital care of
osteoporosis-related vertebral fractures. Osteoporos Int, 14(1), 53-60. doi: 10.1007/s00198-002-1313-z

Johnell, O., &; Kanis, J. A. (2006). An estimate of the worldwide prevalence and
disability associated with osteoporotic fractures. Osteoporos Int, 17(12),
1726-1733. doi: 10.1007/s00198-006-0172-4

Kang, H. Y., Yang, K. H., Kim, Y. N., Moon, S. H., Choi, W. J., Kang, D. R., &; Park, S.
E. (2010). Incidence and mortality of hip fracture among the elderly population in South Korea: a population-based study using the national health insurance claims data. BMC Public Health, 10, 230. doi: 10.1186/1471-2458-10-230

Kanis, J. A., Oden, A., McCloskey, E. V., Johansson, H., Wahl, D. A., &; Cooper, C.
(2012). A systematic review of hip fracture incidence and probability of fracture
worldwide . Osteoporos Int. doi: 10.1007/s00198-012-1964-3

Lai, S. W., Liao, K. F., Liao, C. C., Muo, C. H., Liu, C. S., &; Sung, F. C. (2010).
Polypharmacy correlates with increased risk for hip fracture in the elderly: a population-based study. Medicine (Baltimore), 89(5), 295-299. doi: 10.1097/MD.0b013e3181f15efc

Lee, Y. H. D., Lim, Y. W., &; Lam, K. S. (2008). Economic cost of osteoporotic hip
fractures in Singapore. Singapore Med J, 49(12), 980-984.

Medicare Payment Advisory Committee. (2008). Report to the Congress: Reforming the
Delivery System. Retrieved from http://www.medpac.gov/documents/20080916_Sen%20Fin_testimony%20final.pdf

National Institutes of Health (2012, August 6). Osteoporosis Handout on Health.
Retrieved from http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/osteoporosis_hoh.asp

National Osteoporosis Foundation (2012, August 6). Why Bone Health is Important.
Retrieved from http://www.nof.org/aboutosteoporosis/bonebasics/whybonehealth

Oinuma, T., Sakuma, M., &; Endo, N. (2010). Secular change of the incidence of four
fracture types associated with senile osteoporosis in Sado, Japan: the results of a 3-year survey. J Bone Miner Metab, 28(1), 55-59. doi: 10.1007/s00774-009-0097-z

Orsini, L. S., Rousculp, M. D., Long, S. R., &; Wang, S. (2005). Health care utilization
and expenditures in the United States: a study of osteoporosis-related fractures.
Osteoporos Int, 16(4), 359-371. doi: 10.1007/s00198-004-1694-2

Ottenbacher, K. J., Smith, P. M., Illig, S. B., Peek, M. K., Fiedler, R. C., &; Granger, C.
V. (2003). Hospital readmission of persons with hip fracture following medical rehabilitation. Arch Gerontol Geriatr, 36(1), 15-22.

Pike, C. T., Birnbaum, H. G., Schiller, M., Swallow, E., Burge, R. T., &; Edgell, E. T.
(2011). Prevalence and costs of osteoporotic patients with subsequent non-vertebral fractures in the US. Osteoporos Int, 22(10), 2611-2621. doi: 10.1007/s00198-010-1494-9

Riggs, R. V., Roberts, P. S., Aronow, H., &; Younan, T. (2010). Joint Replacement and Hip Fracture Readmission Rates: Impact of Discharge Destination. PM&;R, 2(9), 806-810. doi: 10.1016/j.pmrj.2010.05.008

Shao, C. J., Hsieh, Y. H., Tsai, C. H., &; Lai, K. A. (2009). A nationwide seven-year
trend of hip fractures in the elderly population of Taiwan. Bone, 44(1), 125-129. doi: 10.1016/j.bone.2008.09.004

Shyu, Y. I., Chen, M. C., Liang, J., Lu, J. F., Wu, C. C., &; Su, J. Y. (2004). Changes in
quality of life among elderly patients with hip fracture in Taiwan. Osteoporos Int, 15(2), 95-102. doi: 10.1007/s00198-003-1533-x

Tsai, C. H., Muo, C. H., Fong, Y. C., Lo, W. Y., Chen, Y. J., Hsu, H. C., &; Sung, F. C.
(2011). A population-based study on trend in incidence of distal radial fractures in adults in Taiwan in 2000-2007. Osteoporos Int, 22(11), 2809-2815. doi: 10.1007/s00198-010-1489-6

Vanasse, A., Courteau, J., Cohen, A. A., Orzanco, M. G. &; Drouin, C. (2010).
Rural-urban disparities in the management and health issues of chronic diseases in
Quebec (Canada) in the early 2000s. Rural and Remote Health, 10, 1548.

World Health Organization (2012, August 6). Chronic diseases and health promotion.
Retrieved from http://www.who.int/chp/topics/rheumatic/en/

World Health Organization Study Group. (1994). Asseement of fracture risk and its application to screening for postmenopausal osteoporosis. WHO Technical Report
Series, 843.

Yang, N. P., Chan, C. L., Yu, I. L., Lee, C. Y., &; Chou, P. (2010). Estimated prevalence
of orthopaedic fractures in Taiwan--A cross-sectional study based on nationwide
insurance data. Injury, 41(12), 1266-1272. doi: 10.1016/j.injury.2010.05.025