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  • 學位論文

探討頭部外傷的傷害機轉與醫療資源耗用

The mechanism and medical resources utilization in head injury

指導教授 : 黃崇謙
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摘要


事故傷害所導致頭部外傷一直是世界關注的公共衛生議題,造成潛在生命(Years of Potential Life Lost,簡稱YPLL)及工作年數損失(Work Years of Potential Life Lost,簡稱WYPLL)的首位遠比癌症、心血管疾病嚴重,藉由健保住診醫療申報資料針對頭部外傷探討,重點係以中央健康保險局(簡稱健保局)台北分局歸戶後全年住院資料庫與串聯衛生署死亡檔為工具,針對大台北區域單一頭部外傷事件為期五年次級資料之人口族群回溯性分析,探討不同傷害機轉類型的病人人口學特質、住院發生率與死亡率、季節性變動量等相關因素分佈情況與後續衍生醫療資源耗用程度。 本研究共收集2000年-2004年歸戶頭部外傷住院個案43,239人,總耗用住院醫療資源2,799,103,526元,平均年齡43.3歲(男性42.7歲、女性44.3歲),其中男生佔多數值男女比1.65:1、平均住院日數11日(男性11.9日、女性9.4日、65歲以上老人18.2日)、住院死亡率6.38﹪(男性7.49﹪、女性4.70﹪、65歲以上老人14.13﹪)、平均每人住院醫療費用64,736元(男性73,685元、女性49,933元、65歲以上老人116,394元),區分季節性則以第一季分佈佔多數25.6﹪,其次第四季25.1﹪。 傷害機轉別(Mechanism of Injury,簡稱MOI)隨年齡、性別不同危險因子特色呈現明顯差異,其中運輸事故(Traffic Accidents)佔總樣本54.8﹪,集中於中壯年與青少年佔總樣本81.4﹪,平均事故發生年齡38.3歲,平均每人住院醫療費用62,797元;機動車交通事故(Motor Vehicle Traffic Accidents,簡稱MVTA)有17,996人(53.3﹪),平均事故發生年齡39.3歲,平均住院日數10.7日、住院死亡率5.8﹪、平均每人住院醫療費用63,242元,其中機車事故有9,039人(50.2﹪),平均年齡31.3歲,平均住院日數9.9日、住院死亡率4.5﹪、平均每人住院醫療費用58,016元、死亡個案每人住院醫療費用184,646元;意外墜落事故(Accidental Falls)是造成頭部外傷第二位原因有10,486人(31﹪),平均事故發生年齡較高為55.9歲、平均住院日數15.7日、住院死亡率10.4﹪且每人住院醫療費用高於運輸事故有100,111元之多,也是老人族群頭部外傷首因(61.3﹪),老人意外墜落平均住院日數21.3日、住院死亡率15.3﹪、平均每人住院醫療費用126,797元、死亡個案每人住院醫療費用309,678元;相對機動車交通事故常見65歲以下人口,影響所及平均生命年數損失(Average Years of Life Lost,簡稱AYLL)為38.19人年數,再細分傷害情境與受傷者身份發現:機動車乘客50.72人年數、機車乘客49.94人年數、機車騎士39.35人年數、房屋建築物墜落40.79人年數、被落物擊中41.15人年數、故意傷害42.65人年數皆比衛生署2004年統計之事故傷害平均生命年數損失29.9人年數高,衝擊社會經濟生產深遠。 最後調查頭部外傷住院總平均發生率有120.14/每十萬人口,區域觀察發現宜蘭地區323.14/每十萬人口、金門地區232.65/每十萬人口較嚴重,分齡層別75歲以上之老老人住院發生率418.05/每十萬人口,高過頭部外傷全國發生率230/每十萬人口,情況比青少年171.91/每十萬人口嚴重,再則死亡風險比以故意傷害4.878倍相較於未確定故意或意外傷害是最高,顯示該類傷害高完成性特色、被落物或人撞擊2.403倍、意外墜落2.074倍及運輸事故1.778倍;青少年、中壯年故意傷害(自、他殺)與目前高齡化社會的老人意外墜落所致頭部外傷都是不容忽略的議題。 歸納發現傷害機轉類型之年齡層別與季節分佈達到統計顯著相關性,而老人發生則無季節之分;針對不同傷害機轉間之年齡、平均住院日數與醫療資源耗用程度均顯著差異性,其相呼應的手術種類、電腦斷層放射線檢查與輸血處置施行率之病情嚴重度有顯著相關性,實證研究顯示頭部外傷所造成社會影響甚於其他傷害類型,衛生機關應針對不同的傷害危險因子研擬防治政策與醫療資源的優先分配。

並列摘要


The head injury caused by unintentional and intentional incidents remaines a global concern in the public health agenda. The Years of Potential Life Lost (YPLL) and Work Years of Potential Life Lost (WYPLL) resulted from head injury are much higher than cancers or cardiovascular diseases. This is a population-based study including descriptive and inferentiical statistics.Combining the total annual inpatient dataset from The Bureau of National Health Insurance (BNHI) of Taipei-branch during the year 2000 to 2004 and the domicile files of death certification issued by Department of Health (DOH), this research focues on the five years retrospective analysis in head injuries. The impacts of Mechanism of Injury (MOI), inpatient characteristic distribution, mortality, incidence and seasonal changes on the medical resources utilization are analyzed. The outcomes could provide excellent references for the clinical services and health policymakers to prioritize the medical resource allocation for injury prevention. An analysis from 43,239 head injury patients in the Year 2000 to 2004 has indicated the total hospitalization expenses were NTD 2,799,103,526 with the average age of 43.3 year old. The gender ratio of the patients is 1.65:1 for male to female. Average Length of Stay (LOS) is 11 days, and average hospitalization expense is NTD 64.736 per person. Seasonal respectively distribution lies in the order of 1st and 4th seasons, which accounts for 25.6% and 25.1 % . There are significant differences in MOI, depending on the risk factors of age, gender and season. Traffic accidents account for 54.8% of the total patients and is concentrated in youth and teenager with average age of 38.3 and average hospitalization expense of NTD 62,797 per person. Among them, there are 17,996 persons (53.3%) of Motor Vehicle Traffic Accidents (MVTA) with average age of 39.6, 10.7 days of LOS, inpatient mortality rate of 5.8% and average hospitalization expense of NTD 63,242 per person. Accidental Falls is the second mechanism of head injury with 10,486 persons (31%) and higher average age of 55.9, 15.7days of LOS, mortality rate of 10.4% and higher average hospitalization expense of NTD 100,111 per person. Accidental Falls is also the leading cause of the head injury in elderly(65 years and above) citizen (51.2%) with average 21.3 days of LOS, mortality rate of 15.3% and average hospitalization expense of NTD 136,797 per person. On the contrary, MVTA is often observed in the age group under 65 years old. The impact to Average Years of Life Lost (AYLL) is 38.19 years per person. The analysis of the situations and identities show the AYLL of the head injury victims, passenger in motor vehicle (50.72 years per person), passenger on motorcycle (49.94 years per person), motor bikers (39.35 years per person), falling from or out of building or other structure (40.79 years per person), struck accidentally by falling object( 41.15 years per person), and intentional injury (42.65 years per person), is much higher than the AYLL (29.9 years per person) of accidental injury reported by DOH. The higher AYLL resulted tremendous losses to the social economics. At last, the geographic distribution of the head injury is also analysed, with result of highest county in I-Lan (323.14 per 100, 000), and JinMen (232.65 per 100, 000). Head injury in elderly population over 75 years old causes higher hospitalization rate of 418.05 per 100, 000, which is also higher than the national average of 418.05. This is far more serious than the average in Taiwan of 230. This evidence- based study indicates the head injury from accidental falls in elderly people is an emerging issue which cannot overlooked in the aging society. In the analysis of odds ratio in death risks, Intentional injury accounts for 4.878 times more than other MOI, including 2.403 times more than accidental hits by falling object, 2.074 times more than accidental falls, and 1.788 times more than traffic accident. In summary of the MOI analysis, the differences in age groups and seasonal distribution are significatly correlated. However, the difference is not significant in the aged people. The age groups, LOS and medical resources utilization are also significant and the injury severity of variables in operation, expensive examination (CT, MRI), blood transfusion are also significant .This research illustrates that head injury causes more economic losses than other injury patterns. With the evidence, the clinical services and health policymakers should allocate the reasonable medical resources in dealing with different injury patterns.

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