以骨折聯合照護服務建構個案管理網絡系統

Implementing the Case Management Network System of Fracture Liaison Services

洪暐傑(Wei-Chieh Hung) ； 邱姿蓉(Tzu-Jung Chiu) ； 洪緯惟(Wei-Wei Hong) ； 劉美芳(May-Fan Liou) ； 蔡秀慧(Hsiu-Hui Tsai) ； 鄭暐霖(Wei-Lin Chin) ； 林季緯(Chi-Wei Lin) ； 吳至行(Chih-Hsing Wu)

《台灣醫學》 22卷2期 (2018/03) Pp. 161-167

https://doi.org/10.6320/FJM.201803_22(2).0007

摘要

隨著全球人口老化比例逐漸增加，脆弱性骨折的個案數也隨之快速增多，台灣每年髖骨骨折的發生人數從2010年的18,338人，預計在2035年將會增加2.7倍至50,421人。根據過去的研究發現，即便是有脆弱性骨折的個案，得到完整骨質疏鬆症評估與治療的個案比例，通常不到三分之一。尤其發生於髖部的脆弱性骨折，可能造成高死亡率與失能的問題，這類病患一年內的死亡率可高達20%，而約30%的個案可能產生永久性的失能，約40%的個案無法獨立行走，由此可知脆弱性骨折為社會帶來更多長期照護的難題，因此，預防脆弱性骨折的發生成為目前重要課題。目前台灣已有多項慢性疾病透過個案管理網絡系統顯著減少相關併發症的發生率。為減少脆弱性骨折所帶來的併發症及社會成本，應儘速建立以骨折聯合照護服務的個案管理網絡系統，此系統從辨識脆弱性骨折的潛在高危險個案，為其提供個案良好評估與生活衛教，進而給予適當的介入治療與定期追蹤，同時為了提高個案管理架構的效率，資訊系統的輔助成為不可或缺的重要工具。本文旨在探討於某大型醫院以骨折聯合照護服務，建構個案管理網絡架構的建立過程。

關鍵字

骨鬆 ； 個管 ； 系統 ； 程式

並列摘要

Aging is a worldwide issue, following it there are rapid increased of fragility fracture subjects. The incidence of hip fragile fracture was 18,338 persons per year in 2010, and the predictive incidence was 2.7 folds increased to 50,421 persons per year in 2035. According to the past researches, only less than one third of patients, who got fragile fracture, received the comprehensive assessment and treatment. In particularly, the hip fracture caused high morbidity and loss of independency, such as 20% patients with mortality in one year, 30% patients with permanent disability, and 40% patients with unable to walk independently. Fragile fractures lead to more hurdles for long term care of the society. Therefore, prevention of fragility fracture is the most important issue at presence. Taiwan has several chronic disease management case management systems ongoing those reduce incidence of complications. In order to decrease the complications of fragility fractures and the disease burdens, a case management system of Fracture Liaison Service (FLS) should be established at earliest. The scope of FLS includes identification those high risk subjects of fragility fracture, investigation subjects risk assessment and life style education, intervention of pharmacological treatment and follow-up plan. Furthermore, maximizing information system support is essential to provide efficiency to the case management process. This article is to provide guidance of FLS framework implementation to a hospital.

並列關鍵字

osteoporosis ； case management ； system ； program

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