臺灣博碩士論文加值系統

前言
近年來隨著平均餘命的增加，加上醫學科技進步，過去死亡的重症病患，如今可以使用呼吸器等相關維生設備延續生命。VAP好發于長期利用呼吸器且疾病嚴重度高的病人，使病人的生命產生重大的威脅，也是造成高死亡率的重要原因。本研究嘗試以群組化軌跡模式(Group Based Trajectory Model ,GBTM)，分析呼吸器病人的長期資料，主要目的是以GBTM來瞭解重複發生VAP的感染風險因子。

研究方法
本研究主要針對呼吸器病人進行重複觀察和長期的追蹤，將觀察值依照本研究之目的，使用群組化軌跡模式(Group-Based Trajectory Modeling , GBTM)進行分析，期望能瞭解影響呼吸器病人罹患VAP的主要影響因數及其影響力。
本研究使用卡方檢定、變異數分析及T檢定，進一步以GBTM進行呼吸器依賴病人罹患呼吸器相關肺炎之發展軌跡分析，並以邏輯斯回歸或多變項邏輯斯回歸探討影響發展軌跡類型之相關因素。

研究結果
VAP研究族群各項變項與照護結果關係，可命名為高發生率、中發生率、低發生率三組，由資料上顯示，在入住呼吸照護病房後轉院的分佈上是有差異的(P<0.05)。平均年齡的部分，高發生率組為62.2歲，中發生率組為73.44歲，低發生率組為74.18歲，且分佈上有差異(P<0.05)。病患入院後VAP次數方面，第一年、第二年、第三年的資料在分佈上皆有非常顯著的差異(P<0.001)。在照護醫師數及罹患VAP前一年之合併症分數(CCI)的資料在統計上亦有顯著差異(P<0.05)。

討論及結論
本研究結果發現，入住呼吸照護病房病患的年齡、有無轉院、有無轉入加護病房、照護醫師數、合併症分數等，對於影響呼吸器病人罹患VAP具有顯著影響，此影響是長期且持續性的。
臺灣正面臨人口急速老化及重症醫療技術必須持續提升的問題，雖然近年政府政策大力推行安寧療護，但人口老化及重症疾病的趨勢，還是會令使用呼吸器延長生命的病患不斷增加，「預防勝於治療」是整個醫療照護體系面對VAP最重要的議題。

Introduction
In recent years, with the increase of life expectancy, the help of the progress of medical science and technology, the critically ill patients who would die in the past, now, they can use the ventilator and other related subsist equipments to prolong their life. VAP is easy to occur in long-term use of a ventilator and the patients with severe disease, which threatens the patient's life seriously, also it is the main reason of causing the high mortality.This study tries to adopt the Group Based the Trajectory Model (GBTM) to analyze the correlation of VAP observed values collected at different times, which from the long-term data of ventilator patients. The main purpose of this study is to learn the multiple productions of risk factors in VAP infection by GBTM.
Methods
This study conducts the repeated observation and long-term track mainly for the ventilator patients, as the purpose of this study, the observation value will be analyzed by Group-Based Trajectory Modeling (GBTM), and expected to learn the main factors of affecting the ventilator patients suffering from VAP and the influence.
This study by adopting Chi square test, ANOVA and T test, and GBTM in further to analyze the developmental trajectories of ventilator-dependent patients suffering from ventilator associated pneumonia, and by logistic regression and multinomial logistic regression to discuss the related factors of influencing the type of developmental trajectories.
Results
The relationship between each variables of VAP ethnic and care results can be named as high incidence, middle incidence and low incidence, the data show that there have difference on the distribution (P < 0.05) of transfer after in respiratory care ward(RCW). As for the average age, the high incidence is 62.2 years old, the middle incidence is 73.44 years old, the low incidence is 74.18 years old, and there is the distribution difference (P < 0.05). In terms of VAP times after the patients in hospital, there have significant distribution difference (P < 0.001) in the data of the first year, the second years and the third years. And there also have statistically significant difference (P < 0.05) in the date of care physicians and CCI of one year before suffering from VAP.
Discussion and Conclusion
This study found that, for the patients in respiratory care ward(RCW), their age, any transfer, any change over to ICU, the number of care physicians, CCI, etc. have significant impact on ventilator patients suffering from VAP , the impact is long-term and sustainable.
Taiwan is facing the problems of rapid aging population, and must improve the intensive medical technology. In recent years, the government's policy pushes forward the hospice care, however, the trend of aging population and critical illness still can make the patients using ventilator to prolong life increase, "prevention is better than cure" is the important issues of whole health insurance system in the face of VAP.

目錄

誌謝 i
中文摘要 ii
英文摘要 iv
目錄 vi
表目錄 viii
圖目錄 ix
第一章 前言 1
第二章 研究設計及方法 4
第一節 研究設計 4
第二節 資料來源 5
第三節 樣本描述 6
第四節 研究變項及定義 7
第五節 統計方法 10
第三章 研究結果 12
第四章 討論及結論 27
第一節 討論 27
第二節 結論 31
第三節 研究限制 32
參考文獻 33
附錄-English Manuscript 39


表目錄
表一 有效預防VAP發生的措施 3
表二 自變項、依變項、控制變項之操作型定義 9
表三 呼吸器相關肺炎(VAP)研究族群基本特質(BASELINE) 15
表四 呼吸器相關肺炎(VAP)研究族群各項變項與照護結果關係(以3組比較) 18
表五 呼吸器相關肺炎(VAP)研究族群各項變項與照護結果之影響力(以低發生率組別為基準進行比較) 21
表六 呼吸器相關肺炎(VAP)研究族群各項變項與照護結果關係(以2組比較) 23
表七 呼吸器相關肺炎(VAP)研究族群各項變項與照護結果之影響力(高發生率組合併中發生率組後再與低發生率組別進行比較) 26


圖目錄
圖一VAP次數軌跡分布曲線 13

參考文獻
1. Shai Efrati, MD, Israel Deutsch, BSc, Massimo Antonelli, MD, Peter M. Hockey, MD, Ronen Rozenblum, PhD, MPH and Gabriel M. Gurman, MD. (2010). Ventilator-associated pneumonia: current status and future recommenndations. Journal of Clinical Monitoring and Computing (2010) 24:161–168.
2. Chawla R. (2008). Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries. Journal of Infect Control (2008); 36: S93–S100.
3. American Thoracic Society–Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Journal of Respir Crit Care Med (2005); 171:388–416.
4. Lu, H., Hung. J., Chen. C., Fan, P., & K.(2010). The incidence rates of prolonged mechanic ventilation, and the successful weaning rates and health care expenditures of patients experiencing this health condition in Taiwan. Paper presented at 2010 台灣人口學年會發表論文。
5. 李純馥(2005)。呼吸器依賴患者整合性照護支付制度之未來展望專題演講。中華民國呼吸照護學會研討會。高雄：義守大學會議廳。
6. 黃煌雄、沈美真、劉興善(2011)。全民健保總體檢。p.515-536
7. 林燕堂(2007)。台灣長期呼吸器依賴病患IDS整合性照護計畫下呼吸照護病房(RCW)照護結果之分析─以中部地區七間醫院為例。長榮大學。台南。
8. Francois Barbier, Antoine Andremont, Michel Wolff, and Lila Bouadma.(2013). Hospital-acquired pneumonia and ventilator-associated pneumonia: recent advances in epidemiology and management. Journal of Curr Opin Pulm Med (2013), 19:216–228.
9. Blamoun J, Alfakir M, Rella ME, et al. (2009). Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in themedical Intensive care unit. Journal of Infection Control (2009); 37(2):172–175.
10. Anand N, Kollef MH. (2009). The alphabet soup of pneumonia: CAP, HAP, HCAP, NHAP, and VAP. Journal of Semin Respir Crit Care Med (2009); 30:3–9.
11. 劉偉倫、張炳欽、陳婉玲、林玉秀、林心嵐、陳家容、賴志政 (2013)。導入跨領域團隊組合式照護降低呼吸器相關肺炎發生率。醫療品質雜誌2013年3月號，第7卷第2期，85-94.
12. Muscedere J.G., Martin C.M., Heyland D.K. (2008). The impact of ventilator-associted pneumonia on the Canadian health care system. Journal of Crit Care, 23(1), 5-10.
13. Dahmash, N., & Chowdhury,M.(1994).Re-evaluation of pneumonia requiring admission to an intensive care unit: a prospective study. Thorax(1994), 49(1),71-76.
14. Forel JM, Voillet F, Pulina D, et al. (2012). Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy. Journal of Crit Care (2012); 16:R65.
15. Bouadma L, Wolff M, Lucet JC. (2012). Ventilator-associated pneumonia and its prevention. Journal of Curr Opin Infect Dis (2012); 25:395-404.
16. Rello J, Ollendorf DA, Oster G, et al. (2002) .VAP Outcome Scientific Advisory Group Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Journal of Chest (2002); 122(6): 2115-2121.
17. Ibrahim EH, Tracy L, Hill C, Fraser VJ, Kollef MH.(2001).The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Journal of Chest (2001); 120(2): 555-561.
18. Marcos I. Restrepo , MD, MSc; Antonio Anzueto , MD; Alejandro C. Arroliga , MD; Bekele Afessa , MD; Mark J. Atkinson , PhD; Ngoc J. Ho , PhD; Regina Schinner , Dipl-Stat; Ronald L. Bracken; Marin H. Kollef , MD.(2010). Economic Burden of Ventilator-Associated Pneumonia Based on Total Resource Utilization. Journal of Infection Control and Hospital Epidemiology, Vol. 31, No. 5 (May 2010), 509-515.
19. 毛蕙心、葉淑真、李聰明 (2013)。呼吸治療之感染管制。醫療品質雜誌2013年1月號，第7卷第1期，62-68.
20. Sheng W.H., Chie W.C., Chen Y.C., Hung C.C., Wang J.T.,Chang S.C.(2005). Impact of nosocomial infections on medical costs, hospital stay, and outcome in hospitalized patients. Journal of Formos Med Assoc, 104(5), 318-326.
21. Weigelt J.A., Lipsky B.A., Tabak Y.P., Derby K.G., Kim M., Gupta V.(2009). Surgical site infections: Causative pathogens and associated outcomes. Journal of Infect Control (2009) , 38(2), 112-120.
22. 楊智傑(2010)。呼吸器相關肺炎對醫療資源耗用之長期影響。國立陽明大學。台北市。
23. Hunter J.D. (2006). Ventilator associated pneumonia. Postgrad Med J, 82(965), 172-178.
24. Hess DR. (2005). Noninvasive positive-pressure ventilation and ventilator associated pneumonia. Respir Care (2005); 50:924–929.
25. Caruso P, Denari S, Ruiz SA, et al. (2009). Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Med (2009); 37:32-38.
26. Drakulovic MB, Torres A, Bauer TT, et al. (1999).Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet (1999); 354:1851–1858.
27. Delaney A, Gray H, Laupland KB, Zuege DJ. (2006). Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care (2006); 10:R70.
28. Labeau SO, Van de Vyver K, Brusselaers N, et al. (2011). Prevention of ventilator associated pneumonia with oral antiseptics: a systematic review and metaanalysis. Lancet Infect Dis (2011); 11:845–854.
29. Lawal, B.(2003).Categorical Data Analysis with SAS and SPSS Applications,London: Lawrence Erlbaum Associates
30. 吳肖琪、陳啟禎(2004)。加護病房院內感染指標—影響呼吸器相關肺炎感染因素之探討。臺灣公共衛生雜誌，23(6)，440-446。
31. 嚴小燕、彭銘業、楊美紅、陳依雯、張峰義(2001)。某醫學中心Acinetobacter baumannii院內感染調查。感染控制雜誌，2001；11：216-226。
32. 李珮琳、呂欣茹(2005)。加護病房之病人安全─以呼吸器相關肺炎(VAP)感染與Acinetobactor baumannii相關因素分析及護理措施為例。慈濟醫學，2005；17：47-50。
33. 林金龍(2003)。全民健康保險呼吸器依賴患者整合照護試辦計畫實施成效之研究。國立陽明大學。台北。
34. Lim, SC, Doshi V, Castasus B, Lim JK, Mamun K: Factors causing delay in discharge of elderly patients in an acute care hospital. Ann Acad Med Singapore 2006; 35: 27-32.
35. 吳肖琪、林麗嬋、藍忠孚、吳義勇(1998)。全民健保實施後急性病床住院病患超長住院情形之分析。中華衛誌 1998；17：139-47。
36. 江昇達、王勝廣、高東煒、方文輝、張耀文、高森永、周稚傑(2011)。高齡患者長期住院醫療利用影響因子之探討。台灣老年醫學暨老年學雜誌 2011；6(2)：86-104
37. 紀昭全(2008)。台灣地區呼吸器依賴患者整合性照護的效率評估─資料包絡分析法之應用。國立中山大學。高雄。
38. 中央健保署：「全民健康保險呼吸器依賴患者整合性照護前瞻性支付方式」試辦計畫給付項目及支付標準(102年1月1日起啟用)。支付通則公告版，2014.06.14摘自http://www.nhi.gov.tw/Resource/webdata/23292_2_%E5%91%BC%E5%90%B8%E5%99%A8%E8%A9%A6%E8%BE%A6%E8%A8%88%E7%95%AB%E6%94%AF%E4%BB%98%E6%A8%99%E6%BA%96-102.01.01%E8%B5%B7(102.03.11%E6%9B%B4%E6%96%B0).pdf
39. 楊育純、林朝順。轉診病人急診室延遲原因分析。臺灣急診醫學會醫誌6:1 民93.03 頁261-268
40. 陳明智(2010)。地區醫院急診病患轉院現況調查-以南投縣某地區醫院為例。亞洲大學。台中市。
41. 王少谷、廖訓禎、胡百敏、馬雲鵬、張玉龍、葉時烊、林作彥、金霍歌、王佐才、彭錦池(2002)。急診轉診制度執行現況之探討--以某區域醫院及某地區醫院之經驗為例 。中華民國急診會醫誌4:2民91.06頁82-90
42. Arnold, F. W., LaJoie, A. S., Brock, G. N., Peyrani, P., Rello, J., Menéndez, R., et al. (2009).Improving outcomes in elderly patients with community-acquired pneumonia by adheringto national guidelines: Community-acquired pneumonia organization international cohortstudy results. Archives of Internal Medicine, 169(16), 1515-1524.
43. Johnstone, J., Marrie, T. J., Eurich, D. T., & Majumdar, S. R. (2007). Effect of pneumococcal vaccination in hospitalized adults with community-acquired pneumonia. Archives of Internal Medicine, 167(18), 1938-1943.
44. McCabe, C., Kirchner, C., Zhang, H., Daley, J., & Fisman, D. N. (2009). Guideline-concordant therapy and reduced mortality and length of stay in adults with community-acquired pneumonia: Playing by the rules. Archives of Internal Medicine, 169(16), 1525-1531.
45. 王庭荃、楊長興（2008）。醫師年資、醫療服務量與消化性潰瘍治療效果之相關研究。臺灣公共衛生雜誌，27(1)，57-66。
46. 柯玲晶、譚醒朝、譚家惠（2007）。Charlson 合併症指數對全民健康保險資料庫適用性之探討。臺灣公共衛生雜誌，26(6)，491-498。
47. 羅健銘、陳素秋、賴允亮、林家瑾、陳建仁（2007）。住院癌末病患照護型態對住院醫療費用與住院天數之影響。臺灣公共衛生雜誌，26(4)，270-282。
48. Lin, H. C., Xirasagar, S., Chen, C. H., & Hwang, Y. T. (2008). Physician's case volume of intensive care unit pneumonia admissions and in-hospital mortality. American Journal of Respiratory and Critical Care Medicine, 177(9), 989-994.
49. Charlson, M. E., Pompei, P., Ales, K. A., & 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.
50. Birim, O., Kappetein, A. P., Goorden, T., Van Klaveren, R. J., & Bogers, A. J. J. C. (2005).Proper treatment selection may improve survival in patients with clinical early-stage nonsmall cell lung cancer. Annals of Thoracic Surgery, 80(3), 1021-1026.
51. 朱峻賢，軍方及非軍方醫院的權屬別特性與肺炎病人於住院期間死亡之關係探討。未發表的碩士論文，2010，臺北，臺北醫學大學
52. Agrafiotis M, Siempos II, Ntaidou TK, Falagas ME. Attributable mortality of ventilator-associated pneumonia: a meta-analysis. Int J Tuberc Lung Dis 2011; 15:1154–1163.
53. Melsen WG, Rovers MM, Koeman M, Bonten MJ. Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies. Crit Care Med 2011; 39:2736–2742.
54. Timsit JF, Zahar JR, Chevret S. Attributable mortality of ventilator-associated pneumonia. Curr Opin Crit Care 2011; 17:464–471.
55. De Maeseneer JM, De Prins L, Gosset C, Heyerick J(2003). Provider continuity in family medicine: does it make a difference for total health care costs? Ann Fam Med 2003;1:144-8.
56. Alpert JJ, Robertson LS, Kosa J, Heagarty MC, Haggerty RJ(1976). Delivery of health care for children: report of an experiment. Pediatrics 1976;57:917-30.
57. Mainous AG III, Gill JM(1998). The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician? Am J Public Health 1998;88:1539-41.
58. 黃郁清、支伯生、鄭守夏(2010)。照護連續性與醫療利用之相關性探討。台灣衛誌 2010；29(1)：46-53
59. 陳啟禎、鄭守夏(2013)。照護連續性之文獻回顧。台灣衛誌 2013；32(2)：116-12
60. 鄧世雄(2010)。台灣連續性、整合性之長期照護服務發展。2010年兩岸社會福利學術研討會P.197-209。