臺灣博碩士論文加值系統

研究背景
當細菌感染進入血流引起全身性發炎反應稱為敗血症，嚴重時器官衰竭而危及生命，流行病學研究顯示，敗血症具有高發生率及高死亡率；台灣學者的研究顯示，由1997年敗血症的發生率135人/十萬人，增加到2006年的217人/十萬人，而10年平均死亡率30.8%。2013~2015年衛生福利部公佈男女性十大死因，敗血症在女性排名第十位；而敗血症在各國的研究，其發生率在317~560人/十萬人，估計死亡率18~ 33%；降低敗血症的發生率及死亡率，是公認的健康挑戰，有鑑於台灣缺乏2006以後的敗血症流行病學研究，急需要一個全國代表樣本的研究以估算敗血症對大眾健康的影響。
研究目的:
使用2013年健保資料庫，比較住院病人診斷為敗血症與非敗血症於病
人、疾病、環境特性的差異，及瞭解敗血症病人於住院期間死亡與存活病人在病人、疾病、環境特性的差異；並且，找出住院病人中被診斷為敗血症的病人，在病人、疾病、環境特性的相關風險，以及探討住院病人診斷為敗血症病人，於住院期間死亡在病人、疾病、環境特性的相關風險。

研究方法:
資料庫串檔後，排除住慢性病床、2013年前住院及無出院日期的病人後，以主診斷的ICD-9-CM診斷碼為敗血症病人及非敗血症病人，再進行歸人後，將資料庫的項目進行病人、疾病、環境特性分類及變項的建立，包括年齡計算、住院死亡定義、ICD-9-CM診斷碼進行器官功能障礙(衰竭)定義等，之後，設定參考組及Code後，使用SPSS 22.0版軟體進行統計分析。
結果:
敗血症發生率2.9%，女性高於男性；住院死亡率19.3%，男性高於女性；男性風險是女性的1.461倍，發生率與住院死亡率隨年齡增加而增加，每增加1歲住院死亡風險增加3.9%。
敗血症住院死亡病人之住院天數0-1天佔19.7%，住院天數2-3天佔16.3%；死亡病人的住院天數為0-1天沒有發生器官衰竭佔8.24%，住院死亡病人的住院天數≦3天發生器官衰竭種類中，以呼吸衰竭佔最多(15.95%)。
敗血症發生率以醫學中心最高(嚴重度相關)，住院死亡率則是區域醫院最高(可近性、便利性)；季節以夏天發生率最高，住院死亡率以冬天最高，住院死亡風險冬天是秋天的1.332倍。
結論:
台灣2013年敗血症病人於住院期間死亡的平均住院天數低於敗血症存活病人的住院天數，但是，敗血症住院死亡病人之平均醫療費用比敗血症存活病人高85.4%；然而，敗血症住院死亡病人沒有發生器官功能障礙的病人佔43.2%，與其他國家的研究顯示，敗血症住院死亡病人沒有發生器官功能障礙小於20%，有顯著差異；另外，敗血症及敗血症住院死亡病人的主診斷以ICD-9-CM 038.9 未指定的敗血症，而且，在各種敗血症的主診斷多數於病人住院24小時的住院死亡比例最高，其中ICD-9-CM 038.11金黃色葡萄球菌敗血症住院死亡比例最高。
敗血症病人的住院死亡風險與性別、年齡、器官衰竭、醫院等級、季節、住院天數有關；本研究僅根據住院病人的住院診斷碼進行估計發病率及住院死亡率，若能再運用死亡登記資料庫，更能準確地估計死亡率，及建議相關預防、治療措施應參考本國的流行病學研究資料，例如疫苗施打年齡層可以根據發病率及死亡率做調整。

Background
When the bacterial infection into the blood flow caused by systemic inflammation called sepsis, severe organ failure and life-threatening, epidemiological studies have shown that sepsis has a high incidence and high mortality; Taiwan scholar's study shows that by the 1997 sepsis The incidence of 135 people / 100,000, increased to 217 / 100,000 in 2006, while the 10-year average mortality rate of 30.8%. Ministry of Health and Welfare announced the top ten causes of death in men and women in 2013 to 2015, sepsis in women ranked tenth; and sepsis in countries of the study, the incidence of 317 to 560 people / 100,000, estimated mortality rate of 18 to 33% ; Reduce the incidence of sepsis and mortality, is recognized as a health challenge, in view of Taiwan's lack of epidemic study of sepsis after 2006, the urgent need for a national representative sample of the study to assess the impact of sepsis on public health.
Objectives:
The use of 2013 health insurance database, compared the diagnosis of sepsis and non-sepsis in patients, diseases, environmental characteristics of the differences, and understanding of patients with sepsis during hospitalization and survival of patients in patients, diseases, environmental characteristics of the differences; The risk associated with the patient, disease, and environmental characteristics of the patient diagnosed with sepsis in the inpatient, as well as the risk associated with death, patient, disease, and environmental characteristics during the hospitalization of patients diagnosed with sepsis.
Methods:
After the database was removed, the patients were diagnosed with sepsis and non-sepsis, and the patient was diagnosed with the ICD-9-CM diagnostic code. The classification of the patient, the disease, the classification of environmental characteristics and the establishment of variables, including age calculation, hospital death definition, ICD-9-CM diagnostic code for organ dysfunction (failure) definition, etc., after setting the reference group and Code , Using SPSS version 22.0 software for statistical analysis.
Results:
The incidence of sepsis was 2.9% and that of women was higher than that of men. The hospital mortality rate was 19.3% and the male was higher than that of female. The incidence and hospital mortality increased with age. The risk of death was increased by 3.9% for each additional 1 year.
The number of days of hospitalization for patients with sepsis was 19.7% in 0-1 days and 16.3% in hospital days. The number of hospitalized days for death was 8.24% for 0-1 days without hospitalization, and the number of days of hospitalization Among the 3 days of organ failure, respiratory failure accounted for the largest (15.95%).
The incidence of sepsis was highest in the medical center (severity-related), hospital mortality was the highest in the regional hospital (accessibility, convenience); the highest incidence of summer in summer, hospital mortality in winter the highest.
Conclusion:
The average length of hospital stay in patients with septicemia in 2013 was lower than the number of hospitalized patients who survived sepsis. However, the average cost of hospitalized patients with sepsis was 85.4% higher than that of patients with sepsis. However, there was no organ function in patients with sepsis Obstructive patients accounted for 43.2%, with other countries of the study showed that sepsis hospitalized patients did not occur organ dysfunction less than 20%, there were significant differences; In addition, sepsis and sepsis hospitalized patients with primary diagnosis of ICD-9-CM 038.9 Designated sepsis, and the majority of sepsis in the main diagnosis of the majority of patients hospitalized for 24 hours the highest proportion of hospitalization, which ICD-9-CM 038.11 Staphylococcus aureus sepsis hospital death rate of the highest.
The risk of hospitalization death in patients with sepsis was related to gender, age, organ failure, hospital grade, season, and hospital days. This study was based on the hospitalized diagnostic codes for inpatients and hospitalized mortality. If the death registration database , More accurately estimate the mortality rate, and suggest that the relevant prevention and treatment measures should be based on national epidemiological research data, such as vaccine age can be adjusted according to morbidity and mortality.

正文目錄 頁
第一章、緒論 1
第一節、研究背景與重要性 1
第二節、研究動機 8
第三節、研究目的 10
第二章、文獻查證 11
第一節、敗血症的歷史 11
第二節、敗血症的定義 13
第三節、敗血症的發生原因 15
第四節、臨床表現與治療 18
第五節、器官功能障礙(衰竭) 21
第六節、敗血症住院死亡的相關因素 24
第七節、敗血症的發生率與死亡率 29
第八節、全民健康保險資料庫住院檔與醫事機構基本資料檔 32
第九節、ICD-9-CM 34
第十節、衛生福利部死亡統計 37
第十一節、查爾森合併症嚴重度指標 38
第十三節、健保資料庫之主要診斷與次要診斷編碼原則 41
第十四節、Receiver Operating Characteristic curve( ROC)曲線 43
第十五節、羅吉斯回歸與廣義估計方程式 47
第三章、研究材料與方法 50
第一節、研究對象選樣流程 50
第二節、研究架構 54
第三節、研究設計 56
第四節、變項重要性比較 63
第五節、統計軟體與統計方法 67
第四章、結果 68
第一節 預測能力評估-ROC曲線的圖形及曲線下的面積 68
第二節 敗血症流行病學描述 77
第三節 敗血症相關因素 88
第四節 敗血症住院死亡的描述 98
第五節 敗血症住院死亡的相關風險因素 107
第六節 發生敗血症及住院死亡的主診斷種類之住院天數 118
第五章 討論 123
第一節 發生率與住院死亡率 123
第二節 住院天數與醫療費用 126
第三節 住院死亡風險因素 127
第四節 發生敗血症及住院死亡的主診斷種類之住院天數 129
第五節 敗血症與器官功能障礙(衰竭)的關係 132
第六節 敗血症住院死亡與衛福部統計處之死亡統計之比較 136
第七節 研究限制 142
第六章、結論 143
第七章、參考文獻 146
 


『表』目錄 頁
表 1 2013年台灣全國死因排行 5
表 2 CCI 合併罹病症指數之項目與ICD-9-CM對照 40
表 3 變項建立目錄 60
表 4 變項設定-A 70
表 5 變項設定-B 71
表 6 變項設定-C 72
表 7 變項設定-D 73
表 8 年齡分層設定 74
表 9 醫療費用分層設定 75
表 10 住院科別設定 76
表 11 敗血症與非敗血症的病人特性 78
表 12 敗血症與非敗血症的疾病特性-就醫科別 80
表 13 敗血症與非敗血症的疾病特性比較-器官功能障礙(衰竭) 81
表 14 敗血症與非敗血症的疾病特性比較-CCI &器官衰竭數量 82
表 15 敗血症與非敗血症的疾病特性比較-住院天數 83
表 16 敗血症與非敗血症的疾病特性比較-醫療費用 84
表 17 敗血症與非敗血症的環境特性比較 86
表 18 敗血症與非敗血症的環境特性比較 87
表 19 敗血症相關因素-病人特性 89
表 20 敗血症相關因素-疾病特性_科別 91
表 21 敗血症相關因素-疾病特性_器官功能障礙 92
表 22 敗血症相關因素-疾病特性_住院天數 93
表 23 敗血症相關因素-疾病特性_醫療費用 94
表 24 敗血症相關因素-環境特性 96
表 25 相關因素-環境特性_月份 97
表 26 敗血症存活與住院死亡_病人特性比較 99
表 27 敗血症存活與住院死亡_疾病特性比較-就醫科別 101
表 28 敗血症存活與住院死亡_疾病特性比較-器官功能障礙 102
表 29 敗血症存活與住院死亡_疾病特性比較-住院天數 103
表 30 敗血症存活與住院死亡_疾病特性比較-醫療費用 104
表 31 敗血症存活與住院死亡_環境特性比較 106
表 32 敗血症住院死亡相關風險因素-病人特性 108
表 33 敗血症住院死亡相關風險因素-疾病特性-就醫科別 111
表 34 敗血症住院死亡相關風險因素-疾病特性-器官功能障礙 112
表 35 敗血症住院死亡相關風險因素-疾病特性 113
表 36 敗血症住院死亡相關風險因素-疾病特性-醫療費用 114
表 37 敗血症住院死亡相關風險因素-環境特性 116
表 38 敗血症住院死亡相關風險因素-環境特性-月份 117
表 39 發生敗血症(診斷種類)之住院天數 119
表 40 敗血症住院死亡(診斷種類)之住院天數 120
表 41 敗血症病人住院天數(時數) 與器官衰竭分佈 121
表 42 敗血症住院死亡病人住院天數(時數) 與器官衰竭分佈 122
表 43 敗血症引發器官功能障礙(衰竭)的風險OR值 134
表 44 器官功能障礙(衰竭)與敗血症風險之OR值 135


 
『圖』目錄 頁
圖 1 1997-2006年住院死亡率(A)，住院死亡率之年齡分層(B) 3
圖 2 2015年性別十大死因死亡率(出自102年衛福部主要死因分析) 6
圖 3 女性主要死因標準化死亡率及死亡人數佔率2015 vs 2005年 7
圖 4 ROC曲線 45
圖 5 ROC取線之AUC閾值 46
圖 6 個案選取流程 53
圖 7 研究架構 55
圖 8 全民健康保險資料庫串檔變項說明 57
圖 9 連續變項ROC曲線的圖形及曲線下的面積AUC數值 69
圖 10 2013年台灣住院病人敗血症發生率及住院死亡率 125
圖 11 2013年健保敗血症住院在各年齡層的性別住院死亡率 138
圖 12 2013年衛福部與健保住院之敗血症在各地區性別死亡率 139
圖 13 2013年衛福部及健保住院敗血症各年齡層死亡率 140
圖 14 ICD-9轉譯ICD10及衛福部年齡層敗血症死因統計 141

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