影響嬰兒膽道閉鎖存活因素之多層次因子分析-脈絡效果分析

背景：新生兒黃疸是相當常見的問題，由於近年來衛生福利部積極推動母乳哺育政策，我國嬰兒母乳哺育率獲得明顯提升，但因此新生兒延長性黃疸超過出生後兩週甚至四週者就變得相當常見。肝外膽汁滯留症中以膽道閉鎖為兒童肝病常見之致死原因及換肝的主因。雖有部份嬰兒延遲性黃疸是因為嚴重的膽汁滯留所引起，卻常被誤以為是母乳哺育所造成之黃疸，以致延誤早期診治時機，而失去生命，或需要換肝。我國是世界上第一個將嬰兒大便卡篩檢推行至全國的國家，然而目前多數家長及醫護人員對延長性黃疸嬰兒的觀念仍嫌認知不足，可能會影響膽道閉鎖症患兒的預後情形。目的：了解影響台灣膽道閉鎖症嬰兒的個人影響因子、出生醫院變項和跨層次交互作用對其存活及預後的影響。方法：本研究使用2002年至2014年「財團法人兒童肝膽疾病防治基金會」嬰兒大便卡中心全國膽道閉鎖症嬰兒確診通報資料及衛生福利部醫事查詢系統之樣本資料進行次級資料分析。研究對象為膽道閉鎖症嬰兒，有效樣本共381個。統計分析採用描述性分析、獨立樣本t檢定、單因子變異數分析、皮爾森相關係數檢定、存活模式及層級線性模式分析。結果：研究結果發現，如果可以及早確診並儘早進行葛西手術是影響膽道閉鎖症嬰兒存活及預後的重要關鍵因素，每延遲一天進行葛西手術，就會增加患兒死亡或換肝機率的相對風險。在考慮樣本的個人屬性時，我們發現早產的膽道閉鎖症嬰兒會延遲進行葛西手術，而造成患兒不佳的預後。在控制了個人屬性變項之後，發現患兒在設置有小兒專科的醫院出生，能顯著縮短患兒進行葛西手術的時間。但若考慮早產及出生醫院跨層次的交互作用影響，則發現早產的膽道閉鎖症嬰兒出生在有設置小兒專科醫師的醫療機構中，反而會進一步增加延遲患兒進行葛西手術的天數。結論：兒童的個人屬性與出生醫院因素對於膽道閉鎖症嬰兒的預後及存活扮演一定的角色。

關鍵字

膽道閉鎖症；葛西氏手術；原肝存活；存活分析；階層線性模式

並列摘要

Background: Neonatal jaundice is a common problem during infancy. Recently due to the active promotion of breast feeding by the Ministry of Health and Welfare, breast feeding rates in infants has increased markedly. Consequently, prolonged jaundice beyond 2 to 4 weeks of life is quite common. Biliary atresia is the most common cause of extra-hepatic cholestasis in infancy, and is the leading cause of childhood death due to liver disease. Although part of the prolonged jaundice in infancy is caused by cholestasis, it is often unrecognized and mixed up with breast feeding jaundice, resulting in delays for the child during the optimal treatment time, ultimately leading to poor outcomes. The first universal screening system using infant stool cards was established in Taiwan in 2004. However, it is still not a well known system, nor is it widely used by medical personnel and the care takers, may result in poorer outcomes of biliary atresia infants. Aims: To investigate the effects of individual-level and hospital-level variables, as well as cross-level effects on survival factors of biliary atresia infants. Methods: We enrolled 381 infant with biliary atresia who were born between 2002 and 2014 and were registered on the Taiwan Children Liver Foundation (TCLF) database in this study. Descriptive statistics, independent t-test, One-way Analysis of Variance (One way ANOVA) Pearson correlation test, survival analysis and Hierarchical Linear Modeling were conducted. Results: We identified children through early detection and diagnosis after birth, and found that children who underwent a Kasai operation earlier on in their diagnosis resultd in significant improvements in the overall prognosis of these children. Preterm delivery utilmately delays the Kasai operation time resulting in a poor prognosis of biliary atresia infants. Children who were born in hospitals or clinics with pediatricians will accept Kasai surgery early. However, we discovered that the cross-level interaction of premature biliary atresia infant and professional pediatricians will significantly delay the optimal Kasai operation time leading to poorer outcomes. Conclusion: Different individual-level and hospital-level variables were related to outcomes of biliary atresia infants.

並列關鍵字

Biliary atresia ； Kasai operation ； Native liver survival ； Survival Analysis ； Hierarchical Linear Modeling (HLM)

參考文獻

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影響嬰兒膽道閉鎖存活因素之多層次因子分析-脈絡效果分析

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