臺灣博碩士論文加值系統

背景：隨著精神疾病罹病人數逐年的增加，罹病率與再住院之間的問題愈來愈受重視。而再住院率成為近年來醫院評估與預測醫療照護品質結果的重要指標之一，短期的再住院率（<1年）可反應出病患前次住院所接受的照護品質的高低，而長期的再住院率（≧1年）不僅除了能反應出病患前次住院之照護品質外，另一方面更能反應出病患出院後回歸社區中是否受到適當且完整的健康照護。因此，本研究利用全民健保資料庫，擷取精神疾病患者首次住院資料，探討病患於首次住院出院後14天、30天、1年與5年內之再住院率及其相關預測因子。

目的：本研究之主要目的為：（1）針對全體精神疾病患者、以及精神分裂症患者、情感性精神病患及其他精神疾病患者於不同觀察時間內（<14天、<30天、<1年、<5年），探討其再住院之累積發生率與發生密度。（2）探討可能影響全體精神疾病患者於不同觀察時間內發生再住院事件之相關預測因子。

方法：本研究採回溯性世代研究設計，資料來源取自於1997年至2004年國家衛生研究院所發行之全民健康保險資料庫，使用其中之住院醫療費用清單明細檔（DD）、醫事機構基本資料檔（HOSB），以及2004年之承保資料檔（ID）。研究對象為1999年1月1日起，被診斷為精神疾病之首次住院患者，共44,237名，並進行6年連續的追蹤。資料處理部份採SPSS 15.0版之統計軟體進行主要之分析。統計分析包括：估計不同觀察期間之累積再住院率與發生密度；並以Cox多變量比例危害迴歸模式（Cox proportional hazard model）計算住院精神疾病患者之性別、年齡、首次住院天數、平均投保金額、出院診斷別、醫院所屬分局別、醫院等級以及醫院型態別等因素對再住院風險之校正後相對風險估計值（adjusted hazard ratio）。

結果：本研究發現5年內發生再住院之精神病患共有16,752人，佔總人數之37.9%，其中精神分裂症患者所佔的比例約為13.4%。而本研究計算出精神疾病住院患者出院後14天、30天、1年及5年內再住院率分別為6.1%、8.5%、22.3%以及37.9%，而因精神分裂症與情感性精神病而再住院之相對應數值則分別約為，13.6%、17.3%、41.0%、67.2%與8.7%、13.2%、32.7%、55.1%。另外，研究對象於14天、30天、1年及5年內發生精神疾病再住院之發生密度分別為4.58人次/1,000人日、3.11人次/1,000人日、1.04人次/1,000人日以及0.69人次/1,000人日。有關再住院之預測因子方面，經多變項迴歸模式控制潛在之干擾因子後發現，男性、經濟較不富裕者、住院天數以及個案所住醫院之轄區分局以及醫院層級等因素不論於任何觀察時間內（<14天、<30天、<1年、<5年）皆為發生精神疾病再住院之顯著預測因子。而在14天與30天中，首次住院天數介於5~7天之患者發生再住院之風險明顯較低。此外，本研究也發現，區域醫院與地區醫院不論於14天、30天、1年以及5年內，因精神疾病而再住院之風險皆明顯高於醫院中心。

結論：本研究發現精神疾病患者5年內再住院大多發生於出院後14天內，大約佔16%。從危險因子的分析中發現，14天與30天再住院中，首次住院天數愈長（≧8天）或愈短（≦4天）之精神疾病患者，其再住院之相對風險均比5~7天患者高。而在長期（1年、5年）再住院中，則是以住院天數介於0~4天之患者其再院相對風險為最小。有鑑於此，適當的住院天數對於精神疾病患者而言相當重要，因此，建議未來醫療專業相關人員應僅慎的評估精神疾病病患適當的出院條件，並精進住院精神疾病患者之照顧品質，以及積極落實病患出院後的準備計畫與加強地區醫院之專業照顧能力，皆可有效地降低精神疾病長、短期之再住院率，進而使得精神疾病病患可以獲得較佳的照顧與預後。

關鍵字：回溯性世代研究、精神分裂症、情感性精神病、累積發生率、發生密度、相對風險

Background: With an ncreasing annual number of psychiatric patients, the morbidity and re-hospitalization problems have been more concerned than ever. The re-hospitalization rate becomes one of important indexes for the evaluation and prediction of medical care quality in hospitals. The short-term re-hospitalization rate (<1 year) can reflect the quality of medical care received by patients in the last hospitalization, while the long-term re-hospitalization rate (≧1 year) can not only reflect the quality of medical care received by patients in the last hospitalization, but also reflect whether the patients have received proper and complete health care after discharge from the hospital. Therefore, this study obtained the first-time hospitalization data of psychiatric patients from the National Health Insurance database, and calculated the re-hospitalization rate within 14 days, 30 days, 1 year and 5 years after discharge from the first-time hospitalization. The potential predictors for re-hospitalization were also explored.

Objectives: The main objectives of this study are: (1) to calculate the cumulative incidence and incidence density of re-hospitalization of all psychiatric patients, schizophrenic patients, affectivedisorder patients, and other psychiatric patients in different durations of observation (<14 days, <30 days, <1 year, <5 years); (2) to explore the significant predictors associated with re-hospitalization of psychiatric patients in different durations of observation.

Methods: This study adopted the retrospective cohort study design, and collected data from the National Health Insurance (NHI) database provided by the National Health Research Institutes of Taiwan from 1997 to 2004, including the Inpatient Expenditures by Admissions (DD), Registry for Contracted Medical Facilities (HOSB) and the Beneficiery Registry (ID) of 2004. The subjects were 44,237 psychiatric patients hospitalized for the first time as since January 1, 1997, and who had been tracked for six consecutive years (1999-2004). The data were analyzed with SPSS 15.0. The statistical analyses included estimating the cumulative re-hospitalization rate and incidence density for different observation durations. Cox proportional hazard model was also used to calculate the adjusted hazard ratio of re-hospitaliation in association with gender and age of hospitalized patients, the number of days of the first hospitalization, average insured amount, discharge diagnosis category, districts of the hospitals, hospital accreditation rank, and hospital type.

Results: This study found that 16,752 psychiatric patients were re-hospitalized within 5 years, accounting for 37.9% of total patients, and about 13.4% were schizophrenic patients. The re-hospitalization rates of psychiatric patients within 14 days, 30 days, 1 year and 5 years after discharged from hospitals were 6.1%, 8.5%, 22.3% and 37.9%, respectively. The ratios for schizophrenic patients were 13.6%, 17.3%, 41.0% and 67.2%, respectively; while those for affectivedisorder patients were 8.7%, 13.2%, 32.7% and 55.1%, respectively. In addition, the incidence densities of psychiatric illness that led to re-hospitalization for different time periods of obersvation were 4.58 person-time/1,000 person-day, 3.11 person-time/1,000 person-day, 1.04 person-time/1,000 person–day, and 0.69 person-time/1,000 person–day, respectively. As for the predictors of re-hospitalization, after using multi-variable regression model to control for the potential confounders, it was found that, male patients, patients with lower income, length of stay, hospital district, and hospital rank are significant predictors for re-hospitalization regardless of durations of observation (<14 days, <30 days, <1 year, <5 years). Patients who had been hospitalized for 5~7 days for the first time showed a lower risk in re-hospitalization within 14 days and 30 days. In addition, this study also found that the re-hospitalization risk of psychiatric patients in regional hospitals was higher than that of medical centers, within 14 days, 30 days, 1 year and 5 years.

Conclusions: This study found that the re-hospitalization of psychiatric patients within 5 years mostly occurred within 14 days after discharge from the hospitals, accounting for about 16% of all re-hospitalized patients. The analysis of risk factors suggested that, patients who had longer (≧ 8 days) or shorter (≦ 4 days length of stay) had higher relative risk of <14 days and <30 days re-hospitalization than those who were hospitalized for 5~7 days. For long-term (1 year, 5 years) re-hospitalization, patients who were hospitalized for 0~4 days had the lowest relative risk of re-hospitalization. Therefore, a proper duration of hospitalization is important for psychiatric patients. It is suggested that medical workers should evaluate proper discharge conditions for psychiatric patients carefully in the future, improve the quality of medical care for those patients, carry out preparation plans for patients after they were released from hospitals, and strengthen the professional care ability of local hospitals, so that the long-term and short-term re-hospitalization rates of psychiatric patients can be reduced effectively, and those patients could receive better care.
Key words: retrospective cohort study, Schizophrenia, affective psychosis, cumulative incidence (CI), incidence density (ID), hazard ratio

目 錄
論文摘要…………………………………………………………………………………………IV
目錄………………………………………………………………………………………………IX
表目錄……………………………………………………………………………………………XI
圖目錄 …………………………………………………………………………………………XII
第壹章 緒論 ……………………………………………………………………………………1
第一節 研究背景與動機 ………………………………………………………………………1
第二節 研究目的…………………………………………………………………………………6
第貮章 文獻探討…………………………………………………………………………………7
第一節 精神疾病之介紹…………………………………………………………………………7
一、精神疾病之定義 ……………………………………………………………………………7
二、精神疾病的診斷與分類標準 ………………………………………………………………8
三、精神疾病之盛行率…………………………………………………………………………11
第二節 各國精神疾病病人出院後之再住院比率 ……………………………………………14
第三節 影響精神病患再住院之主要原因 ……………………………………………………16
（一）人口與社會學特徵與再住院之間的關係………………………………………………17
（二）治療因素與再住院間之相關因素………………………………………………………25
（三）政策與再住院間之相關因素……………………………………………………………30
（四）社區照護與再住院間之相關性…………………………………………………………33
第叄章 研究材料與方法 ………………………………………………………………………41
第一節 資料來源與研究設計 …………………………………………………………………41
第二節 研究時間與研究對象之選取 …………………………………………………………43
第三節 研究變項與操作型定義 ………………………………………………………………44
第四節 資料處理與統計分析 …………………………………………………………………46
一、研究世代篩選流程…………………………………………………………………………46
二、再住院資料取得之處理流程………………………………………………………………47
三、追蹤（follow up）與觀察人日數（person-days）之計算 ………………………48
四、統計分析……………………………………………………………………………………49
第肆章 研究結果 ………………………………………………………………………………52
第一節 研究世代基本資料特性之描述性統計 ………………………………………………53
第二節 再住院之累積發生率與發生密度 ……………………………………………………61
第三節 再住院之預測因子 ……………………………………………………………………65
第四節 不同觀察時間內再住院預測因子之分析比較 ………………………………………74
第伍章 討論與結論 ……………………………………………………………………………76
第一節 研究結果與討論 ………………………………………………………………………76
一、本研究之主要發現…………………………………………………………………………76
二、國內、外精神病患者於不同觀察時間內再住院率之探討………………………………77
三、影響再住院率之預測因子…………………………………………………………………79
第二節 研究優點與限制 ………………………………………………………………………91
中文參考文獻……………………………………………………………………………………94
英文參考文獻 …………………………………………………………………………………103
附錄 ……………………………………………………………………………………………180

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