臺灣博碩士論文加值系統

背景：尿失禁(Urinary incontinence)是一種常見且令人困擾的疾病，會嚴重影響生活品質。子宮切除術(Hysterectomy)為婦女第二常見手術，子宮切除術與尿失禁皆為女性健康重要議題。近來已有一些研究針對子宮切除術與尿失禁發生的關連性。這些研究大部分為問卷調查，缺少病歷診斷資料，且未排除子宮切除術前已有尿失禁之患者。本研究將探討近年子宮切除術的盛行率，子宮切除術與發生尿失禁相關因素。
方法：本研究利用國家衛生研究院全民健康保險特殊需求，此資料庫涵蓋1997年至2010年所有住院申報資料。據此，我們探討台灣近年來子宮切除術的趨勢並計算醫院及醫師子宮切除服務量。在此研究期間，共有327,507人進行過子宮切除術；另以國家衛生研究院全民健保2005年百萬抽樣歸人檔，涵蓋1997年至2010年健保門診、急診與住院申報資料，探討子宮切除術與術後發生尿失禁之相關。子宮切除組選取良性子宮疾病進行子宮切除術之患者，並利用1:3配對資料，配對條件為與子宮切除組同年出生、就診醫院相同、且於子宮切除組手術該年有就診紀錄，並排除進入研究前已有尿失禁診斷或手術、生殖器脫出症診斷及相關手術者，共得子宮切除組10,415人，未子宮切除組31,245人。
結果：在1997-2010年間，台灣年齡標準化子宮切除率呈現下降趨勢，各術式變化與國際趨勢相似。在台灣，健保支付價格調整會影響子宮切除術整體的施行的改變。農保、勞保及公保對於未滿45歲接受子宮切除術之婦女提供失能給付.這樣的情況恐引起道德風險危害 (Moral Hazard)，失能給付對於較低社經地位者會有較高的誘因。關於子宮切除術與尿失禁的關係，當調整相關危險因子後，子宮切除組對於未子宮切除組其發生尿失禁之Hazard ratio值為1.87，95%信賴區間為1.71-2.04；接受抗尿失禁手術之Hazard ratio值為1.53，95%信賴區間為1.08-2.18，即子宮切除術與病患術後發生尿失禁及接受抗尿失禁手術有顯著正相關。各類型子宮切除術式術除腹式次全子宮切除術外,皆會顯著增加尿失禁風險。當調整相關危險因子後，手術醫院子宮切除術年服務量與手術醫師年齡，與其病患術後尿失禁發生率呈現負相關，低社經地位者與有合併症之病患術後尿失禁發生率較高。
結論：本研究發現婦女因良性疾病接受子宮切除術後與之後發生尿失禁有顯著相關，且此相關性受到醫院服務量及醫師年齡之影響。據此，建議健保署可公開揭露手術醫院和醫師子宮切除術年服務量、子宮切除術後相關品質指標。農、公及勞保的相關主管機關，應重新評估對於45歲以下婦女接受子宮切除術給予失能津貼之規定。建議婦產科醫師在病患因良性疾病接受子宮切除術前，詳細解釋手術優缺點。醫師應告知病患應考量未來發生尿失禁可能之風險,並告知是否有其他替代治療選擇。對於已經接受子宮切除術病患，應加強術後防治尿失禁之衛生教育。

Background：Urinary incontinence is a common and bothersome symptom and can seriously affect patients’ quality of life. Hysterectomy is the second most common major surgical procedure in women. Both urinary incontinence and hysterectomy are important health issues for women. Several studies on the association between urinary incontinence and hysterectomy have been conducted recently. Most of them were based on questionnaires, and rarely used clinical data. In addition, most of the previous studies did not exclude prior urinary incontinence history. This study aims to investigate the prevalence of hysterectomy during the past decade and factors associated with subsequent urinary incontinence after hysterectomy.
Method：Since the inception of the single-payer Taiwan NHI program in 1995, the Taiwan National Health Insurance (NHI) Administration has collected claim records covering all inpatient and outpatient medical benefit claims for nearly the entire population of Taiwan. This study utilized two databases from National Health Insurance Research Database (NHIRD). The first one comprised all inpatient claim records from 1997 through 2010. We analyzed the prevalence and temporal trend of hysterectomy in Taiwan and compared to other countries during the period. We also calculated the associations between hospital and surgeon volumes with outcomes of hysterectomy. A total of 327,507 women underwent some types of hysterectomy and were included as the study sample. The second database was a subset of the NHIRD known as the Longitudinal Health Insurance Database 2005, which contains all inpatient and outpatient medical benefit claims from 1997 through 2010 for a sample of one million beneficiaries randomly drawn from the National Health Insurance registry of beneficiaries. Based on this dataset, the second study included 10,415 women who underwent hysterectomy for benign diseases and had no prior and concomitant pelvic organ prolapse and incontinence. The unexposed group comprised of 31,245 individuals without a history of hysterectomies. They were matched with the exposed group by age, gender, and calendar year of medical visit at the same hospital.
Result：Similar to the international trend, the age-standardized rate of hysterectomy in Taiwan declines during the period of 1997-2010. The alterations in the insurance payment for hysterectomy were associated with the utility of various types of hysterectomies in Taiwan. According to the regulations of labor insurance, public employee insurance and farmer insurance in Taiwan, only women under 45 years are eligible for the disability benefits of hysterectomy. This may create “moral hazard”; women with low socioeconomic status tend to be more likely to receive hysterectomy due to the disability benefit.
We observed that subjects in the hysterectomy group had significantly higher risk of developing subsequent urinary incontinence when compared to those in the unexposed group (adjusted hazard ratio, 1.87; 95% CI, 1.71-2.04). Subjects in the hysterectomy group had a significantly higher risk for receiving subsequent anti-incontinence surgery (adjusted hazard ratio, 1.53; 95% CI, 1.08-2.18). Various types of hysterectomies, with the exception of abdominal subtotal hysterectomy, were associated with increased risk of subsequent urinary incontinence. When adjusted for risk factors, we found subsequent urinary incontinence after hysterectomy was associated with lower hospital volumes and younger surgeons. In addition, low socioeconomic status and comorbidities were associated with higher risk of developing subsequent urinary incontinence.
Conclusion: We found significant association between hysterectomy and subsequent urinary incontinence in women underwent hysterectomies for benign diseases. We also found significant association between hospital volume, surgeon age and post-hysterectomy incontinence. We suggest National Health Insurance Administration should reveal the information concerning hospital and surgeon volumes of hysterectomy, and quality indicators of hysterectomy to the public. The authorities on labor, public employee and farmer insurance should re-evaluate adequacy of regulations concerning the eligibility to receive disability benefits for hysterectomy in women younger than 45 years. Additionally, gynecologists should explain to the patients about the pros and cons of hysterectomies for benign diseases. Care-providers should remind patients of the risk of urinary incontinence after hysterectomy and offer other alternative treatment options. It is also important to educate patients on methods to avoid subsequent incontinence after hysterectomy.

中文摘要………………………………………………………………………i
英文摘要………………………………………………………………………ⅲ
目錄……………………………………………………………………………vi
第一章 緒論……………………………………………………………………1
第一節 研究背景與動機……………………………………………………1
第二節 研究目的……………………………………………………………5
第三節 研究問題……………………………………………………………6
第四節 研究重要性…………………………………………………………7
第二章 文獻探討………………………………………………………………8
第一節 子宮切除術…………………………………………………………8
第二節 子宮切除術國際趨勢比較…………………………………………15
第三節 尿失禁………………………………………………………………22
第四節 子宮切除術對於尿失禁影響………………………………………29
第五節 健康服務利用行為模式理論及學習曲線理論……………………45
第三章 材料與方法……………………………………………………………52
第一節 研究架構……………………………………………………………53
第二節 研究假說……………………………………………………………56
第三節 資料來源與處理……………………………………………………57
第四節 研究變項操作型定義………………………………………………65
第五節 資料分析方法………………………………………………………70
第四章 結果……………………………………………………………………71
第一節 子宮切除術盛行率趨勢及健保支付標準調整對術式影響…………71
第二節 子宮切除術與尿失禁之相關研究結果………………………………80
第三節 子宮切除術之醫院及醫師服務量與尿失禁之相關結果……………89
第五章 討論……………………………………………………………………95
第一節 子宮切除術盛行率趨勢及健保支付標準調整對術式影響…………95
第二節 子宮切除術與尿失禁之相關…………………………………………100
第三節 子宮切除術之醫院及醫師服務量與尿失禁之相關…………………104
第四節 研究限制………………………………………………………………106
第六章 結論與建議……………………………………………………………107
第一節 結論……………………………………………………………………107
第二節 建議……………………………………………………………………109
參考文獻 ………………………………………………………………………110

圖目錄
圖2-2-1 比較美國、OECD16國、台灣及西班牙各年齡層每十萬人子宮切除率.15
圖2-2-2 比較OECD各國及台灣每十萬名婦女年齡標準化子宮切除率…………16
圖2-2-3 比較美國、OECD16國平均及西班牙子宮切除率年齡別累積發生率…17
圖2-2-4 OECD各國每十萬名婦女陰道式子宮切除率(未標準化)趨勢比較…17
圖2-2-5 美國15歲及以上婦女子宮切除率(未標準化)歷年變化………………18
圖2-2-6 美國15歲及以上婦女子宮切除術式歷年變化…………………………19
圖2-2-7 美國北加州20歲以上婦女子宮切除術術式歷年趨勢…………………20
圖2-2-8 台灣婦女子宮切除術各術式之歷年趨勢………………………………21
圖2-3-1 美國婦女年齡標準化各類型尿失禁盛行率趨勢………………………23
圖2-3-2 挪威婦女各年齡層尿失禁盛行率………………………………………24
圖2-5-1 Andersen第一階段健康服務行為模式模型…………………………45
圖2-5-2 Andersen第二階段健康服務行為模式模……………………………46
圖2-5-3 Andersen第三階段健康服務行為模式模……………………………47
圖2-5-4 Andersen第四階段健康服務行為模式模……………………………47
圖2-5-5 Andersen第五階段健康服務行為模式模……………………………48
圖3-1-1 第二部分之研究架構圖…………………………………………………54
圖3-1-2 第三部分之研究架構圖…………………………………………………55
圖3-3-1 第二部分研究處理流程圖………………………………………………61
圖3-3-2 第三部分研究處理流程圖………………………………………………64
圖4-1-1 台灣1997年至2010年子宮切除術式所占比率統計圖………………72
圖4-1-2 台灣每十萬名婦女年齡別子宮切除率…………………………………73
圖4-1-3 台灣子宮切除率年齡別累積發生率……………………………………73
圖4-1-4台灣依農保、勞保及公保分類之年齡別標準化子宮切除率……………74
圖4-1-5台灣每十萬名婦女依農、勞、公保年齡別粗子宮切除率(1997年)…75
圖4-1-6台灣每十萬名婦女依農、勞、公保年齡別子宮切除率(2010年)……75
圖4-1-7 比較OECD各國及台灣每十萬名婦女年齡標準化子宮切除率…………76
圖4-1-8 比較2008年OECD各國及台灣每十萬名婦女年齡別子宮切除率……77
圖4-1-9 比較2008年OECD與台灣子宮切除術年齡別累積發生率……………78
圖4-1-10 比較2008與1998年美國、芬蘭、丹麥、瑞典、挪威與台灣子宮切
除術年齡標準化發生率…………78
圖4-1-11 OECD與台灣婦女陰道式子宮切除率(未標準化)趨勢比較…………79
圖4-2-1 子宮切除組與未子宮切除組之年齡別尿失禁發生率…………………81
圖4-2-2 子宮切除組與未子宮切除組之年齡別尿失禁發生率之Hazard ratio81
圖4-2-3 子宮切除組與未子宮切除組未發生尿失禁存活曲線…………………82

表目錄
表2-1-1 子宮切除術(各術式)術後併發症之比較………………………………10
表2-1-2 子宮切除術各術式歷年支付標準之變化………………………………11
表2-1-3 論病例計酬子宮完全切除術各層級醫院歷年支付標準之變化………12
表2-1-4 論病例計酬次全子宮切除術各層級醫院歷年支付標準之變化………12
表2-1-5 論病例計酬腹腔鏡子宮完全切除術各層級醫院歷年支付標準變化…12
表2-1-6 子宮切除術DRG編碼一覽表……………………………………………13
表2-3-1 國際尿控協會ICS對於應力性、急迫性及混合型尿失禁之定義……22
表2-3-2 尿失禁影響因子…………………………………………………………26
表2-4-1 近年來國際間有關子宮切除術與尿失禁影響論文彙整表……………36
表2-5-1 子宮切除術之醫院服務量及醫師服務量相關論文彙整表……………51
表4-1-1 台灣地區各類型子宮切除術人數及百分比……………………………71
表4-2-1 研究族群基本變項及尿失禁診斷及手術發生率一覽表………………80
表4-2-2 研究族群基本變項與尿失禁發生率……………………………………82
表4-2-3 有無合併症之後尿失禁發生率…………………………………………83
表4-2-4 不同追蹤時間之OR值……………………………………………………83
表4-2-5 子宮切除組與未子宮切除組不同追蹤時間之HR值……………………84
表4-2-6 尿失禁診斷及手術相關危險因子………………………………………85
表4-2-7 各類型子宮切除術研究族群其年齡及尿失禁發生率…………………85
表4-2-8 不同子宮切除術式後續發生尿失禁診斷之Hazard Ratio…………86
表4-2-9 研究族群年齡及各類型尿失禁診斷發生率一覽表……………………88
表4-2-10 接受子宮切除術病患術後各類型尿失禁發生率之Hazard Ratio…88
表4-3-1 接受子宮切除術族群基本變項、手術醫院及醫師特質變項一覽表…89
表4-3-2 病患特質及手術醫院及醫師特質對於術後尿失禁發生率之影響……91
表4-3-3 術後發生尿失禁相關危險因子………….……………………………93
表4-3-4 術後發生尿失禁之相關危險因子(追蹤60個月)……………………94

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