婦科重大手術病人術後醫療品質影響因素之研究-以南部某地區醫院為例

Factors Affecting Postoperative Medical Quality in Patients with Major Gynecological Surgery- A Case Study of One District Hospital in Southern Taiwan

林芸羽(Yun-Yu Lin)

指導教授 ： 馬震中

義守大學/醫學院/醫務管理學系/碩士(2018年)

摘要

目的:婦科重大手術結果的優劣對病人術後醫療有重大影響，因此本研究目的為探討人口學變項、手術相關變項對婦科重大手術術後醫療品質的影響，藉由此研究結果以期提供臨床醫病間共同決定最適治療方案參考。
方法:本研究採回溯性研究設計，以病歷回顧方式收集資料，個案來源為台灣南部某地區醫院2014年1月1日至2017年12月31日，共363位婦產科手術之病人；本研究已經人體試驗倫理委員會核准執行(計畫編號: 18-012-B)。資料進行以描述性統計、卡方檢定及複回歸、羅吉斯回歸進行分析，找出影響術後醫療品質(住院天數、併發症)之影響因子。
結果: 平均手術年齡為45.9±58歲，身體質量指數24.4±4.55 kg/m2，住院天數為4.46±1.04天，經卡方檢定結果顯示手術方式對併發症具有統計上顯著差異；複回歸分析結果顯示手術種類對住院天數具有統計上顯著的差異；經ANOVA變異數分析手術種類、手術方式對住院天數有顯著差異，經Scheffe事後檢定可發現，執行卵巢或輸卵管切除住院天數小於執行子宮肌瘤切除住院天數及小於子宮切除術住院天數，在使用傳統腹腔鏡手術住院天數小於單孔腹腔鏡手術及小於經陰道手術；經羅吉斯迴歸分析結果，出血量對併發症有顯著差異，出血量每增加1單位時，產生併發症為沒有產生併發症的1.003倍(p=0.001:β=0.003，Odds ratio=1.003，95%CI:1.001-1.005)；使用腹腔鏡手術的併發症的勝算是較使用經陰道手術產生為6.033倍(p=0.010:β=1.797，Odds ratio=6.033， 95%CI: 1.544-23.578) ，使用單孔腹腔鏡手術產生的併發症的勝算是較使用經陰道手術為7.312倍(p=0.005:β=1.989，Odds ratio=7.312，95%CI: 1.544- 23.578)，因此出血量、手術方式為併發症預測因素。
結論:本研究結果發現手術種類為住院天數的預測因素，出血量、手術方式也為併發症預測因素，其結果可供臨床醫師擬定治療計畫時之參考，並提升醫療照護人員對併發症之瞭解及關注，能即時給予適當醫療照護處置，降低併發症程度並藉此提升病人的術後醫療品質，以及臨床上醫病之間共同決定治療方式的參考。

關鍵字

婦科手術 ； 醫療品質 ； 併發症 ； 住院天數

並列摘要

Purpose: Successful gynecology operation result or not is important for post surgery cares. This paper aims to investigate parameters of demographic variables and surgical related variables affects medical quality. Providing references t for the optimal treatment plan for clinical decision-making.
Methods: This study used retrospective study design to collect data by means of medical record review. The case was from a district hospital in southern Taiwan from 1-1-2014 till 12-31-2017, with a total of 363 patients undergoing gynecological surgery. This study has been approved by the Institution Review Bord (IRB number: 18-012-B). The data were analyzed by descriptive statistics, chi-square test and multiple regression, and logistic regression to find out the factors affecting postoperative medical quality (hospitalization days, complications).
Results: Patients average age is 45.9±58 yrs-old, body-mass index is 24.4±4.55 kg/m2 and hospitalization period is 4.46±1.04 days. The result of the chi-square test showed statistically significant differences in complications. The result of multiple regression analysis showed that the type of surgery had statistically significant differences in the number of hospital days. The results of ANOVA analysis revealed the type of surgery and the surgical procedure had significant differences in the number of inpatient days. The Scheffe's post-hoc test revealed the number of hospital days for patients undergoing ovarian or fallopian tube resection was less than the number of hospital days for patients undergoing uterine myomectomy and less than the number of hospital days for patients undergoing hysterectomy. The hospital days of patient receiving traditional laparoscopic surgery was less than single-port laparoscopic surgery and less than transvaginal surgery. The results of the Logistic regression analysis showed that the amount of bleeding was significantly different in complication. When the amount of bleeding increased by 1 unit, the complication was 1.003 times than that of no complications (p=0.001: β=0.003, Odds ratio=1.003, 95% CI: 1.001-1.005); the odds of using laparoscopic surgery were 6.033 times higher than those using transvaginal surgery (p=0.010: β=1.797, Odds ratio=6.033, 95% CI: 1.544-23.578). The odds of complication using single-port laparoscopic surgery were 7.312 times than those using transvaginal surgery (p=0.005: β=1.989, Odds ratio=7.312, 95% CI: 1.544-23.578). Therefore, the amount of bleeding and the surgical approach were predictors of complications.
Conclusions: The results of this study found that the type of surgery is the predictor of hospitalization days. The amount of bleeding and the surgical procedure are also predictors of complications. The results can be used for clinicians to draw up a reference for treatment planning and improve the understanding and concern of complications for medical caregivers. Otherwise, it can immediately give appropriate medical care and treatment, reduce the degree of complications and improve the patient's postoperative medical quality.
And as a reference for the shared decision making between doctor and patient in clinically.

並列關鍵字

Gynecological surgery ； Medical quality ； Complications ； Hospitalization days

參考文獻

何菊修、陳宗鷹(2005)．急性術後疼痛．慈濟醫學雜誌，17(6)，43-50。

中文部分

衛生福利部統計處(2015)．表八住院手術人次統計－按就醫科別分．取自https://www.mohw.gov.tw/sp-GS-1.html?Query=%E4%BD%8F%E9%99%A2%E6 %89%8B%E8%A1%93%E4%BA%BA%E6%AC%A1%E7%B5%B1%E8%A8%88

衛生福利部國民健康署(2017)．BMI 測試．取自http://health99.hpa.gov.tw/ Onlink Health /Onlink_BMI.aspx

醫策會(2018)．台灣臨床成效指標系統/指表清單．取自http://tcpi.jct.org.tw/tcpi/