急性後期照護對腦中風病人功能狀況之探討

Research of Functional Status among Patient’s with Stroke Receiving Post-Acute Care

洪麗瀅(Li-Ying Hung)

指導教授 ： 許弘毅

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2017年)

摘要

研究目的
急性後期照護讓病人能視其失能狀況，在急性期後之三個月黃金治療期接受積極且高密度整合性住院復健照護。本研究探討腦中風病人急性後期照護(Post-Acute Care, PAC)功能狀況之恢復情形，進而找出相關影響因素，以做為該政策推行檢討與修正時之參考。
研究方法
資料來源取自某地區醫院自103年3月至105年12月31日止之121位PAC收案病人。描述性統計以樣本數及百分比呈現研究樣本類別變項資料，以平均值與標準差、中位數與IQR呈現變項資料之分佈情形。推論性統計分析部份，首先，以Cochran–Armitage Chi-Square Test for Trend進行趨勢分析；接著，針對病人在不同時間點各量表評估功能狀態分數，以廣義估計方程式(GEE)分析其功能改變趨勢，並尋找重要危險因子；最後，以COX迴歸統計分析再入院及死亡狀況。本研究使用SPSS 20.0版統計套裝軟體及STATA 11統計軟體進行分析。
研究結果
腦中風急性後期照護的病人，以男性、缺血性中風、無管路及無身障證明者居多，平均住院天數21.5天。趨勢分析顯示男性、無身障證明、無再入院者有增加趨勢。連續變項以學歷增加幅度(0.043)及CCI指數分數減少幅度最多(-0.043)。巴氏量表不論是在PAC第三周至PAC入院日或PAC第12周至PAC第三周增加幅度皆最大，且達統計上顯著差異(p <.001)。研究結果亦發現，各項量表影響因子表現不盡相同，但在時間分期(六周後)及初評的分數皆具顯著性意義。另外多變量分析中發現，整體功能量表(MRS)在性別上；生活品質量表(EQ-5D)在有管路及有身障證明；平衡量表(BBT)在有管路、PAC住院天數及急性期住院天數；認知功能量表(MMSE) 在CCI指數等因子呈現顯著。在存活分析控制變項後，以教育程度(HR = 1.6，p =.022)及BMI(HR = 0.5，p =.006)呈現顯著。
結論與建議
急性後期照護的住院復健治療模式，藉由醫學中心下轉至承作醫院，達到醫療與健保資源更有效率的分配，是醫療分級推行的理想配套措施，健保署於106年7月1日公告實施擴大試辦計畫，對象除腦中風、燒燙傷外，更擴大至創傷性神經損傷、脆弱性骨折、心臟衰竭、衰弱高齡病患等，相信成效是指日可待。
關鍵詞：急性後期照護、腦中風、功能狀況

關鍵字

急性後期照護 ； 腦中風 ； 功能狀況

並列摘要

Objects：
Post-Acute Care (PAC) provides aggressive, high-intensity integrated inpatient rehabilitation during the first three months of golden period for treatment. This study is aimed to investigate functional outcomes of patients with stroke after PAC program and to identify important factors that could be referenced by the ongoing policies.
Method：
A total of 121 stroke patients who received PAC program were enrolled from a local community hospital between March 1, 2014 and December 31, 2016. In descriptive statistics, categorical variables were described by the number and percentage of the study participants, and continuous variables were demonstrated by the mean, standard deviation, median, and interquartile range (IQR) to measure the statistical dispersion. In inferential statistics, the Cochran-Armitage test for trend was used to estimate the trend of categorical data over time. Furthermore, generalized estimating equation (GEE) was used to analyze longitudinal measurements of functional status of the study participants, and thus to identify the important risk factors. Cox regression was used to determine the risks of readmission and mortality. All analyses were performed using the SPSS Statistics (version 20.0) and STATA (version 11).
Results：
In all, there were 121 patients with stroke were recruited. Most of them were male, having ischemic stroke, without any catheterization and without handicap certificates. The average length of stay in hospital was 21.5 days. Trend analysis showed an increasing trend of male, without handicap certificates and without readmission. Among the continuous variables, we found the most significant increase in education level (0.043) and the most decline in Charlson comorbidity index (CCI) scores (-0.043). The greatest increase in Barthel index scores was observed between the date of admission and the third week of PAC, and between the twelfth week and the third week of PAC (p <.001). Although factors varied in the different evaluating scales, PAC beyond three weeks and the baseline scores remained statistically significant. After adjusting covariates, education level (HR = 1.6, p=.022) and body mass index (BMI) (HR=0.5, p =.006) were significant factors in survival analysis.
Conclusion：
PAC rehabilitation program could be an ideal measure to implement the hierarchical medical system and to distribute medical resources more efficiently.
Keyword： Post-Acute Care, Stroke, Functional Status

並列關鍵字

Post-Acute Care ； Stroke ； Functional Status

參考文獻

英文文獻

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