腦中風患者急性後期住院復健治療連續性之成效探討-以台中某區域醫院為例

Exploring the effect of continuity of post-acute inpatient rehabilitation for stroke in a Taichung regional hospital

陳義豪(Yi-Hao Chen)

指導教授 ： 董鈺琪

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2021年)

https://doi.org/10.6342/NTU202102764

摘要

研究背景與目的：
台灣衛生福利部統計資料顯示，腦血管疾病於我國自1981年起始終名列我國十大死因之一，於2019年排名第四大死因。許多存活的中風患者在接受治療與復健後，依然存留著一定的失能狀況，對於日常生活功能能力與生活品質存在著終身的影響，同時許多研究指出腦中風疾病會耗用高昂的醫療照護花費。
我國於103年01月01日起分階段開辦「急性後期照護試辦計畫」，以腦中風為第一階段推行試辦，於區域或地區醫院以住院方式提供最長為期12週的跨專業團隊整合照護，在復健治療方面強調提供「高強度高頻率」介入模式。
照護連續性為初級照護的基礎，已有研究提出照護連續性可有效減少非必要住院、住院天數以及急診率，也可以提昇病人與照護提供者的自覺滿意度。
然而，目前我國探討急性後期照護成效的研究中，大多著重於我國急性後期照護計畫所提及的高頻率與高強度復健治療介入的影響，較無研究對於其中中是否因照護連續性的影響進行探討，因此本研究希望探討腦中風病人住院復健治療連續性的不同，對於功能性回復成效的影響，進而在未來可針對急性後期病患，提出合適的照護模式建議。
研究方法：
本研究為單一中心病歷回溯性研究，研究樣本收集「台中慈濟醫院電子病歷資料庫」的腦中風患者病歷資料，將符合收案條件之納入樣本分為實驗組：高連續性參與急性後期計畫住院復健治療組與對照組：低照護連續性一般住院復健治療組，對其臨床功能性結果透過成對樣本Ｔ檢定、獨立樣本Ｔ檢定與多元線性迴歸以及差異中差異法進行成效分析。
研究結果：
本研究總共納入267人，分別為高照護連續性組227人、低照護連續性組40人，經過獨立樣本Ｔ檢定發現，高照護連續性在整體功能量表、日常生活功能-巴氏量表與功能性行走分級三個依變項中的介入前後差異相較低照護連續性組是有顯著的差異，p值分別為p<0.001、p<0.001、p=0.033。多元線性迴歸分析中差異中之差異法發現高照護連續性組介入後改善幅度相較低照護連續性組在整體功能量表與日常生活功能-巴氏量表皆有統計上顯著效果，高照護連續性組改善幅度較低照護連續性組分別多-0.48分（p<0.001）與10.63分（p=0.016）
結論：
急性腦中風患者在病發一個月內，接受高照護連續性組的急性後期照護計畫住院復健治療，相較低照護連續性組的一般住院復健患者，在整體功能量表及日常生活功能-巴氏量表上獲得顯著的功能改善。

關鍵字

腦血管疾病 ； 急性後期 ； 住院復健 ； 照護連續性 ； 功能性恢復

並列摘要

Background and purpose:
According to the data of Ministry of Health and Welfare, cerebrovascular disease has consistently been the top ten causes of death in our country since 1981 and the fourth leading cause of death in 2019. Many survivors still had some disabilities after receiving adequate treatment and rehabilitation, which impacted their activities of daily living and quality of life permanently. Moreover, many studies suggested that cerebrovascular disease tend to consume higher medical care cost.
Since Jan. 1st, 2014, Taiwan started the ”Post-Acute Care(PAC) pilot program” and stroke was in the first phase. This program provided transdisciplinary team care for up to twelve weeks in regional or district hospitals. In rehabilitation domain emphasized in “high intensity and high frequency” model.
Continuity of Care (COC) is the base of primary care. Some studies have suggested that continuity of care can effectively reduce unnecessary hospitalizations, length of stay, and the rate to visit emergency department. In addition, COC can also increase the self-reported satisfaction of both patients and care providers.
However, most studies investigated the effect of the PAC in Taiwan focused on the impact of high intensity and high frequency rehabilitation treatments. To our knowledge, there is no research focusing on the impact of the Continuity of Care in PAC program.
Therefore, this study aim to explore the impact on functional recovery in stroke patients of different continuity of rehabilitation care during hospitalization period.
Method:
This is a retrospective study in a single medical center. The medical records were collected from “Taichung Tzu-Chi hospital’s electronic medical record database”. The inclusion samples were divided into two groups. The experimental group was “the higher continuity group” who joined the PAC program, and control group was “the lower continuity group who joined the general inpatient rehabilitation”. The data has been analyzed through the SPSS.
Result:
This study recruited 267 participants, 227 in the higher continuity group and 40 in the lower continuity group. The differences between pre- and post-intervention in modified Rankin scale (mRS), Barthel Index (BI) and Functional Ambulation Category (FAC) improved significantly in the higher continuity group (p<0.001, p<0.001 and p=0.033 respectively). Furthermore, the higher continuity of care group improved significantly in mRS and BI pre- and post-intervention, under multiple linear regression analysis. The higher continuity group have more improvement than the lower continuity group for values of -0.48 (p<0.001) and 10.63 (p=0.016), respectively.
Conclusion:
Acute stroke patients who received PAC program, as in the higher continuity, improved significantly in daily function in mRS and BI, compared to the lower continuity of inpatient rehabilitation group.

並列關鍵字

Cerebrovascular disease ； stroke ； inpatient rehabilitation ； functional recovery ； continuity of care

參考文獻

1. Organization WH. The top 10 causes of death. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death2020.

2. 衛生福利部統計處 死因統計 https://dep.mohw.gov.tw/dos/np-1776-113.html

3. Lekander I, Willers C, von Euler M, et al. Relationship between functional disability and costs one and two years post stroke. Plos One 2017;12.

4. Virani SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020;141:e139-e596. doi: 10.1161/CIR.0000000000000757.

5. 衛生福利部 全民健康保險急性後期整合照護計畫https://www.nhi.gov.tw/Content_List.aspx?n=5A0BB383D955741C topn=5FE8C9FEAE863B46