醫師服務量與院內死亡之相關性研究－以葉克膜氧合器為例

A Study on Relationship between Physician Volume and In-Hospital Mortality －Example for Extracorporeal Membrane Oxygenation

江依倫(Yi-Lun Chiange)

指導教授 ： 林恆慶

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2010年)

https://doi.org/10.6831/TMU.2010.00112

摘要

研究背景與目的：隨著急救設備和技術不斷進步，一般常見的急救方式，除了氣管插管治療及其他處置之外，葉克膜氧合器(ECMO)，近年來已成為發展迅速且使用頻率較高的儀器。不過ECMO終究僅能維持生命徵象並非具有治癒效能。根據文獻發現，雖然ECMO急救後的存活率高於較其他方式，但手術後可能受到醫師(性別、年齡和科別)或患者特質(性別、年齡、主診斷和合併症)等，影響死亡率的高低。因此，本研究將試圖以葉克膜氧合器為例，同時也是第一篇探討醫師服務量與院內死亡之相關性研究。
研究方法：本研究資料來源為全民健康保險資料庫2005年至2008年之醫事機構基本資料檔(HOSB)、專科醫師證書主檔(DOC)、醫事人員基本資料檔(PER)及住院醫療費用清單明細檔 (DD)等。其研究對象為曾經使用ECMO (ICD-9-CM code 39.65)之18歲以上患者。在醫師服務量方面，將醫師分為中服務量、高服務量及較高服務量共三組，照護結果則為院內死亡。統計方法採用卡方檢定(χ2 test)及條件式廣義估計方程式(GEE)，檢視醫師使用ECMO服務量對院內死亡關係。

研究結果：在卡方檢定中三組死亡率分別在中、高及較高醫師服務量為60.77%、53.70%、50.21%；p< 0.01)。在控制其他變項之後，經條件式廣義估計方程式顯示，高服務量及較高服務量醫師之院內死亡分別為中服務量的0.73倍(95% C.I.= 0.54-0.98)及0.63倍(95% C.I.= 0.46-0.87)。

結論：經校正後得知，高服務量及較高服務量的院內死亡達統計上顯著性差異(p<0.05；p <0.01)。整體而言，當醫師服務量愈高時，其照護結果愈好。

研究建議：(1)衛生主管機關可設立醫療品質標準指標及專責制度；(2)醫療院所可制定標竿學習團隊與臨床教育訓練；(3)未來研究者可建立醫師訪談制度。

關鍵字

葉克膜氧合器

並列摘要

Objectives: With the continuous improvement of first-aid equipment and technologies, one of the general first-aid methods except Endotracheal Intubation and other treatments, Extracorporeal Membrane Oxygenator (ECMO), has become a rapidly developing and frequently used instrument for first-aid in recent years. However, ECMO can only maintain the vital signs of patients rather than for the utilization of effective treatments. According to the documents from the ECMO manual and other reports, the patients who received ECMO for first-aid has a greater chance of survival than other patients who receive other first-aid treatments. The main factors that may affect the mortality of patients after the operations are the physicians (sex, age, and department) or the characteristics of patients (sex, age, principal diagnosis, and Charlson Comorbidity Index). Therefore, the study attempts to use ECMO as an example; meanwhile, it is the first research on the relationship between the volume of physician service and in-hospital mortality as well.

Methods: The information for the study are obtained from National Health Insurance Research Database of Taiwan from the years 2005 to 2008 that includes Registry for Contracted Medical Facililities (HOSB), Registry for Board-certified Specialists (DOC), Registry for Medical Personnel (PER), and Inpatient Expenditures by Admissions (DD). The subjects of the study are patients over the age of eighteen who received ECMO (ICD-9-CM code 39.65) treatment for first-aid. The volume of physician service was separately divided into three groups (medium, high and very high). The outcome of taking care of patients is the in-hospital mortality. The information was analyzed by Chi-square Test (χ2 Test) and Conditional Generalized Estimating Equation Model (GEE) in order to observe the relationship between the volume of the physician service and in-hospital mortality.

Results: In Chi-square Test (χ2 Test), the unadjusted rates of mortality among the groups of the physician service divided into medium, high and very high were separately presented the percentage of 60.77%, 53.70% and 50.21% (p <0.01). After controlling and removing all other variables through Conditional Generalized Estimating Equations (GEE), it shows that the ratio of in-hospital mortality in the high and very high volume of physician service groups were 0.73(95% C.I.= 0.54-0.98) and 0.63(95% C.I. = 0.46-0.87) compared to the medium volume of physician service group.

Conclusion: After obtaining the result from the adjustment, it is concluded that the ratio of in-hospital mortality among the high volume and the very high volume of physician service groups have significant discrepancy (p<0.05; p<0.01). All in all, the in-hospital mortality can be reduced by increasing the volume of the physician service.

Recommended: (1) The Central of Health Authorized Association in Taiwan may establish medical quality control standard indexes and specified obligation systems. (2) All of the hospitals may develop the benchmark of team learning and clinical education training. (3) The researchers may institute a physician interviews system for the future study.

並列關鍵字

ECMO (Extracorporeal Membrane Oxygenator) ； The volume of physician service, In-Hospital mortality.

參考文獻

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