臺灣博碩士論文加值系統

研究目的:
電腦斷層在急診的使用量逐年上升。雖然電腦斷層是準確度高的診斷工具，但由於高輻射劑量可能帶給兒童潛在傷害，近年來備受關注。許多研究呼籲應評估電腦斷層使用的適當性。腹痛是兒童急診常見的主訴，由於腹痛的成因非常廣泛，造成確診疾病的成因具極大挑戰，而電腦斷層可以快速幫助醫師找出腹痛的成因；儘管電腦斷層可降低診斷的不確定性，但由於輻射的曝露可能提高日後得癌症的風險，對於電腦斷層的使用仍具爭議性。目前台灣針對腹痛兒童在急診使用電腦斷層的情形了解有限，因此了解台灣腹痛兒童在急診使用電腦斷層的情況是很重要的，所以本文檢視兒童在急診使用電腦斷層的趨勢及相關因素，另評估相關的臨床結果是否有改善。

方法:
研究設計使用重複性橫斷性研究(pooled cross-sectional study)，資料來源為健保資料庫2000年、2005年及2010年的百萬抽樣歸人檔。本文除了評估腹痛兒童在急診使用的趨勢，另外也評估其他診斷工具的使用趨勢，以及相關臨床結果如三天後返急診、返回急診後住院、延遲診斷闌尾炎及闌尾炎穿孔等趨勢。再者，本文檢視不同特質下如:個人、醫師、醫院特性，與接受電腦斷層的相關性。統計方法是使用趨勢檢定(trend analysis)及羅吉斯迴歸來(logistic regression)看各趨勢及相關因子的情形。

結果:
腹痛兒童在急診使用從2000年的0.38%增加至2010年的1.68% (p-value <0.001)，X光使用從55.83%增加至62.38% (p-value <0.001)，超音波使用則維持1.95% 至2.12% (p-value =0.2868)。在臨床結果方面，三天內返回急診、三天內返急診後住院比例、急性闌尾炎的比例沒有顯著變化，但三天內返急診後住院診斷急性闌尾炎穿孔的比例有顯著上升，從4.5% 至 9.48% (p-value= 0.0273). 另外，在延遲診斷闌尾炎中，穿孔的比例也有顯著增加從20.31% 上升至45.45% (p-value= 0.0042)。在校正其它因子後，14至19歲的兒童較0-4歲兒童較容易使用電腦斷層(odds ratio: 18.07, 95% confidence interval (CI): 7.32 -44.61)，年紀輕(odds ratio: 2.02, 95% CI: 1.33 -3.07)或是非兒科的醫師(odds ratio: 2.57, 95% CI: 1.79 -3.71)都較容易使用電腦斷層；醫學中心也較其他醫院層級容易使用電腦斷層(odds ratio:6.30, 95% CI: 3.66 -10.83)；地區方面，南部相對於北部較少使用電腦斷層(odds ratio: 0.36, 95% CI: 0.23 -0.57)。

結論:
在研究期間，腹痛兒童在急診使用電腦斷層有增加的趨勢，但在相關的臨床結果沒有顯著的改善。另外，研究發現年紀較大的兒童、年紀較輕的醫師、非兒科的醫師、醫院層級較高較容易使用電腦斷層；另外，電腦斷層的使用也存在地區的差異。建議未來針對醫師及醫院在急診使用電腦斷層的使用變異性做更深入的探討，有效的降低不必要的電腦斷層使用及兒童的輻射曝露。

Research Objective:
Increasing computed tomography (CT) use among children presenting to emergency care settings has raised concerns of associated radiation exposure and overuse of health care resources. Abdominal pain is one most common complaint among children in emergency departments, but the evaluation of abdominal pain is challenging, especially in children. Although CT may be help in reducing some diagnostic uncertainty, the increased use of CT in children is of special patient safety concerns as health and cancer risks due to radiation exposure may outweigh its benefits. Therefore, it is important to understand the trends in and factors associated with CT use among children with abdominal pain in emergency departments in Taiwan. We also want to examine if clinical outcomes of pediatric patients with abdominal pain improved.
Study Design:
This study was a population-based trend analysis. We conducted a pooled cross-sectional study, obtaining the longitudinal health insurance data of 2000, 2005 and 2010 samples. We assessed CT use among pediatric patients presenting to all emergency departments. Other imaging use such as ultrasound and plain radiograph were also examined. Other than the trend analysis, patient-, physician- and hospital-level characteristics were also determined for their associations with the CT use. Patient characteristics included gender, age, socioeconomic status and if their parents are health professionals. Physician characteristics included gender, age, and specialty. Hospital characteristics included accreditation level, geographic area of practice, urbanization, and timing of emergency department (ED) visit. We then preformed the trend analyses of CT use and the related clinical outcomes including the proportion of return ED visits, delay hospital admission after revisit, diagnosis of delay appendicitis and perforated appendicitis. Multilevel modeling and logistic regression were used to assess the relationship between different levels of factors and CT use.
Population Studied:
The National Health Insurance Research Database of nationally representative samples of one million NHI beneficiaries from 2000, 2005, 2010 separately were used. We identified visits by children aged 0-19 years presenting to an emergency department with a principal diagnosis of abdominal pain. A total of 683,021 pediatric emergency visits during the study period was identified. From 2000 to 2010, of all the pediatric emergency department visits were 9.61% visits for abdominal pain.
Principal Findings:
CT use increased from 0.38% in 2000 to 1.68% in 2010 (p-value <0.001), in the meanwhile, radiograph use also increased from 55.83% from 62.38% (p-value <0.001) while ultrasound use remained stable from 1.95% to 2.12% (p-value =0.2868). The related clinical outcomes, including the proportion of return ED visits, delay hospital admission after revisit, and diagnosis of appendicitis did not change significantly over time. However, the proportion of delay hospital admission with a diagnosis of perforated appendicitis increased significantly from 4.5% to 9.48% (p-value= 0.0273); the proportion of delayed diagnosis of perforated appendicitis also increased significantly from 20.31% to 45.45% (p-value= 0.0042). After adjusting for other characteristics, children aged 14-19 were more likely to receive CT (odds ratio: 18.07, 95% confidence interval (CI): 7.32 -44.61). Younger (odds ratio: 2.02, 95% CI: 1.33 -3.07) and non-pediatric physicians (odds ratio: 2.57, 95% CI: 1.79 -3.71) were more likely to perform CT. Children presenting to the ED in medical centers were more likely to receive CT scans (odds ratio: 6.30, 95% CI: 3.66 -10.83). Hospitals in the south area were less likely to obtain CT scans (odds ratio: 0.36, 95% CI: 0.23 -0.57).
Conclusions:
There was an increase in CT use among children with abdominal pain presenting to ED while most of clinical outcomes didn’t show improvement. Significant physician and hospital variations in pediatric CT use in ED were observed. More investigations about physician and hospital variations in pediatric CT use in ED may help to devise effective interventions in reducing potential unnecessary radiation exposure among children.

Contents
致謝 I
中文摘要 II
Abstract IV
Contents VII
List of Tables VIII
List of Figures IX
Introduction 1
-Literature review 4
-Study objective 11
Methods 12
Results 19
Discussion 23
Conclusion 27
References 47
Appendix: supplementary tables 54

List of Tables
Table 1: Exclusion criteria 14
Table 2: The distribution of demographic characteristics of pediatric ED visits for abdominal pain in samples 29
Table 3: The trends of image use and clinical outcomes among pediatric patients seen at the ED for abdominal pain from 2000 to 2010 32
Table 4: The distribution of CT/non- CT use in three samples 34
Table 5: The distribution of CT/non- CT use in all sample 37
Table 6: ORs and adjusted ORs for CT use in children with abdominal pain in ED in 2010 sample 43
Table 7: Sensitivity analysi 45

List of Figures
Figure 1: Sample selection and analytical process 28
Figure 2: The trend of image use among pediatric patients seen at the ED for abdominal pain from 2000 to 2010 33
Figure 3: The trend of clinical outcome among pediatric patients seen at the ED for abdominal pain from 2000 to 2010 33
Figure 4: The trend of CT use by factors 39

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