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研究生:陳怡霖
研究生(外文):Yi-Lin Chen
論文名稱:以核心療效指標評估介入計畫對老年髖部骨折病人術後之整體效益
論文名稱(外文):Performance of Intervention Program on Core Outcome Set for Surgical Hip Fractured Patients
指導教授:邱亨嘉邱亨嘉引用關係
指導教授(外文):Herng-Chia Chiu
學位類別:碩士
校院名稱:高雄醫學大學
系所名稱:醫務管理暨醫療資訊學系碩士班
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2016
畢業學年度:104
語文別:中文
論文頁數:148
中文關鍵詞:髖部骨折核心療效指標骨折照護介入計畫醫療資源利用
外文關鍵詞:Hip fractureCore Outcome SetFracture care Intervention ProgramMedical utilization
相關次數:
  • 被引用被引用:1
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  • 收藏至我的研究室書目清單書目收藏:2
研究背景與目的
多數健康照護機構已使用核心療效指標來評估髖部骨折病人之療效,但目前在台灣並無合適的評估指標適用於髖部骨折手術病人。本研究目的主要為三部分:(一)以核心療效指標評估老年髖部骨折病人有無接受手術介入照護計畫之差異、(二)評估病人於當次療效之影響因素、(三)探討當次資源利用之影響因素。
研究方法
本研究屬前瞻性設計,研究對象為在2015年08月01日至2016年05月31日間於南部某醫學中心與區域醫院接受髖部骨折手術治療之病患,樣本依據有無接受髖部骨折照護介入計畫分為介入組與控制組,總樣本數為96人,其中介入組為52人。研究資料來源主要為三部分:1. 病歷審查、2.醫療資源使用、3.核心療效指標測量,核心療效指標於術後住院期間、術後1、3個月進行測量。研究工具為:視覺疼痛類比量表(VAS)、日常生活活動量表(ADL)、歐洲生活品質量表(EQ-5D)以及自擬性問卷(復健、跌倒情形)等量表。統計方法利用SPSS20統計軟體,以卡方檢定、獨立樣本T檢定、變異數檢定、差異中之差異法(DID)、廣義估計方程式(GEE),統計工具為STATA13.0版、SPSS20.0版進行資料分析與驗證假說。

研究結果
介入組平均年齡為76.52±8.02、控制組平均年齡78.89±7.31,皆以女性居多(70.83%),手術方式皆以半人工髖關節置換(HA)居多(57.29%)。兩組隨治療時間增長各核心療效指標皆達顯著改善(P<0.001)。整體的效用分數:介入組為0.23、0.58、0.68;控制組為0.23、0.63、0.67,介入組與控制組之五量表隨時間逐漸改善,但兩組並無顯著差異。短期成效在復健率在術後1、3個月:介入組75%、72.09%;控制組65.85%、77.78%。術後1個月內跌倒率:介入組3.85%、2.44%;術後1-3個月內則兩組皆無人跌倒,以上並無顯著差異。使用GEE迴歸模型證實於術後有接受相關復健者在ADL、EQ-5D-Index、EQ-5D-VAS、Utility score比無接受相關復健者分別多16.54分、1.92分、12.64分、0.21分,接受復健者有較佳的療效。

結論和建議
老年髖部骨折手術病患之核心療效指標趨勢皆隨術後三個月內有顯著改善,於出院後有接受相關復健者有較佳的療效(ADL、EQ-5D-Index、EQ-5D-VAS、Utility score)之影響因子
,可見術後復健的重要性。介入組與控制組間在生活品質間並無顯著差異,可能原因為短期追蹤三個月內尚未看出兩組差異變化,建議後續研究需延長追蹤時間加以探討。本研究發現與前瞻性支付制度相比發現Tw-DRG支付制度導致住院天數有顯著改變。


Purpose
Several healthcare systems started to use “Core Outcome Set (COS) to evaluate the outcome of hip fracture patients No comprehensive effectiveness evaluation indicators have been applied for surgical hip fracture patients at Taiwan. The first objective of this study was to use COS to identify outcomes for a hip fracture intervention program as compare with patients without enrolled the programs The second objective was to examine the factors associate with the outcomes The third objective was to analysis the factors affected the healthcare utilization for hip fracture patients underwent surgery.

Methods
The study adopted a prospective study design. The study subjects were hip fractured patient admitted to one medical center and regional hospitals in southern Taiwan , from August 2015 to May 2016. The samples were grouped into interventional group (IG) and comparison group (CG) based on whether received a hip fracture intervention program Totally, 96 patients were included at the study, among them 52 were IG Three data sources used in the study were: patient clinical parameters derived from chart review, medical utilization obtained from hospital in-house claim data, and COS were obtained from patients interview during hospitalization and 1- and 3-month follow up surveys after patients discharge COS indicators included Pain Visual Analogue Scale (VAS), Activities of daily living (ADL), The European Quality of 5 Dimension (EQ-5D) Analytical methods included chi-square test, independent t-test, Difference in Difference (DID), and general linear regressions The statistical tool which we used are STATA 13.0 and SPSS 20.0. 
Results
The mean ages for IG and CG were 76.52 (± 8.02) and 8.89 (± 7.31) respectively. Female gender accounted for 70.83% of the study sample. More than 57.29% patients received semi-artificial hip replacement (HA) procedure. Both groups patients experienced a better COS outcomes after discharged from hospitals. The utility scores for during hospitalization, 1-month, 3 month were was 0.23, 0.58, 0.68 for intervention group and 0.23, 0.63, and 0.67 for comparison group patients. No statistical differences in all COS indicators between groups across times.GEE models demonstrated that patients with rehabilitation after discharge had better outcomes in ADL、EQ-5D-Index、EQ-5D-VAS、Utility score were was. 16.54, 1.92, 12.64,.0.21.

Conclusions
The study confirmed that COS indicators have been improved 3 months after surgery for in elderly hip fracture patients Patients with rehabilitation after discharge experienced a better outcomes in ADL, EQ-5D, Utility score, it suggested that postoperative rehabilitation is very important. To restore the patient quality of life. No significant differences in COS indicators between two groups might be due to the shorter follow-up time (3-month), a long term longitudinal observation is suggested. Our study also identified the impact of DRG on the length of stay of hip fracture patients as we compared with patients prior to the PPS payment system


摘要 I
Abstract III
目錄 V
第一章 緒論 1
第一節 背景和動機 1
第二節 研究目的 3
第三節 預期貢獻 4
第二章 文獻探討 6
第一節 髖部骨折發生率及治療方式 6
第二節 老年髖部骨折照護計畫 13
第三節 髖部骨折核心療效指標及評估工具 19
第四節 髖部骨折手術病人核心療效指標趨勢之影響因子 28
第五節 老年髖部骨折病人術後當次及短期醫療效果之影響因子 31
第六節 老年髖部骨折病人當次醫療資源使用及影響因子 35
第三章 研究方法 37
第一節 研究架構和研究假說 37
第二節 研究設計 40
第三節 研究樣本與資料來源 44
第四節 核心療效指標之研究工具及信效度測量 49
第五節 研究變項定義 51
第六節 資料處理及統計分析方法 57
第四章 研究結果 59
第一節 介入組與控制組之基本資料 59
第二節 介入組與控制組核心療效指標趨勢 63
第三節 老年髖部骨折病人術後核心療效指標之影響因子 73
第四節 老年髖部骨折病人當次療效之影響因子 81
第五節 老年髖部骨折病人當次資源使用之影響因子 87
第五章 討論與結論 95
第一節 介入照護計畫之核心療效指標結果與短期成效討論 95
第二節 介入照護計畫之核心療效指標影響因子討論 98
第三節 老年髖部骨折病人當次醫療效果之影響因子討論 100
第四節 老年髖部骨折病人當次醫療資源利用之影響因子討論 101
第五節 回溯性與前瞻性驗證討論 103
第六節 研究限制與未來研究方向 107
第七節 結論與建議 109
參考文獻 111
英文文獻 111
中文文獻 117

表目錄

表2-1-1 髖部骨折流行病學相關研究文獻彙整表 8
表2-2-1 髖部骨折介入照護計畫相關研究文獻彙整表 15
表2-2-1(續) 髖部骨折介入照護計畫相關研究文獻彙整表 16
表2-3-1 髖部骨折核心療效指標相關研究文獻彙整表 21
表2-4-1 髖部骨折核心療效指標及影響因子研究文獻彙整表 30
表2-5-1 髖部骨折術後當次及短期醫療效果及影響因素相關彙整表 33
表2-5-1(續) 髖部骨折術後當次及短期醫療效果及影響因素文獻彙整表 34
表2-6-1 髖部骨折當次醫療資源使用及影響因子相關研究文獻彙整表 36
表3-2-2-1 過去一年藥物使用統整表 41
表3-2-2-2 併發症統整表 42
表3-2-2-2 (續) 併發症統整表 43
表3-4-1 本研究核心療效指標彙整表 50
表3-5-1 研究變項操作型定義 55
表3-5-1(續) 研究變項操作型定義 56
表4-1-1 老年髖部骨折病患基本特質描述性統計 61
表4-1-2 老年髖部骨折病患基本特質描述性統計 62
表4-2-1 介入組與控制組病患生活品質差異情形(DID)-校正前 67
表4-2-2 介入組與控制組病患生活品質差異情形(DID)-校正後 68
表4-2-3 核心療效指標趨勢與改善幅度(與住院期間比較) 69
表4-3-1 老年髖部骨折疼痛程度(VAS)之影響因子GEE迴歸分析 76
表4-3-2 老年髖部骨折日常生活活動能力(ADL)之影響因子GEE迴歸分析 77
表4-3-3 老年髖部骨折生活品質(EQ-5D-Index)之影響因子GEE迴歸分析 78
表4-3-4 老年髖部骨折視覺健康狀況(EQ-5D-VAS)之影響因子GEE迴歸分析 79
表4-3-5 老年髖部骨折效用分數(Utility score)之影響因子GEE迴歸分析 80
表4-4-1 老年髖部骨折併發症描述性統計 82
表4-4-2老年髖部骨折併發症之影響因子 83
表4-4-3 老年髖部骨折超長住院之描述性統計 85
表4-4-4 老年髖部骨折超長住院之影響因子 86
表4-5-1 老年髖部骨折住院天數之描述性統計 88
表4-5-2 老年髖部骨折住院天數之影響因子 89
表4-5-3前瞻性當次費用描述性統計 91
表4-5-4 前瞻性當次費用之影響因子 92
表4-6-1 前瞻性與回溯性之描述性統計 94
表5-1-1再跌倒病人資料 97
表5-2-1 術後一個月內有復健者之核心療效指標影響因子GEE迴歸分析 99
表5-2-2核心療效指標之影響因子GEE迴歸分析彙整表 99
表5-3-1 超長住院天數人數表 100
表5-4-1醫療資源使用之影響因子(多變量)彙整表 102
表5-5-1前瞻性與回溯性比對差異彙整表 103
表5-5-1前瞻性與回溯性比對輸血彙整表 103
表5-5-2前瞻性與回溯性比對一般併發症彙整表 104
表5-5-3 比對其他國家當次輸血與出院後30天內再入院結果彙整表 105
表5-5-4比對其他國家當次住院天數結果彙整表 106
表5-5-5比較其他國家平均住院費用彙整表 106


圖目錄
圖2-1-1 髖部解剖示意圖 10
圖2-1-2 髖部骨折型態示意圖 10
圖2-1-3 單極性半人工髖關節 11
圖2-1-4 雙極性半人工髖關節 11
圖2-1-5 不移位股骨頸骨折及關節囊外骨折較常實施的內固定物 12
圖2-3-1 數字疼痛評估量表(NRS) 23
圖2-3-2 視覺類比量表(VAS) 24
圖2-3-3 臉部表情量表(FPS) 24
圖3-1 研究架構圖 38
圖3-3-2-1 研究樣本收案流程圖 46
圖3-3-2-2 費用篩選流程圖 47
圖3-3-2-3 健保資料庫抽樣檔(回溯性)篩選流程圖 48
圖4-2-1 疼痛程度(VAS) 趨勢圖 70
圖4-2-2 日常生活活動能力(ADL) 趨勢圖 70
圖4-2-3 生活品質量表(EQ-5D) 趨勢圖 71
圖4-2-4 視覺健康狀況量表(EQ-5D-VAS) 趨勢圖 71
圖4-2-5 效用分數(Utility score) 趨勢圖 72





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