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標題: | 體外膜氧合技術(ECMO)醫院執行量之軌跡類型及其與醫療結果之相關性 The trajectory patterns of Hospital-based Extracorporeal Membrane Oxygenation (ECMO) Performance Volume and its Association with Treatment Outcome |
作者: | Hsi-Chieh Chen 陳錫杰 |
指導教授: | 楊銘欽 |
關鍵字: | 體外膜氧合技術,群體軌跡分析,病人結果, Extracorporeal Membrane Oxygenation,ECMO,Group-based trajectory analysis,patient outcome, |
出版年 : | 2020 |
學位: | 博士 |
摘要: | 研究背景:體外膜氧合技術(Extracorporeal Membrane Oxygenation, ECMO),是透過體外循環的方式,爭取更多急救時間。我國健保於2002年將ECMO納入給付後,使用病患數逐年增加。ECMO屬於高費用的醫療服務,為提高使用之效率與結果,應進一步瞭解我國的使用情況,包括病患的特性分布與預後結果,以及醫療費用。不同醫院的執行量,是否造成醫療結果的變異性,也需要進一步評估。
研究目的:使用健保資料庫了解我國ECMO使用情況,以及醫院ECMO執行量之軌跡類型,並探討軌跡類型對於病人結果的影響。 材料與方法:本研究為次級資料分析,採用回溯性追蹤研究設計,使用全民健保資料庫,分析2002-2017年ECMO的使用趨勢,以及執行ECMO之醫院的特性。使用群體軌跡分析方法以了解2002-2015年醫院ECMO執行量的軌跡,並進行軌跡分組,探討不同軌跡類型與ECMO病人醫療結果之相關性。 研究結果:2002-2017年共有13,880人曾於住院或急診執行ECMO,以男性病患居多(68.7%),平均年齡52.3歲,ECMO平均使用天數4.5天,平均住院天數26.6天,當次住院點數912,930點。使用ECMO之病人數逐年上升,由2002與2003年的283人,增加到2017年的1,437人;平均ECMO使用天數,由2002-2003年的4.3天上升到6.4天;住院死亡率逐年下降,由2002-2003年的70%下降到64%。使用群體軌跡分析法將納入分析的醫院之執行量區分為三種軌跡類型,軌跡類型1是始終少量執行的醫院,約占71%,起始值4.03,每年成長0.63;軌跡類型2是中度成長的醫院,約占22%,起始值7.11,每年成長2.74;軌跡類型3則是一開始就呈現高成長的醫院,約占7%,起始值36.89,每年成長5.53;校正其他變項後,2016-2017年的病人,在軌跡類型1的醫院使用ECMO,與在軌跡類型3的醫院使用ECMO相比,病人住院死亡風險高出1.39倍(95% CI: 1.02-1.88)。 結論:執行ECMO有較高成長的醫院,比始終少量執行ECMO的醫院,病人的醫療結果顯著較好。 Background: Extracorporeal Membrane Oxygenation (ECMO) is a temporary life support treatment modality using the cardiopulmonary bypass device. The use of ECMO in Taiwan increases after covered by the National Health Insurance in 2002. ECMO is a hospital-based high-cost and skill-intensive medical treatment. The association between ECMO service volume and patient survival is yet to be examined. Objective: To describe the utilization of ECMO in Taiwan and to explore the trajectory patterns of hospital-based ECMO service volume and its association with treatment outcome using a population-based database. Methods: A longitudinal cohort study was conducted and the patients were retrieved from National Health Insurance Database between 2002 and 2017 to evaluate the trend of ECMO use and the characteristic of the hospital. Group-Based Trajectory Model (GBTM) was used to explore the trajectory patterns of hospital-based ECMO service volume and Cox Regression Models with Mixed Effects to examine the association between ECMO service volume trajectory pattern and patient outcome. Results: A total of 13,880 ECMO patients were retrieved from 2002 to 2017. Overall, 68.7% were male, mean age was 52.3 years old, ECMO duration was 4.5 days, length of stay was 26.6 days and cost of hospitalization was 912,930 points. From 2002 and 2003 to 2017, the number of ECMO patients increased from 283 to 1,437, the duration of ECMO use increased from 4.3 days to 6.4 days, but the in-hospital mortality declined from 70% to 64%. The hospital-based ECMO service volume was categorized by GBTM into three trajectory groups: low growth, median growth, and high growth. About 71% of hospitals were categorized in low growth type, started from 4.03 cases per year and increased by 0.63 cases annually; about 22% of hospitals were categorized in median growth type, started from 7.11cases per year and increased by 2.74 cased annually; about 7.1% of hospitals were categorized in high growth type, started from 36.89 cases per year and increased by 5.53 cases annually. After adjusting confounding factors, patients in low growth type hospital receive ECMO treatment had higher in-hospital death risk than those in high growth type hospital (Adjusted HR=1.39; 95% CI: 1.02-1.88). Conclusions: Based on ECMO service volume, hospitals in high growth trajectory type had significantly better patient survival than hospitals in low growth trajectory type. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/15272 |
DOI: | 10.6342/NTU202000228 |
全文授權: | 未授權 |
顯示於系所單位: | 健康政策與管理研究所 |
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