臺灣博碩士論文加值系統

背景：結核病是全球最重要的傳染病，也是單一病原引起最多死亡的傳染病。結核病在台灣亦是重要傳染病，每年新發生和死亡個案數居法定傳染病之首。近年來由於HIV盛行、抗藥性結核出現、移民結核病問題以及老化導致之結核病再活化等問題，全球結核病控制再度被關注。然而有關台灣結核病流行趨勢以及結核病通報與死亡現況仍有待進一步釐清。因此，本研究目的為瞭解台灣結核病流行趨勢、評估結核病通報完整性、時效性與影響因素及探討結核病人死因及其影響因素。
方法：利用2002-2008年結核病全國資料庫通報確診結核病人，以敘述性統計描述2002-2008年結核病發生與死亡趨勢；利用健保資料與結核病全國資料庫串連，以邏輯斯回歸分析2005-2007年影響通報完整性及時效性因素；同時也利用健保資料、結核病全國資料庫及死亡登記資料串連，以Cox存活分析2006-2008年結核病人追蹤一年內死因及其影響因素。
結果：2002-2008年結核病新案數由16,758 降至 14,265人，發生率由每十萬人口75人降至62人；死亡率由每十萬人口5.7人降至3.3人，超過一半的的死亡發生在65歲以上老人。評估台灣推動結核病十年減半防治計畫後，2005-2008年發生率與死亡率分別下降了14%以及23%。
通報議題研究顯示，健保資料服用2類或2類以上抗結核病藥物的病人，3.7%未通報。影響未通報因素為：年齡（25-44歲）、再治病人、外籍人士、肺外結核、診所就醫以及就診次數少者。通報時效分析顯示，81.8%病人治療7天內通報，18.2%病人治療7天後通報。延遲通報因素為：高齡（≧75 歲）、再治個案、本國人、痰塗片陰性、痰培養陰性、大型醫院就診以及就診次數少者。
死亡議題研究顯示，16.5%病人通報1年內死亡（4%死因為結核病，12.5%死於其他疾病），常見死因為惡性腫瘤、肺炎、心臟病、腦血管疾病及糖尿病。死因為結核病者，約50%追蹤1個月內死亡；死於其他疾病者約一半追蹤2個月內死亡。顯著影響死亡之因素為：年齡≧65歲、男性、痰細菌學陽性、肺結核、居住在東台灣、具共病（HIV、慢性腎臟病、中風、惡性腫瘤）。年齡分層分析顯示，惡性腫瘤、慢性腎臟病、中風和慢性肝炎及肝硬化等共病為顯著影響死亡之危險因子，尤其＜65歲且有共病者死亡危險性顯著高於無共病者。
結論：雖然2002-2008年結核病的發生與死亡有下降趨勢，然而，仍有部分地區或縣市的發生率呈現不降反升情形，因此防治單位仍應積極早期發現個案並落實個案追蹤轉介及管理工作，嚴密監測與持續追蹤發生與死亡變動情形。此外，台灣仍有少部分結核病人未被通報，以及部分病人有延遲通報情形，因此應加強改善影響通報完整性及時效性，以強化結核病監視體系。追蹤期間死亡之結核病人，死因多為結核病以外的共病，而死亡發生的時間以通報後2個月內為多；病人如同時併有其他共病，死亡危險性則顯著增加，尤其是年齡<65歲且合併其他共病者，因此應強化具高死亡危險因子個案之追蹤照護，降低追蹤過程之死亡。

Background: Tuberculosis (TB) is one of the most important communicable diseases, and also one of the world's most lethal diseases. TB is a notifiable infectious disease with the highest number of confirmed cases and deaths in Taiwan. Today TB control mission encompasses related issues, such as HIV prevalent, emerging of drug resistance TB, immigrant issues, as well as aging society. While Taiwan TB epidemiological trend, notifiable data and current status of TB death need to be clarified, the purposes of this study are to investigate factors associated with TB trends, reporting completeness, timeliness, and deaths.

Methods: We adopted the TB confirmed cases from National Surveillance Network of Communicable Diseases (TB) from 2002 to 2008. Descriptive analysis was used to illustrate trends of TB incidence and death during 2002 to 2009; National Health Insurance Claim Database (NHICD) was linked with notifiable TB data, and then investigated reporting completeness as well as timeliness during 2005 to 2007 via Logistic Regression; furthermore, Death Registration System (DRS) was then linked, and analyzed factors associated with death within one year follow-up from 2006 to 2008 via Cox Survival Analysis.

Results: TB annual incident cases declined from 16,758 to 14,265 since 2002 to 2008, with incidence of 75 to 62 per 100,000. Mortality declined 5.7 to 3.3 per 100,000, and over 50% death occurred in elderly aged over 65 years old. After implementation of “Mobilization Plan to Halve Tuberculosis Incidence in Ten Years” in 2005, it was estimated that incidence and mortality rates were reduced by 14% and 23%.
The study revealed that cases received two or more anti-tuberculosis drugs in NHICD were defined as potential TB patients, and among which, 3.7% were not notified. Factors associated with non-reporting were aged 25-44, retreatment case, foreigners, extra-pulmonary, clinic-level visit, and non-frequent attenders. Reporting timeliness indicated that 81.8% cases were reported with 7 days after treatment was initialed, and 18.2%. Factors associated with delay in notification were aged over 75 years old, retreatment case, Taiwanese citizens, sputum smear negative, sputum culture negative, hospital-level visit, non-frequent attenders.
Regarding death analysis, 16.5% cases were deceased within 1 year after reporting, (causes of death (COD): 4% was TB and 12.5% was not related to TB). Major causes of death were metabolism, pneumonia, cardiovascular diseases, cerebrovascular diseases, and diabetes. For those COD were TB, approximately 50% were deceased within one month follow up; those COD were not related to TB, about 50% were dead within 2 months follow up. Factors associated with death were aged over 65 years old, male, sputum smear positive, pulmonary TB, inhabitants in Eastern Taiwan, comorbidity (HIV, chronic renal diseases, stroke and metabolism). Analysis stratified by age revealed that factors associated with death were metabolism, chronic kidney disease, stroke, chronic hepatitis and cirrhosis, and those who aged less than 65 years old and with comorbidity had higher probability of death than without comorbidity.

Conclusion: Although the overall incidence and mortality declined during 2002 to 2008, incidence increased in some areas. Health authorities should find cases more actively and implement case follow up and management, and closely monitor incidence and mortality trends. Furthermore, few TB cases were not notified and some were delay reported, and which indicated improving factors associated with reporting completeness and timeliness should be addressed. TB patients who died with follow up period, their major causes of death were not related to TB, and over 50% occurred within two months; cases with other comorbidities had higher risk of death, especially for those aged less than 65 years old and had comorbidities. Therefore, health authorities and health care workers should address high risk cases management to decrease mortality during follow up period.

目錄
中文摘要 I
英文摘要 III
圖目錄 III
表目錄 IV
第一章：前言 1
第一節 背景 1
第二節 問題現況 2
第三節 研究目的 5
第二章：文獻回顧 6
第一節 結核病流行病學回顧 6
第二節 結核病通報完整性、時效性與影響因素文獻回顧 7
第三節 結核病死亡與影響死亡因素文獻回顧 9
第四節 文獻回顧小結 15
第三章 方法 17
第一節 資料來源 17
第二節 研究設計 19
第三節 建立研究變項 20
第四節 統計分析 25
第四章：結果 28
第一節 台灣結核病流行病學趨勢及十年減半計畫實施前後發生與死亡變化分析 28
第二節 結核病通報完整性、時效性與影響因素 35
第三節 結核病死亡與影響死亡因素 43
第五章：討論 49
第一節 台灣結核病流行病學趨勢及十年減半計畫實施前後發生與死亡變化分析 49
第二節 結核病通報完整性、時效性及影響因素 52
第三節 結核病死亡與影響死亡因素 54
第四節 研究限制 57
第六章 結論 60
參考文獻 62
附錄A：已接受刊登文章 79
附錄B：已投稿文章(Ι) 80
附錄C：已投稿文章(Ⅱ) 81

圖目錄
圖一：台灣全民健保申報資料篩選2005-2007年通報結核病個案流程 38

表目錄
表一: 2002-2008年台灣結核病新案人口學特性 30
表二：2002-2008年台灣結核病死亡個案人口學特性 31
表三：2005-2008年地區別結核病發生數（率）與死亡數（率）統計 32
表四：2005-2008年台灣結核病發生率與死亡率變動統計 34
表五：邏輯斯迴歸分析2005-2007年影響台灣結核病人通報因素 39
表六：本國人與外籍人士通報與未通報之人口學特性分析 40
表七：2005-2007年台灣結核病人通報時效統計 41
表八：邏輯斯迴歸分析2005-2007年影響台灣結核病延遲通報相關因素 42
表九：2006-2008年結核病個案人口學特性、X光與痰檢查結果分布情形 45
表十：2006-2008年結核病人死亡原因與死亡時間分布 46
表十一：2006-2008年結核病個案共病分布情形 47
表十二：COX迴歸分析2006-2008年結核病個案追蹤一年內死亡之預測因子 48

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