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研究生:董文雅
研究生(外文):Wen-Ya Tung
論文名稱:神經外科醫師駐診離島前後之顱內出血病患的緊急空中轉診和死亡率之比較
論文名稱(外文):Comparison of Use of Emergency Air Medical Transport and Mortality among Intracranial Hemorrhage Patients between Before and After Routine Dispatch of Neurosurgeons to a Remote Island
指導教授:鄧宗業鄧宗業引用關係
指導教授(外文):Chung-Yeh Deng
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:醫務管理研究所
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:2018
畢業學年度:106
語文別:英文
論文頁數:25
中文關鍵詞:離島醫療神經外科醫師空中緊急轉診死亡率
外文關鍵詞:NeurosurgeonEmergency air medical transportMortalityRemote island
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研究背景:離島常缺神經外科醫師,神經外科病患常由他科醫師、急派神經外科醫師,或轉送醫學中心照護之。迄今尚無常規派遣神經外科醫師駐診離島之成效的研究,本研究旨在實證比較此成效,聚焦於顱內出血病患的緊急空中轉診和死亡率。
研究方法:本研究收集衛生福利部金門醫院2006年1月至2016年12月急診及住院病患接受腦部電腦斷層其報告有顱內出血的患者資料,分無神經外科專科醫師駐診的前期,2006年1月至2009年8月,以及有神經外科專科醫師駐診的後期,2009年9月至2016年12月,比較前後期的空中緊急轉診頻率及病患接受電腦斷層後90天內的死亡率,解釋變項包括性別、年齡、診斷(依致病原因,分「外傷顱內出血」和「非外傷性顱內出血」二組)、及嚴重度(以昏迷指數(Glasgow coma scale)區分為低(GCS:13–15)、中(GCS:9–12)、高(GCS:3–8)三組),分析性統計採卡方(Chi square)檢定做單變項分析,並以複邏輯斯迴歸(multiple logistic regression),控制其他變項後,比較有無神經外科專科醫師駐診之顱內出血病患的緊急空中轉診的差異,再以Cox 比例風險(Cox proportional hazards)模型,控制其他變項後,比較有無神經外科專科醫師駐診之顱內出血病患90天內死亡的差異。
研究結果:本研究總共有560位顱內出血的患者,其中空中緊急轉診167位,117位接受電腦斷層後90天內死亡,前期空中緊急轉診比率為53.2% ,後期為19.4%,前期90天粗死亡率為26.6%,後期為18.3%,控制其他變項後,使用空中緊急轉診的調整後風險,相對於前期,後期明顯減少(AOR 0.23, 95% CI 0.15–0.35),相對年長者(大於等於81歲)年輕者明顯較高 (年齡 0–20: AOR 7.20, 95% CI 2.63–19.38; 年齡 21–40: AOR 10.20, 95% CI 4.25–24.465; 年齡 41–60: AOR 4.01, 95% CI 1.86–8.64; 年齡 61–80: AOR 3.57, 95% CI 1.68–7.61),相對於低嚴重度者,中、高嚴重度者明顯較高(GCS 3–8: AOR 2.36, 95% CI 1.50–3.72, GCS 9–12: AOR: 2.55, 95% CI 1.40–4.67),次分組的分析,除了年齡 0–20及年齡 21–40兩組以外,其餘各組相對於前期,後期空中緊急轉診明顯減少,尤其是年齡 41–60 和 ≧81 歲者、外傷顱內出血者、以及中嚴重度者。90天累積存活率前期為73%,後期為 82%,後期存活率較高(log-rank statistic, P=0.032),控制其他變項後,90天死亡率,相對於女性,男性明顯較高(AHR 1.81, 95% CI 1.78–2.76),相對於低嚴重度者,中、高嚴重度者明顯較高(GCS 9–12: AHR 7.46, 95% CI 3.24–17.20; GCS 3–8: AHR 35.52, 95% CI 17.62–71.60),相對於前期,後期明顯減少(AHR 0.67, 95% CI 0.46–0.97),年齡 21–40者明顯減少(AHR 0.46, 95% CI 0.22–0.94),使用空中緊急轉診者明顯減少(AHR 0.59, 95% CI 0.38–0.91),次分組的分析,前後期未達顯著差異。
研究結論:常規派遣神經外科醫師駐診離島後,顱內出血病患的緊急空中轉診和死亡率可能顯著減少。
Background: WHO’s Universal Health Coverage (UHC) aims to ensure that everyone receives the quality services they need and is protected from health threats, seeking to leave no one behind. Existing studies about caring neurosurgical patients in remote areas focused on treating them by non-neurosurgical doctors or neurosurgeons emergently dispatched or by transportation to medical centers. However no study has examined effects of routine neurosurgeon dispatch on the use of EAMT and health outcomes for intracranial hemorrhage cases. Therefore the purpose of this study is to compare the frequencies of EMAT and mortality among patients with intracranial hemorrhage between before and after the routine dispatch
Methods: This pre-post comparison collected data of patients admitted to the emergency room(ER) and wards at Kinmen hospital from January 2006 to December 2016. Patients receiving computed tomography (CT) scans of the brain that reported intracranial hemorrhage were all enrolled in this study. The pre stage of routine neurosurgeon dispatch was from January 2006 to August 2009 and the post stage was from September 2009 to December 2016. The study has two outcome variables. One is whether study subjects used EAMT or not. The other is whether they died in 90 days after the brain CT examination for the diagnosis of intracranial hemorrhage or not. The main explanatory variable was pre-post stage concerning whether a neurosurgeon was available at the hospital or not. Control variables included subject age, gender, neurosurgical diagnosis, and severity. Chi square test was used to assess association of selected factors. Multiple logistic regression analysis was used to estimate adjusted ORs (aORs) and their 95% confidence intervals (CIs) for factors associated with the use of EAMT. Kaplan-Meier curves were created and comparisons were assessed based on the factors associated with mortality. Cox proportional hazards regression models were used to investigate risk factors associated with mortality. HRs and adjusted HRs (aHRs) with 95% CIs are reported to show the strength and direction of association.
Results: A total of 560 patients with intracranial hemorrhage found by brain CT examinations at Kinmen hospital were identified. Overall, 167 patients used EAMT and 117 died. The incidence of EAMT was 53.2% in the pre stage and 19.4% in the post stage. The crude mortality rate was 26.6% in the pre stage and 18.3% in the post stage. After controlling for other covariates, the adjusted risk of using EAMT was significantly lower in the post stage (AOR 0.23, 95% CI 0.15–0.35) than in the pre stage but higher in younger patients than in those aged≧81 years (age 0–20: AOR 7.20, 95% CI 2.63–19.38; age 21–40: AOR 10.20, 95% CI 4.25–24.465; age 41–60: AOR 4.01, 95% CI 1.86–8.64; age 61–80: AOR 3.57, 95% CI 1.68–7.61) and in patients with moderate or severe severity than in those with minor severity (GCS 3–8: AOR 2.36, 95% CI 1.50–3.72, GCS 9–12: AOR: 2.55, 95% CI 1.40–4.67). Patients used EAMTs significantly less often in the post stage was found consistently among all subgroups of patients except among those aged 0–20 and 21–40 years. Moreover, the decrease concerned was obvious relatively in those aged 41–60 and ≧81 years, with the diagnosis of TICH, and with moderate severity. The cumulative 90-day survival ratio was 73% and 82% in the pre and post stages, respectively. The survival ratio was significantly higher in the post stage (log-rank statistic, P=0.032). The adjusted risk of mortality was significantly higher in male patients (AHR 1.81, 95% CI 1.78–2.76) or in patients with moderate or severe severity (GCS 9–12: AHR 7.46, 95% CI 3.24–17.20; GCS 3–8: AHR 35.52, 95% CI 17.62–71.60), but the risk was significantly lower in the post stage (AHR 0.67, 95% CI 0.46–0.97) in patients aged 21–40 (AHR 0.46, 95% CI 0.22–0.94) or in patients using EAMT (AHR 0.59, 95% CI 0.38–0.91). Subgroup analysis found no significant difference in the risk of mortality between the two stages.
Conclusions: After regularly dispatching neurosurgeons to a remote hospital, the use of EAMT and overall 90-day mortality for patients with intracranial hemorrhage might decrease significantly.
中文摘要--------------------------------i
ABSTRACT-------------------------------iii
目錄-----------------------------------v
LIST OF FIGURES------------------------vi
LIST OF TABLES-------------------------vii
CHAPTER 1: Introduction----------------1
CHAPTER 2: Literature Review-----------3
CHAPTER 3: Materials and Methods-------9
CHAPTER 4: Results---------------------11
CHAPTER 5: Discussion and Conclusion---17
References-----------------------------21
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