臺灣博碩士論文加值系統

摘要
目的:
本研究嘗試運用全民健保資料庫，來分析國內糖尿病合併下肢血管阻塞的病人，接受下肢血管處置，是否能減少這些病人日後產生下肢大截肢的機會，進一步探討這些病患，住院醫療資源的使用情形。期望藉此研究成果，提供衛生決策當局，做為將來國內這一類型病人治療的參考，以及合理使用健保資源的依據。
方法:
利用國家衛生研究院全民健保資料庫，從特定主題分檔:糖尿病(DB)及住院醫療費用清單明細檔(DD)，找出糖尿病合併下肢動脈粥狀硬化的病人做為研究樣本。追蹤這些病人，在之後7年內(2002~2008)接受下肢血管處置的總人數、未接受下肢血管處置的總人數、下肢大截肢人數、申報健保局之住院費用；探討糖尿病合併下肢動脈阻塞的人，是否因接受下肢血管處置而減少大截肢的發生，以及住院醫療資源的使用情形。
結果:
統計2002年糖尿病合併週邊血管阻塞的病患總人數共1463人，追蹤這些病人從2002年到2008年的住院資料，有接受血管處置的病人213人，其中63位(29.58%)有產生下肢大截肢；無接受血管處置的病人1250人，其中263位(21.04%)有產生下肢大截肢。顯示有接受血管處置的病人，下肢大截肢的比例比較高(p=0.006<0.05)。有無接受血管處置在平均住院日數沒有統計學意義(p=0.2258)，但是在平均住院費用兩者確有統計意義(p<0.05)。住院費用以有接受血管處置又發生大截肢病人最高(NT$441,737)，有接受血管處置無發生大截肢病人其次(NT$216,372)，無接受血管處置有發生大截肢病人較少(NT$166,962)。使用邏輯式迴歸分析，發現有接受血管處置的病人比沒接受血管處置的病人，下肢大截肢機會高1.4279倍。
結論: 接受血管處置術無法減少糖尿病合併週邊血管阻塞的病患，日後發生下肢大截肢的機會。在有限的醫療資源下，對於這些病患，我們應該要審慎思考血管處置術的執行。
關鍵字：糖尿病、下肢動脈粥狀硬化、血管處置術、下肢大截肢

Abstract
OBJECTIVE：Using the National Health Insurance research database, we investigated diabetic patients in Taiwan with peripheral artery occlusive disease. To see if revascularization procedures would protect patients from major lower limb amputation. Also, we analyze the utilization of health care in admission. We expect that the results will be useful for the health administration to make a medical policy for these patients and more fully utilization of the National Health Insurance.
METHODS：We used the National Health Insurance research database from the National Health Research Institute. We collected from the ambulatory care claim in the diabetic special topic files, the patients in 2002 who had been diagnosed with both diabetes and peripheral artery occlusive disease (PAOD). We followed up with these patients for 7 years (2002-2008). We collected the numbers of patients who had revascularization procedures, major lower limb amputation and inpatient claims.
RESULTS：The total number of patients with diabetes and PAOD from 2002 ambulatory care claim was 1463. There were 213 patients with revascularization from the inpatient claims databases(2002-2008). 63(29.58%) of these 213 patients suffered from major lower limb amputation. There were 1250 patients without revascularization and 263(21.04%) of these patients suffered from major lower limb amputation. The revascularized patients had significant higher rates of major lower limb amputation than those without revascularization (p=0.006<0.05). No significant difference was noted of the length of the hospital stay between revascularized and non-revascularized patients(p=0.2258). There was significant difference of inpatient claims between revascularized and non-revascularized patients(p<0.05). The highest report of an inpatient claim occurred in the revascularized patients with major lower limb amputation(NT$441,737). The 2nd highest one occurred in the revascularized patients without major lower limb amputation(NT$216,372). The 3rd highest one occurred in the non-revascularized patients with major lower limb amputation(NT$166,962). In the logistic regression analysis, revascularization and older age were significant predictors of major lower limb amputation (revascularization odds ratio 1.4279).
CONCLUSION: Revascularization does not reduce the major lower limb amputation in these DM patients with PAOD. Because of limited medical resources, we should carefully consider applying the revascularization procedure for future patients.
Keywords：Diabetes, Peripheral artery occlusive disease, Revascularization, Major lower limb amputation

目 錄
第一章 緒論 1
第一節 研究背景及動機 1
第二節 研究目的 4
第三節 研究問題與假設 5
第二章 文獻查證 6
第一節 糖尿病與下肢截肢的關係 6
第二節 下肢血管處置的介紹 8
第三節 下肢血管處置對糖尿病足的成效 9
第三章 研究方法 13
第一節 研究假設與架構 13
一、研究假設 13
二、研究架構 13
第二節 研究對象與資料來源處理 14
一、研究對象 14
二、資料來源與處理 14
第三節 研究變項與操作型定義 16
一、研究變項 16
二、操作型定義 17
第四節 資料處理與分析方法 19
一、描述性統計分析 19
二、推論性統計分析 19
第四章 研究分析與結果 20
第一節 描述性統計分析 20
第二節 推論性統計分析 26
第五章 討論與建議 29
第一節 研究討論 29
第二節 研究假設驗證 32
第三節 研究限制 33
第四節 建議 34
參考文獻 35
一、中文文獻：35
二、英文文獻：35
圖 次
圖3-1 本研究架構圖 13
圖3-2本研究流程 18
表 次
表1-1 2002-2011台灣糖尿病死因順位、死亡人數、每十萬人口死亡率統計 3
表1-2 2000-2009台灣糖尿病人數及盛行率統計 3
表2-1國內健保支付截肢手術費用 7
表2-2台灣地區糖尿病患各年度下肢大截肢人次 7
表2-3 繞道手術及血管整形術費用 8
表2-3 不支持血管處置能降低大截肢相關研究整理 10
表2-4 支持血管處置能降低大截肢相關研究整理 12
表3-1 研究樣本ICD-9 codes 14
表3-2門診處方及治療明細檔本研究有關的欄位整理 14
表3-3住院醫療費用清單明細檔本研究有關的欄位整理 15
表3-4醫事機構基本資料檔本研究有關的欄位整理 15
表3-5變項說明表 17
表4-1有無接受血管處置病患的描述性統計分析 21
表4-2民國九十一年糖尿病合併下肢血管阻塞病人於7年內追蹤分析 23
表4-3研究樣本之共病性分布情形 24
表4-4研究樣本之住院資源使用情形(不論任何原因住院) 25
表4-5研究樣本之住院資源使用情形(因血管處置或截肢原因住院) 25
表 4-6有無接受血管處置其大截肢數差異是否有達到統計上顯著的意義 26
表 4-7有無接受血管處置其住院日數、住院費用等差異是否有達到統計上顯著的意義 26
表 4-8有接受血管處置的病患在大截肢數,住院日數,住院費用,年齡是否有任何變項之間存在高度相關情形 26
表 4-9無接受血管處置的病患在大截肢數,住院日數,住院費用, 年齡是否有任何變項之間存在高度相關情形 27
表4-10有無接受血管處置其大截肢的機率是否有差 28
表4-11將病患共病性列入分析其大截肢的機率是否有差異 28
表 5-1本研究假設與結果彙整表 30

一、中文文獻：
1. 行政院衛生署，民國100年統計年報。
2. 內政部統計處，民國100年統計處簡易生命表。
3. 潘品蓉 (2009)，老年慢性病患之共病性對醫療資源使用影響之探討-以糖 尿病為例，醫務管理研究所，2009國立中山大學。碩士論文。
4. 丁毅 (2006)，非創傷性糖尿病足趾截肢健保費用分析，傷害防治學研究所，2006台北醫學大學。碩士論文。
5. 蔡世澤(2000)，台灣糖尿病照護現況與省思。臨床醫學2000；45：316-320。
6. 戴東原(1994)，台灣地區糖尿病流行病學。遺傳學與分子生物學雜誌，5(4)：83。
7. 中華民國糖尿病衛教學會網。http://www.tade.org.tw/index.asp

二、英文文獻：
1. Attinger CE, Ducic I, Neville RF etc. (2002). The relative roles of aggressive wound care versus revascularization in salvage of the threatened lower extremity in the renal failure diabetic patient. Plast Reconstr Surg 109:1281-1290.
2. Apelqvist JAP, Lepantalo MJA. (2012). The ulcerated leg: when to revascularize. Diabetes Metab Res Rev, 28(suppl 1):30-35.
3. Chen HF, Ho CA, Li CY. (2006). Age and sex may significantly interact with diabetes on the risks of lower extremity amputation and peripheral revascularization procedures. Diabetes Care, 29:2409-2414.
4. Dorweiler B, Neufang A, Schmiedt W, Oelert H. (2002). Pedal arterial bypass for limb salvage in patients with diabetes mellitus. Eur J Vasc Endovasc Surg 24:309-313.
5. Faglia E, Clerici G, Clerissi J, Gabrieli L, Losa S, Mantero M, Caminiti M, Curci V, Lupattelli T, Morabito A. (2006). Early and five year amputation and survival rate of diabetic patients with critical limb ischemia: Data of a cohort study of 564 patients. Eur J Vasc Endovasc Surg 32:484-490.
6. Faglia E, Clerici G, Clerissi J, Gabrielli L, Mantero M, Caminiti M, Curci V, Quarantiello A, Luppattelli T, Morabito A. (2009). Long term prognosis of diabetic patients with critical limb ischemia. Diabetes Care 32:822-827.
7. Faglia E, Clerici G, Caminiti M, Curci V, Clerissi J, Losa S, Casini A, Morabito A. (2010). Mortality after major amputation in diabetic patients with critical limb ischemia who did and did not undergo previous peripheral revascularization Data of a cohort study of 564 consecutive diabetic patients. Journal of Diabetes and Its Complications, 24:265-269. 
8. Faglia E, Clerici G, Losa S, Tavano D, Caminiti M, Miramonti M, Somalvico F, Airoldi F. (2012). Limb revascularization feasibility in diabetic patients with critical limb ischemia: Results from a cohort of 344 consecutive unselected diabetic patients evaluated in 2009. Diabetes Res Clin Pract, 95: 364-371.
9. Fatma AM, Mohammed ES. (2007). Prevalence of risk factors for diabetic foot complications. BMC Family Practice, 8(59):1-9.
10. Feinglass J, Brown JL, Sosasso A, Sohn MW, Manheim LM, Shah SJ, Pearce WH. (1999). Rates of lower-extremity amputation and arterial reconstruction in the United States, 1979 to 1996. Am J Public Health, 89:1222-1227.
11. Gordois A, Scufham P, Shearer A, Oglesby A, Tobian JA. (2003).The health care costs of diabetic peripheral neuropathy in the U.S. Diabetes Care, 26:1790-1795.
12. Gu YQ, Zhang J, Qi LX, Yu HX, Li JX, Li XF. (2007). Vascular surgery and diabetic foot revascularization. Chin Med J, 120:106-109.
13. Hallett JW, Byrne J, Gayari MM, Dlstrup DM, Jacobsen SJ, Gray DT. (1997).Impact of arterial surgery and balloon angioplasty on amputation: A population-based study of 1155 procedures between 1973 and 1992. Journal of vascular surgery 25:29-38.
14. Hinchliffe RJ, Andros G, Apelqvist J, Bakker K, Fiedrichs S, Lammer J, Lepantalo M, Mills JL, Reekers J, Shearman CP, Valk G, Zierler RE, Schaper NC. (2012) A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev, 28(suppl 1):179-217.
15. Holstein P, Ellitsgaard N, Bornefeldt Olsen B, Ellitsgaard V. (2000). Decreasing incidence of major amputations in people with diabetes. Diabetologia 43:844-847.
16. Houtum WH, Lavery LA, Harkless LB. (1996). The impact of diabetes-related lower-extremity amputations in the Netherlands. Journal of Diabetes and its complications, 10;6:325-330.
17. Jeffcoate WJ, Harding KG. (2003). Diabetic foot ulcers. The Lancet, 361:1545-1551.
18. Jiang YD, Chang CH, Tai TY, Chen JF, Chuang LM. (2012). Incidence and prevalence rates of diabetes mellitus in Taiwan: Analysis of the 2000-2009 nationwide health insurance database. Journal of the Formosan Medical Association, 111:599-604.
19. Johnson BL, Glickman MH, Bandyk DF, Esses GE.(1995). Failure of foot salvage in patients with end-stage renal disease after surgical revascularization. J Vasc Surg,22:280-286.
20. Khalifa AA, Gueret G, Badra A, Gouny P. (2009). Diabetic critical ischemia of lower limbs: distal arterial revascularisation. Acta Chir Belg, 109(3):321-326.
21. Kucan JO, Robson MC. (1986). Diabetic foot infections: fate of the contralateral foot. Plast Reconstr Surg, 77(3):439-441.
22. Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, Holt PJE. (2010). Epidemiological study of lower limb amputation in England between 2003 and 2008. British Journal of Surgery, 97:1348-1353.
23. Niekerk LJA, Stewart CPU, Jain AS. (2001). Major lower limb amputation following failed infrainguinal vascular bypass surgery: a prospective study on amputation levels and stump complications. Prosthetics and Orthotics International, 25:29-33.
24. Regnarson Tennvall G, Apelqvist J. (2004). Health-economic consequence of diabetic foot lesions. Clinical Infectious Disease, 39(suppl 2):132-139.
25. Reiber GE, Boyko EJ, Smith DG. (1995). Lower extremity foot ulcers and amputations in diabetes. Diabetes in America, chapter 18:409-422.
26. Shamoun F, Sural N, Abela G. (2008). Peripheral artery disease: therapeutic advances. Expert Rev Cardiovasc Ther, 6(4):539-553.
27. Tseng CH, Tai TY, Chen CJ, Lin BJ. (1994). Ten-year clinical analysis of diabetic leg amputees. Journal of the Formosan Medical Association, 93(5):388-392.
28. Tunis SR, Bass EB, Steinberg EP. (1991). The use of angioplasty, bypass surgery, and amputation in the management of peripheral vascular disease. N Engl J Med, 325:556-562.
29. Uccioli L, Gandini R, Giurato L, Fabiano S, Pampana E, Spallone V, Vainieri E, Simonetti G. (2010). Long-term outcomes of diabetic patients with critical limb ischemia followed in a tertiary referral diabetic foot clinic. Diabetes Care, 33:977-982.
30. Vamos EP, Bottle A, Majeed A, Millett C. (2010). Trends in lower extremity amputations in people with and without diabetes in England, 1996-2005. Diabetes Res Clin Pract, 87: 275-282.
31. Walters DP, Catling W, Mullee MA, Hill RD. (1992). The distribution and severity of diabetic foot disease: a community study with comparison to a non-diabetic group. Diabetic Medicine, 9(4):354-358.
32. Wong KC, Wang Z. (2006).Prevalence of type 2 diabetes mellitus of Chinese populations in Mainland China, Hong Kong, and Taiwan. Diabetes Res Clin Pract, 73(2): 126-34.
33. Wrobel JS, Robbins J, Armstrong DG. (2006). The high-low amputation ratio: A deeper insight into diabetic foot care? The Journal of Foot &; Ankle Surgery 45(6):375-379.
34. Xiao L, Huang DS, Tong JJ, Shen J. (2012). Efficacy of endoluminal interventional therapy in diabetic peripheral arterial occlusive disease: a retrospective trial. Cardiovascular Diabetology, 11(17):1-11.
35. Yang Y, Ostbye T, Tan SB, Abdul Salam ZH, Ong BC, Yang KS. (2011) Risk factors for lower extremity amputation among patients with diabetes in Singapore. Journal of Diabets and Its Complications, 25:382-386.