背景:國內外已有較多研究在探討不同治療術式成效方面的比較，或醫院與醫師特質對治療結果的影響，但較少有針對醫療院所特質與醫師特質因素對醫師選擇治療術式不同影響力之相關研究。現今微創手術(Minimal invasive procedure)已大幅被應用在各種病症。它的低侵襲性、低感染率且高復原度，故可提供良好的醫療品質，增進病人滿意度，縮短術後住院天數而樽節醫療費用，可為醫病雙方帶來更高的效益。血管栓塞術從1980年代發展至今，藉由新的材料發明與技術的提升，國內外已有相當多的研究報告指出，使用血管栓塞術來治療顱內動脈瘤，在手術併發症、感染率、死亡率、住院天數及醫療費用等皆與傳統開顱夾除術的結果相似，甚至是有時候更優於開顱夾除術。
目的:探討醫療院所特質與醫師特質是否對醫師在顱內動脈瘤治療術式選擇方面有顯著性的影響力。
方法:本研究屬於回溯性研究(A retrospective study)，係利用全民健保資料庫2010年的百萬人承保抽樣歸人檔(LHID2010)，取2003年到2012年住院醫療費用清單明細檔(DD)中接受過顱內動脈瘤治療「主、次手術(處置)碼」(ICD_OP_CODE)為39.51、39.52的病患做為研究對象，串連醫事機構基本資料檔(HOSB)、醫事人員基本資料檔(PER)及專科醫師證書主檔(DOC)，並使用邏輯斯?邅k分析(Logistic regression analysis)來探討醫療院所特質與醫師特質對醫師選擇顱內動脈瘤治療術式是否具有影響力。
結果:在418名研究對象中接受開顱夾除術治療為357人(85.4%)，血管栓塞術為61人(14.6%)。卡方檢定及費雪精確檢定結果顯示，在醫師特質中，醫師的性別、年齡及執業年資和醫師選擇治療術式並無顯著的差異；在醫療院所特質中，層級別(p = 0.018)、權屬別(p < 0.0001)及分局別(p = 0.0025)則對醫師選擇治療術式有顯著的關連性。進一步的邏輯斯?邅k分析結果則顯示，醫師特質的性別、年齡及執業年資對醫師術式選擇並無顯著的影響力。而在醫療院所特質方面，分局別中只有台北分局相對於高屏分局在醫師術式選擇有顯著的影響力(OR = 5.67, 95%CI = 1.24-25.97, p = 0.026)。此外，醫院權屬別中只有公立醫院相對於財團法人醫院在醫師治療術式選擇方面有顯著的影響力(OR = 2.19, 95％CI = 1.00-4.77, p = 0.049)。
討論:綜合研究結果與文獻討論可知，醫療院所特質與醫師特質確實對於醫療利用及醫師的診療行為有顯著的關連性，但就本研究結果來說，在醫師特質中的性別、年齡及執業年資對於醫師選擇顱內動脈瘤治療術式並無顯著的關連性。而在醫療院所特質中的層級別、權屬別及分局別，則對於醫師選擇顱內動脈瘤治療術式有顯著的關連性。再者，儘管許多文獻都指出接受血管栓塞術治療的癒後結果優於開顱夾除術治療，但就本研究分析結果顯示，接受開顱夾除術治療的病人數高於血管栓塞術的5倍，當然治療的癒後結果好壞於本研究中是無法進行分析討論的，然而此問題值得深入再探討。此外，建議衛生主管機關應改善醫療資源分配不均的問題，不應讓醫療資源集中在都會區與大醫院中，造成醫療可近性降低。另一方面，在醫師專業技術認證上也要多加培育，加速神經介入性血管栓塞術治療人員培訓，使病人能得到較佳的治療方式。

Background:There have been different studies comparing the effectiveness of different methods of interventional procedures or how the difference in hospital and physician characteristics influence the treatment outcome, but few studies focus on how the difference in hospital and physician characteristics affects the choice of interventional procedures. Today minimally invasive procedure has become a more widely accepted method of management in the medical field. It is minimal-invasive with lower risk of procedure-associated infection and faster recovery, therefore, providing better quality of care, increase patient satisfaction, shorter post-operative hospital stay, and less medical expenses for both doctors and patients. Endovascular coiling has been used since the 1980s. With the progressive development of better types of catheters and coils, studies have shown that endovascular embolization of intracranial aneurysms have the same, or even better, results in post-procedural complications, infection, mortality, and post-procedural hospital stay, and less medical expenses.
Objectives:To investigate whether the characteristics of the medical institutions and physicians affects the choice of surgical methods for intracranial aneurysm.
Methods: This is a retrospective study using the data from the National health insurance research database. We collected patients from 2003 to 2012 who received intracranial aneurysm treatment, and qualified the “The International Classification of Diseases operation codes"(ICD_OP_CODE) of 39.51 and 39.52, and linked with medical institutions basic profile Registry for contracted medical facilities (HOSB), Registry for medical personnel (PER) and Registry for board-certified specialists (DOC), and use logistic regression analysis to investigate wheter the characteristics of the medical institutions and physician affects the choice of surgical methods for intracranial aneurysm.
Results:Of the 418 subjects collected, 357 subjects (85.4%) received surgical clipping of the aneurysm, and 61 subjected (14.6%) received endovascular aneurysm coiling. The chi-square test and Fisher''s exact test showed that the physician characteristics, including the physician''s sex, age, and years of practice, had no effect on the choice of interventional procedure. In medical institutions qualities, including the hospital accreditation level (p = 0.018), hospital ownership (p < 0.0001) and branch of Bureau (p = 0.0025) affect the choice of interventional procedure. Further logistic regression analysis showed that the characteristics of physician has no significant influence, while the characteristics of medical institutions showed that the Taipei Branch has stronger influence on the physician’s choice as the Kaohsiung-Pingtung Branch (OR = 5.67, 95%CI = 1.24-25.97, p = 0.026). In addition, there’s significant difference in the influence on physician’s choice of management between public hospitals and private foundation-owned hospitals (OR = 2.19, 95%CI = 1.00-4.77, p = 0.049).
Discussion:Integrated studies and literature showed that hospital and physician characteristics do have some affect on the physician’s treatment choice. The results of this study showed that sex, age, and years of practice do not affect the physician’s choice of treatment management for intracranial aneurysms. However, the hospital accreditation level, hospital ownership, and branch of Bureau of medical institutions qualities do have some affect on the physician’s choice of treatment management. Further, although several literatures pointed out that the result of endovascular coiling is superior to surgical clipping of the aneurysm, our data showed that the number of patients receiving surgical clipping is 5 times more than endovascular coiling. The prognosis and outcome of the treatments, however, is not discussed in this analysis, and can be another topic of interest. In addition, we believe that the administration of health should focus on the problem of unevenly distributed medical resources, which currently are much more concentrated in major metropolitan areas, causing relative inaccessibility of medical resources elsewhere. Also, the training and certification of the neurointerventional specialist should be promoted, so there will be more physicians available to provide better care of the patients.

致謝 I
中文摘要 II
英文摘要 IV
目錄 VII
表目次 IX
圖目次 X
第一章 緒論1
第一節 研究背景與動機1
第二節 研究的重要性3
第三節 研究目的 4
第二章 文獻探討5
第一節 顱內動脈瘤介紹5
第二節 顱內動脈瘤治療不同術式的治療結果之比較10
第三節 醫療院所特質及醫師特質與醫療利用之相關性12
第三章 研究方法15
第一節 研究架構 15
第二節 研究變項與其操作型定義16
第三節 研究假說 20
第四節 資料來源與研究對象21
第五節 資料處理與統計分析方法23
第四章 結果26
第一節 描述性統計分析結果26
第二節 卡方檢定及費雪精確檢定分析結果31
第三節 邏輯斯?邅k分析結果36
第五章 討論41
第一節 重要研究結果討論41
第二節 研究限制 46
第三節 建議47
參考文獻49
中文文獻49
英文文獻52

表目次
表3-2-1 研究變項及其操作型定義 18
表3-4-1 資料來源與使用欄位21
表4-1-1 醫療院所特質的描述性統計分析結果29
表4-1-2 醫師特質的描述性統計分析結果30
表4-2-1 醫療院所特質與醫師治療術式選擇的卡方檢定及費雪精確
檢定分析結果34
表4-2-2 醫師特質與醫師治療術式選擇的卡方檢定及費雪精確檢定
分析結果35
表4-3-1 醫療院所特質與醫師治療術式選擇的邏輯斯?邅k分析結38
表4-3-2 醫師特質與醫師治療術式選擇的邏輯斯?邅k分析結果39
表4-5-1 研究假說驗證結果45

圖目次
圖2-1-1 開顱夾除術(Surgical clipping)說明8
圖2-1-2 血管栓塞術(Endovascular coiling)說明9
圖3-1-1 本研究之研究架構圖15
圖3-4-1 研究對象的篩選流程圖22
圖3-5-1 資料處理流程圖24

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