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研究生:黃文珍
研究生(外文):Wen-Chen Huang
論文名稱:胸部創傷併多重肋骨骨折使用不同醫療處置之資源耗用與成效分析-以南部某區醫學中心為例
論文名稱(外文):Analysis on Resource Consumption and Effectiveness of Different Medical Treatments for Thoracic Trauma with Multiple Rib Fractures – Example with a Medical Center in Southern Taiwan
指導教授:羅英瑛羅英瑛引用關係
指導教授(外文):Ying-Ying Lo
學位類別:碩士
校院名稱:義守大學
系所名稱:醫務管理學系
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:2019
畢業學年度:107
語文別:中文
論文頁數:78
中文關鍵詞:胸部創傷肋骨骨折肋骨鋼板固定手術醫療資源使用
外文關鍵詞:Thoracic traumarib fracturemetal plate rib-fixation surgerymedical resource consumption
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背景:胸部外傷併多重肋骨骨折會合併氣胸、血胸、連枷胸或心臟及肺臟挫傷、呼吸衰竭等較嚴重的傷害,嚴重者甚至會威脅生命安全及休克;肋骨錯位嚴重且多處肋骨骨折者,會引發劇烈的疼痛,甚至有可能在半年或數年後依然會呈現癒合不良及疼痛的狀況,嚴重影響作息及肺功能。早期視頻輔助胸腔鏡手術(VATS)主要是以排出滯留的氣血胸治療,近日的肋骨鋼板固定手術,臨床上效果較好,但在台灣尚未有多實證驗證,而國外的研究多屬少數個案的研究,因此本研究欲以實證的資料中,探討有執行肋骨鋼板固定手術和無執行肋骨鋼板固定手術治療的醫療資源耗用與預後成效間的差異。
目的:1.瞭解台灣南部地區某醫學中心暨外傷中心對於胸部外傷併多重肋骨骨折患者的臨床現況與醫療資源耗用情形。2.比較有無執行肋骨鋼板固定手術,二種醫療處置之醫療資源使用(呼吸器使用天數、住院天數、加護病房使用天數、止痛藥物使用劑量、手術費用、住院費用、總費用)之差異。3.探討有無執行肋骨鋼板固定手術,二種醫療處置之預後(疼痛指數、併發症)之差異。
結果:胸部創傷合併多重肋骨骨折病人以男性居多,年齡平均53.48歲,研究發現不同手術方式對於術後疼痛指數、止痛藥物使用劑量、呼吸器使用天數、住院天數、住加護病房天數等有顯著差異、以無執行肋骨鋼板固定手術者平均數高;在手術特殊自費材料費,總醫療費用,有顯著差異,以有執行肋骨鋼板固定手術者平均數高;健保住院費用、總健保費用有顯著差異,皆以無執行肋骨鋼板固定手術治療者的平均數為高。
結論:本研究結果發現,兩種不同手術方式在醫療耗用中有顯著差異,有執行肋骨鋼板固定手術者在術後疼痛指數、止痛藥物使用劑量、呼吸器使用天數、住院天數、住加護病房天數、健保住院費用、總健保費用及總醫療費用等醫療耗用上顯著低於無執行肋骨鋼板固定手術者。無執行肋骨鋼板固定手術者,健保需負擔較高的費用,相對採取有執行肋骨鋼板固定手術的病人,健保負擔較低但自費耗材費用較高。本研究在兩種不同手術方式的治療成效結果發現,無執行肋骨鋼板固定手術者的術後疼痛指數與產生肺炎、膿胸併發症的情形,顯著高於有執行肋骨鋼板固定手術者。
Background: Thoracic trauma with multiple rib fractures can be accompanied by pneumothorax, hemothorax, flail chest, or more severe injuries such as cardiac and lung contusion, respiratory failure, etc; death threat and shock may even be experienced in severe patients. Patients with severe rib dislocation and multiple rib fractures can experience severe pain, and there may even be symptoms of inadequate healing and pain after 6 months or a few years, which can severely affect lifestyle and lung function. The early stages of video-assisted thoracic surgery are mainly used in treatment for the drainage of remaining pneumo- and hemothorax. Recently, metal plate rib-fixation surgery has had better clinical effects, but it has not been empirically verified in Taiwan. Foreign studies regarding this are mostly contain few case numbers. Therefore, this study aims to use empirical data to explore the differences in medical resource and prognosis effects for those who undergo metal plate rib-fixation surgical treatment and for those who do not.
Purpose: 1. To understand the current clinical and medical resource consumption situation of a trauma center in a medical center in southern Taiwan regarding patients with thoracic trauma with multiple rib fractures. 2. Compare Differences in medical resource consumption (length of ventilator use, length of stay, length of intensive care, dosage of analgesic used, operation fee, hospitalization fee, total fee) of the two medical treatments with and without metal plate rib-fixation surgery respectively. 3. Explore the differences in the prognosis of the two medical treatments with and without metal plate rib-fixation surgery respectively.
Results: The majority of thoracic trauma patients with multiple rib fractures were male and with a mean age of 53.48 years old. The study found that different operation methods were significantly different regarding post-operative pain score, dosage of analgesic used, length of ventilator use, length of stay, and length of intensive care. Medical treatment with metal plate rib-fixation surgery had higher average costs for special self-paid materials fee for surgery and total medical cost, and this was significantly different. Medical treatment without metal plate rib-fixation surgery had higher average costs for hospitalization fee on national health insurance and total national health insurance cost, and this was significantly different (P<0.05).
Conclusion: This study found that there were significant differences in medical consumptions for the two different operation methods. Those who underwent metal plate rib-fixation surgery, compared with those who did not, had significantly lower medical resource consumption regarding post-operative pain score, dosages of analgesics, length of ventilator use, length of stay, length of intensive care, hospitalization fee on national health insurance, total national health insurance cost, and total medical costs. A higher fee is required for the national health insurance for those who did not undergo metal plate rib-fixation surgery. In comparison, for those who underwent metal plate rib-fixation surgery, there were less burden on the national health insurance but more self-paid costs for materials.
Based on the effectiveness results of the two different operation methods, the study found that those who did not undergo metal plate rib-fixation surgery had significantly higher pain scores and significantly higher incidences of complication with empyema compared with those who did undergo metal plate rib-fixation surgery.
壹、緒論 10
一、研究背景與動機 10
二、研究目的 12
貳、文獻探討 13
一、胸部創傷併多重肋骨骨折概況 13
(一)國內外現況 13
(二)臨床症狀與治療方式 14
二、胸部外傷合併多重肋骨骨折之醫療資源耗用 18
(一)健康服務利用 18
(二)影響創傷醫療資源耗用的相關因素 18
參、研究方法 27
一、研究假說與架構 27
(一)研究假設 27
二、資料來源與收集程序 31
(一)、原始資料之來源 31
三、研究變項的操作型定義 32
(一)醫療資源耗用 32
(二)病人特性 33
(三)創傷情形 33
(四)創傷醫療處置 34
四、資料處理與分析方法 37
(一)敘述性統計之分析 37
(二)推論式統計之分析 37
(三)研究倫理 38
肆、研究分析與結果 39
一、描述性分析 39
(一)病人特性 39
(二)胸部創傷合併多重肋骨骨折合併症 41
(三)胸部創傷合併多重肋骨骨折術式與術後併發症 42
(四)胸部創傷合併多重肋骨骨折醫療資源費用 43
二、推論性分析 44
(一)不同手術方式與醫療資源費用差異 44
(二)不同手術方式在發生併發症的差異 47
(三)疼痛指數、醫療資源利用、住院天數 48
(四)影響醫療資源耗用因素之分析 50
伍、討論與建議 60
一、討論與結論 60
二、研究限制 64
三、研究建議 65
(一)學術研究方面 65
(二)政策制訂方面 65
(三)臨床實務方面 65
四、研究貢獻 66
參考文獻 67
中文部分 67
英文部分 69
附件一 76
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