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研究生:吳惠足
研究生(外文):WU,HUEI-CHU
論文名稱:探討全民健康保險急診品質提升方案對急診嚴重敗血症患者治療處置成效之影響
論文名稱(外文):The Impact of the National Health Insurance Emergency Quality Improvement Program on Emergency Treatment Effectiveness in Patients with Severe Sepsis
指導教授:蔡文正蔡文正引用關係陳維恭陳維恭引用關係
指導教授(外文):TSAI, WEN-CHENCHEN,WEI-KUNG
口試委員:陳維恭李亞欣
口試委員(外文):CHEN,WEI-KUNGLI,YA-HSIN
口試日期:2022-06-30
學位類別:碩士
校院名稱:中國醫藥大學
系所名稱:醫務管理學系碩士在職專班
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:2022
畢業學年度:110
語文別:中文
論文頁數:97
中文關鍵詞:嚴重敗血症急診品質30日內死亡風險住院天數急診品質提升方案
外文關鍵詞:Severe sepsisemergency qualityrisk of death within 30 dayslength of hospital stayNational Health Insurance Emergency Quality Improvement Program
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背景:敗血症為國人2019年第十二位死因,死亡率為 12.4%。由於敗血症的高死亡率,健保署於2012年5月起實施「全民健康保險急診品質提升方案」,其中針對嚴重敗血症病患之照護品質,訂定當病患到達急診後於一定時間內接受必要的用藥或治療處置,若符合處置標準者給予獎勵。本研究探討「全民健康保險急診品質提升方案」實施後對急診敗血症患者急診就醫治療處置之成效及影響。
方法:本研究採回溯性世代研究,應用全民健康保險學術研究資料庫,資料分析使用SAS 9.4版本軟體,研究對象為2011年至2017年主診斷或次診斷碼符合國際嚴重敗血症指引定義之急診敗血症患者。統計分析以邏輯斯迴歸分析探討醫療機構是否申報獎勵方案之相關因素。並應用傾向分數配對法,將研究對象區分實施前與實施後進行逐年1:1方式配對,再以Cox比例風險模式分析探討獎勵方案實施後對急診敗血症患者30日內死亡風險之影響,及以複迴歸分析探討獎勵方案實施後對急診敗血症患者住院天數之影響。
結果:2011年至2017年急診敗血症患者共171,811 人,實施後急診敗血症患者共125,868人,有申報嚴重敗血症照護獎勵者共5,853人,申報獎勵比率 4.65%。依據邏輯斯迴歸分析結果顯示,區域醫院申報獎勵之機率最低 (OR=0.14, 95% CI: 0.13-0.15)。依據Cox比例風險模式分析結果顯示,實施後30日內死亡風險為實施前的0.83倍 ( 95% CI: 0.71-0.98)。平均住院時間由實施前為13.22天減少到實施後為12.46天 (P<0.05)。依據複迴歸分析結果顯示,實施後住院天數(中位數)為實施前的0.97倍 ( 95% CI: 0.96-0.99)。
結論:嚴重敗血症照護獎勵實施後,急診敗血症患者30日內死亡風險顯著較低,住院天數明顯減少。但在醫療機構申報獎勵之比率偏低,有待持續提升獎勵方案之申報。

Background: Sepsis was Taiwan's twelfth leading cause of death, with a mortality rate of 12.4% in 2019. Due to the high mortality rates of sepsis and sepsis shock, the National Health Insurance Administration has been promoting the “National Health Insurance Emergency Quality Improvement Program” (NHIEQIP) since May 2012 to determine the quality of care for patients with severe sepsis. The program rewards timely arrival and appropriate treatment by emergency departments (ED). This study explores the effectiveness and impact of the implementation of the "National Health Insurance Emergency Quality Improvement Program" on emergency medical treatment and treatment of emergency sepsis patients.
Methods: This study is a retrospective cohort study, utilizing data from Taiwan's National Health Insurance Research Database (NHIRD) from 2011 through 2017. Data analysis was conducted with SAS 9.4. Propensity score matching was used to match research subjects before and after implementation on a 1:1 ratio, while the Cox proportional hazards model was used to analyze the impact of the incentive program on the risk of death within 30 days of emergency sepsis.
Regression analysis was conducted to explore the effect of severe sepsis care incentives on hospital length of stay.
Results: There were 171,811 emergency sepsis patients from 2011 through 2017, of which 125,868 were after incentives implementation. A total of 5,853 patients applied for severe sepsis care incentives (4.65%). Logistic regression analysis results showed that regional hospitals had the lowest probability of reporting incentives (OR=0.14, 95% CI: 0.13-0.15). According to the Cox proportional hazards model analysis, the risk of death within 30 days after implementation was 0.83 times before implementation (95% CI: 0.71-0.98). The average length of hospital stay decreased from 13.22 days before implementation to 12.46 days after (P<0.05). Based on the results of multiple regression analysis, the median number of hospitalization days after implementation was 0.97 times that of before implementation (95% CI: 0.96-0.99).
Conclusion: After implementing the severe sepsis care incentives program, the patient risk of death within 30 days of emergency sepsis was significantly lower, and the number of hospitalization days was significantly reduced. However, the rate of reporting incentives in medical institutions is low, and it is necessary to improve the reporting of incentive programs continuously.

目錄
第一章 緒 論 1
第一節、 研究背景與動機 1
第二節、研究重要性 2
第三節、研究目的 5
第二章 文獻探討 6
第一節、敗血症的定義與辨識 6
第二節、敗血症的流行病學 10
第三節、敗血症治療照護準則 14
第四節、全民健康保險急診品質提升方案 17
第五節、影響敗血症預後的相關因素 20
第六節、影響全民健康保險急診品質提升方案處置成效之相關因素 28
第七節、文獻小結 32
第三章 研究設計與方法 33
第一節、研究架構 33
第二節、研究假說 36
第三節、研究對象 37
第四節、資料來源 41
第五節、研究變項之操作型定義及屬性 43
第六節、研究分析方法 48
第四章 結果 50
第一節、急診敗血症患者特性 50
第二節、醫療機構申報「嚴重敗血症照護獎勵」比率及各年度醫療機構申報之變化趨勢。 51
第三節、急診敗血症患者主要就醫醫療機構是否申報嚴重敗血症照護獎勵機率與相關因素 52
第四節、嚴重敗血症照護獎勵實施前後對急診敗血症患者30日內死亡風險之影響 56
第五節、嚴重敗血症照護獎勵實施前後對急診敗血症患者住院天數之影響 59
第五章 討論 61
第六章 結論與建議 69
第一節、結論 69
第二節、研究限制 70
第三節、建議 71
第七章 參考文獻 89


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