物理治療介入對於全膝人工關節置換手術術後之醫療利用與醫療品質探討

The Study on Medical Utilization and Quality of Physical Therapy Intervention after Total Knee Arthroplasty

王雲充(Yun-Chong Wang)

指導教授 ： 馬震中

義守大學/醫學院/醫務管理學系/碩士(2015年)

https://doi.org/10.6343/ISU.2015.00244

摘要

研究目的：早期術後物理治療可以儘早恢復全膝人工關節置換術病人術後之活動功能與避免併發症的發生，本研究目的為探討病人之人口學、手術方式與復健因素對於全膝人工關節置換術病人術後之醫療品質與醫療利用之影響。
研究材料與方法：本研究為回溯性研究，採病歷回顧方法收集2014年1月1 日至2014年12月31 日期間曾經照會某區域教學醫院復健科之接受全膝人工關節置換手術之病人共有523位並以卡方檢定、t檢定、相關分析與ANOVA進行分析。多變量分析以線性複迴歸法與邏輯斯迴歸分析影響醫療利用與醫療品質之影響因子。
研究結果：接受術後復健之病人平均年齡為69.64±8.18歲，平均住院天數為6.72±1.03日，術後平均初次復健時間為48.12±37.17小時，平均物理治療次數為3.52±1.20次。在住院天數差異方面，64歲以下、有合併症、同側再置換、雙側置換、治療次數超過4次之住院天數顯著較高(p<.05)。在醫療品質方面，病人置換經驗、有無合併症、麻醉方式、治療次數與初次復健時間在自行使用助行器行走之比例有顯著差異(p<.05);置換經驗、治療次數在膝彎曲超過90度比例與疼痛改善情形有顯著差異(p<.05)。在多變量分析方面，影響住院天數之正預測因子為有合併症(p=.002)、同側再置換(p<.001)、治療次數(p<0.001)、初次復健時間(p<.001)；負預測因子為單側置換(p<.001)。自行使用助行器行走之預測因子有單側置換、全身麻醉、治療次數、年齡76歲以上、對側置換經驗、同側再置換、有合併症。膝彎曲角度超過90度之預測因子為對側置換經驗、同側再置換、有合併症、治療次數與初次復健時間。疼痛改善之預測因子為治療次數、有合併症。
研究結論：本研究結果初步顯示病人的人口學、手術與復健因素的確會影響全膝人工關節置換術病人術後醫療利用和醫療品質。由於台灣健保規定住院復健為每日進行一次，導致住院天數延長雖可能會伴隨較多的治療次數，但其術後醫療品質卻明顯較佳；此說明在醫療機構面臨降低住院天數的壓力下，對於全膝人工關節置換術病人推行急性後期照護仍有其必要性，以便能持續提升病人醫療品質。

關鍵字

全膝人工關節置換 ； 物理治療 ； 住院天數 ； 醫療品質 ； 醫療利用

並列摘要

Purpose: Early physical therapy can improve functional mobility and prevent contradictions after total knee arthroplasty(TKA). The purpose of this study is to examine the relationship between with demography, surgical factors, timing of physical therapy and length of stay(LOS) and amount of therapy and analysis quality after total knee arthroplasty.
Material and method: This retrospective study use chart review design, collecting data from patients post total knee arthroplasty at a Metropolitan hospital in Southern Taiwan between August 1, 2014 and July 31, 2015. Univariate analysis use Chi-square, t test, analysis of correlation, and ANOVA. Multivariate analysis use liner regression and logistic regression to analyze factors predict length of stay, amount of therapy and quality.
Result: Patients who received thysical therapy mean age were 69.64±8.18 years, mean length of stay were 6.72±1.03 days, mean timing of physical therapy after surgery were 48.12±37.17 hours, mean amount of therapy were 3.52±1.20. Patients who was younger than 64 years old, had cormobidity, reversion TKA, bilateral TKA, amount of therapy over 4 times had higher length of stay. Patients who have been bilateral and reversion TKA, cormobidity, type of anesthesia, amount of therapy and timing of therapy had significant different in quality. Positive predictors of longer LOS were cormobidity, reversion TKA, amount of therapy, and timing of rehabilitation; negative predictors was unilateral TKA. Predicrors of patients who could walk with a walker at discharge were second staged TKA, general anesthesia, amount of therapy, and older than 76 years old. Predicrors of patients who could perform range of motion of knee flexion over 90 degrees at discharge were second stage and reversion TKA, cormobidity, amount and timing of therapy. Predicrors of pain improved at discharge were amount of therapy and cormobidity.
Conclusion: Patients’ demography factors, surgical factors and timing of therapy indeed affected medical utilization and quality of patients who received TKA. In this study, more times of therapy combined with higher LOS because the frequency for physical therapy was once a day, but led to better functional outcome. Post acute care is important for decreasing LOS and improving quality of inpatient care.

並列關鍵字

none

參考文獻

高以信(2010)。探討老年癌末病人住院後至死亡小於或等於14日的預測因子。成功大學老年學研究所碩士論文。取自CETD中文碩博士論文資料庫。

鍾寬智(2012)。全膝關節置換術麻醉方式及術後結果之探討。長榮大學健康科學學院醫務管理學系碩士班在職專班碩士論文。取自CETD中文碩博士論文資料庫。

林晉(2012)。人工關節置換微創手術淺談。台北市醫師公會會刊。56(11)，26-27。

鄭秀容、杜異珍、巫美惠、潘建州、陳昆輝、李政鴻 (1999)。連續被動性運動對於膝關節置換術後老年病人之影響—以台灣某醫學中心骨科病房為例。護理暨健康照護研究。8(2)，158-166。

冼鴻曦、李英俊、馬震中、盧玉強 (2012)。護理之家住民轉住院率的整體分析。台灣老年醫學暨老年學雜誌。7(1)，37-64。