- 學位論文
醫院服務量與醫師服務量對出血性腦中風病人外科手術結果之影響
Association between Hospital and Surgeon Volume and the Outcome of Intracerebral hemorrhage
摘要
研究背景：台灣地區歷年的死因排行中，中風一直居第二位，僅次於所有癌症的總合。過去有研究證實出血性中風病人有三分之一在住院期間死亡，在醫療技術不斷進步的同時，醫院服務量及醫師服務量對病人治療結果的影響也受到越來越多的關注，很多研究關心醫院和醫師服務量在不同疾病治療成果上的影響，結果都顯示高服務量會帶來較好的治療結果，但目前為止出血性中風手術結果和服務量之間關係的研究相當少。 研究目的：本研究以中央健保局「全民健康保險研究資料庫」分析，探討醫院服務量和醫師服務量對出血性中風病人進行腦部手術後，院內死亡、院內感染的影響；更進一步探討醫院服務量及醫師服務量與中風病人住院費用、住院天數間的關係。 研究方法：以回溯次級資料為研究設計，以國家衛生研究院所發行「全民健康保險研究資料庫」為研究材料，選擇以疾病嚴重度高、死亡率高的「出血性腦中風手術」為例，分析醫院、醫師、病人的不同特性以及醫院服務量、醫師服務量對於出血性腦中風術後院內死亡率、院內感染率、超高住院費用、過高住院費用及超高、過高住院天數的影響。 研究結果：在控制病人及醫院、醫師基本條件後，醫師服務量、醫院服務量對於出血性中風病人手術後院內死亡率及院內感染率的預測沒有統計顯著意義。住院天數過高率及過高醫療費用率有隨著醫院服務量上升而下降的趨勢；高醫師服務量組在住院天數超高、過高率及超高、過高住院費用率方面，都顯著低於低醫師服務量組，危險對比值在0.72~0.92間。 結論：我們的研究包含了全部在台灣進行的出血性腦中風手術資料，對於出血性腦中風手術病人手術後死亡及院內感染的預測，病人年齡、CCI分數、診斷及醫院評鑑等級是主要的影響因素。醫院服務量及醫師服務量是除了病人年齡CCI分數、診斷之外出血性腦中風手術病人超高、過高住院天數及超高、過高住院費用的重要預測因子。
並列摘要
Objectives— Stroke is one of the leading causes of death worldwide, and the second most lethal cause of death in Taiwan. Past studies consistently show an inverse relationship between hospital and surgeon volume and the outcome. There is no information available on this aspect of intracerebral hemorrhage surgical care. We used nationwide population-based data to explore the association between hospital and surgeon volume and the outcome for patients with intracerebral hemorrhage. Methods— Data on all 25540 hospitalizations for intracerebral hemorrhage surgery from 1996 to 2005 , treated by 326 surgeons at 148 hospitals in Taiwan, from Taiwan’s National Health Insurance Research Database, was analyzed using multiple logistic regression model to explore associations between surgical outcomes( in hospital mortality, hospital-acquired infection, cost ≧90 percentile, cost ≧75 percentile, length of stay ≧90 percentile, and length of stay≧75 percentile) and hospital volume (1 to 260 cases=low volume, 261 to561 cases=medium volume, ≧562 cases=high volume) and surgeon volume( 1 to 130 cases=low volume, ≧131 cases=high volume ) adjusting for patient’s age, gender, comorbidities, intracerebral hemorrhage type, and operation type; hospital level, and geographic region; and physician age, gender. Results— Adjusted for patient, hospital, and physician variables, there was no relationship between hospital and surgeon volume and in hospital mortality and hospital-acquired infection rate. There was a negative association between hospital volume and the incidence of cost ≧75 percentile, and length of stay≧75 percentile following intracerebral hemorrhage surgery, and a negative association between surgical volume and the incidence of cost ≧90 percentile, cost ≧75percentile, length of stay ≧90 percentile, and length of stay ≧75 percentile. Conclusions—We conclude that for all intracerebral hemorrhage surgeries taking place in Taiwan, adjusted other factors, coding of patient age, comorbidities, diagnosis and hospital level were the strangest predictors for in hospital mortality, hospital-acquired infection, cost ≧90 percentile, cost ≧75 percentile, length of stay ≧90 percentile, and length of stay≧75 percentile. Expect for the factors we mentioned above, hospital volume and surge volume are the important factors for intracerebral hemorrhage surgery in the incidence of cost ≧90 percentile, cost ≧75percentile, length of stay ≧90 percentile, and length of stay ≧75 percentile.