頭部外傷病人之預後與醫療資源使用情形

研究目的: 近5年對於不同傷害原因所導致單一頭部外傷之傷害類型及其衍生出之醫療資源費用耗損與傷患預後之相關研究中，常見其流行病學的研究報告，少數相關論文中只有部分提及輕度頭部外傷（格拉斯哥昏迷指數Glasgow Coma Scale, GCS 13-15分）之研究結果，但未見有深入探討中重度頭部外傷（GCS 3-12分）之本土性研究。本研究之目的為了解頭部外傷之預後與醫療耗用情形；探討影響頭部外傷預後與醫療耗用之因素。希望藉由本研究獲得實證結果，真正了解頭部外傷醫療相關資源之使用情形，並期以能提供政府相關主管單位做為頭部外傷防治醫療政策研擬之參考。研究方法: 本研究採回溯病歷紀錄法，收集高雄某醫學中心於2010年1月31日至2011年3月31日間，由急診入院轉入神經外科加護病房之頭部外傷病患。將頭部外傷病患依照病人到院時之GCS，分成輕、中、重三類，即GCS=13-15分為輕度、GCS=9-12分為中度與GCS=3-8分為重度頭部外傷。從急診與住院病歷中，逐一審視符合收案個案之相關資料。本研究以Excel鍵入資料，再以SPSS 12.0統計套裝軟體程式整合所有資料，進行資料建檔、處理與統計分析。研究結果: 總共95人納入本研究，男女比例為64.2%比35.8%，住院導因以交通運輸事故占64人(64/95=67.4%)最多(其中機車相關交通運輸事故共56人(56/64=87.5%)占最多)，其次為意外墜落之28.4%；意外墜落在老年人17/32(53.1%)是頭部外傷的重要原因。有45.3%的病人接受一次或一次以上的腦部手術，而6.8%(16/95) 的病人家屬有簽署do not resuscitate (DNR)。到院時之頭部外傷嚴重程度輕度占49.5%，中重度為50.5%。而病人預後以格拉斯哥復原程度Glasgow Outcome Scale, (GOS)分，GOS=1分的死亡占24.2%，GOS=2-4分的殘障占40.0%，GCS=5分的完全復原占35.8%。住院總費用平均為164,522 ?b 165,778元。住院健保自付費用平均為7,598 ?b 8,012元。自費費用平均為15,386 ?b 20,672元。中重度頭部外傷病患(GCS=3-12)死亡率高達43.8%(21/48)，而輕度頭部外傷病患(GCS=13-15)為4.3%(2/47)。殘障組在急診費、加護病房費用、普通病房費用、手術費用、住院總費用、住院健保總費用與自費費用上皆比完成恢復組與死亡組有意義的多醫療耗用。以線性迴歸統計預測總住院日數:呼吸治療費用、存活與是否手術(R2=0.745)。預測住院健保總費用: 呼吸治療費用、存活、是否手術與severe haed injury (GCS=3-8)(R2=0.872)。預測住院總費用: 呼吸治療費用、存活、頭部外傷嚴重度與是否手術 (R2=0.866)。預測住院自費費用:是否手術與頭部外傷嚴重度 (R2=0.313)。結論與建議: 頭部外傷之預後仍不佳，尤其是中重度頭部外傷病患。頭部外傷原因仍以交通事故為主，其中又以機車事故為多數，故宣導交通安全仍為減少頭部外傷之重要工作。而老年人的頭部外傷原因中，跌倒為不可忽略的主因，而且老年人的頭部外傷預後不佳，故老年人尤其有行動不便者，更要宣導照護防止跌倒。而中重度頭部外傷病患之預後遠差於輕度頭部外傷病患，預後不良之頭部外傷病患，尤其是GOS=2-4者其醫療耗用遠大於其他預後之頭部外傷病患，仍是家庭、社會與國家的一大負擔。是否健保給付頭部外傷病患時必要使用之醫材與重大傷病之認定，有待健保之再檢討。是否DNR的介入可減少無效醫療之醫療耗用，仍有待進一步的研究。

關鍵字

頭部外傷；頭部外傷之預後；醫療耗用；格拉斯哥昏迷指數

並列摘要

Background: For the recent five years, there have been studies on single injury head trauma brought about by various causes, the patterns of injuries, the medical expenses thus derived, and their prognosis. However, among the epidemiological studies, not many studies were devoted to the outcome of Mild Traumatic Brain Injury, mild TBI, with a Glasgow Coma Scale, GCS, of 13 to 15. No in-depth local studies on moderate to severe TBI, GCS=3-12, were noted. Therefore, this study was aimed to examine and analyze the prognosis, the consumption of medical resources, and factors that affect both the prognosis and the medical expenditure of all three degrees of TBIs. Materials and Methods: This study adopted the backtracking research method through the analysis of medical records of head injury patients who were admitted to the Neurosurgery Intensive Care Unit from the Emergency Department in a medical center in Kaohsiung, Taiwan, during the 14-month period of Jan 31, 2011 to Mar 31, 2011. These patients were categorized into mild, moderate and severe Traumatic Brain Injuries according to their GCS presented on arrival at the emergency department. Results: A total of 95 TBI patients were included in this study. The top cause of TBI was vehicle accident. And accidental falling down injury was an important cause of brain trauma among senior citizens (17/32, 53.3%). 45.3% of these admitted patients received one or more brain surgeries. 6.8% of 95 families signed the Do Not Resuscitate, DNR, documents and all of these cases died. At arrival at emergency department, 50.5% were moderate to severe head injury (GCS=3-12) and 49.5% were mild head injury (GCS=13-15). The outcomes were categorized into deceased (Glasgow outcome score, GOS=1), handicaps (GOS2-4) and good recovery (GOS=5), and the percentages were 24.2%, 40.0% and 35.8% respectively. Statistical analysis revealed no significant difference in the number of days of hospital stay between operative and non-operative patients. But there were significant differences in the cost of hospitalization and self-paying items between patients with DNR documents and those without. Although whether or not a DNR was signed had no significant influence on the number of days in emergency stay, the number of days in the ICU, in-patient ward, and total hospitalization were significantly different. Medical expenses for the handicaps group were significantly higher than both the good recovery and the deceased groups. Predictors of the number of hospitalization days were respiration therapy fees, survival and surgery. Predictors for the total hospitalization fees were respiration therapy fees, survival, the severity of head injury and surgery. Conclusion: The prognosis of brain injury is not satisfactory, especially for those with moderate to severe TBI. The main cause of brain injury was vehicle associated accident, with motorcycle accidents topping the list. Hence, public education on how to achieve safety on road remains an important strategy to reduce brain injury. Since the prognosis of brain injury in the elderly is poor, education on the prevention of falling, especially for those with some extent of physical disability, is essential. Patients discharged with GOS 2 to 4 who need someone to attend to, would consume tremendous medical and social resources and place prominent burden. Reevaluation of governmental policies as to the inclusion of necessary medical procedures, equipments and materials for treatment of brain injury is called for. Moreover, intervention of medical treatment by DNR documents to cut down ineffective wastes on the consumption of medical resources still needs further study and exploration.