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標題: | 利用健保資料探討送醫層級及轉診模式與急重症病患預後
之相關性--以重大創傷以及急性心肌梗塞病患為例 Centralization or decentralization in Caring for the Patients with Major Trauma and Acute Myocardiac Infarction? Suggestions for the Prehospital Transfer Systems by using the NHIRD Data Base and the Medical Cost |
作者: | Dor-ji Harnod 哈多吉 |
指導教授: | 張睿詒 |
關鍵字: | 緊急醫療,分級轉診,重大創傷,急性心肌梗塞, EMSS,tranferral,major trauma,STEMI, |
出版年 : | 2013 |
學位: | 博士 |
摘要: | 邱姓女童事件凸顯國內急重症醫療的兩個重要議題:第一個是到院前救護選擇醫院轉送的問題,第二個則是急重症病患院際間轉診的問題。為瞭解分級醫療制度中影響急重症病患預後之因素,本研究採回溯性研究。利用2005到2009年之健保資料庫百萬歸人檔,以重大創傷及急性心肌梗塞病患為研究對象,在校正年齡/性別/檢傷級數/共病性等病患特質後,利用羅吉斯迴歸等方法探討病人特質以及醫院特質是否會影響急重症病患之預後以及醫療資源耗用。
本研究以健保資料庫分析,發現重大創傷病患在醫學中心的死亡風險較低,但急性心肌梗塞病患在不同層級醫院之死亡風險沒有統計上顯著之差異。其次,本研究證實此兩種急重症病患中,轉院對死亡無統計上顯著之影響。而本研究更在分組分析中,找出建議重大創傷病患應該轉診至醫學中心的院前檢傷條件。並進一步證實重大創傷病患院前檢傷之依存度與急性心肌梗塞病患住院的準則藥物遵囑性,都是影響病患存活出院的重要影響因子,而且是可以努力改善的影響因子。最後本研究完成(1)重大創傷病患未被遵照準則轉送病患至醫學中心 ,(2)急性心肌梗塞病患住院期間未執行心導管介入,及(3)急性心肌梗塞病患住院間未遵囑使用藥物的影響因子。研究發現不是病患之社經狀況,卻是醫院層級,公私立醫院等相關因子。 本研究提供適當的實證依據,建議重大創傷之病患需要衛生主管機關主導集中轉送(centralization),建議將區域醫院急診中(1)ISS>25,(2)檢傷一二級,及(3)年齡>55歲之病患轉送至醫學中心救治。而急性心肌梗塞需要衛生主管機關主導分散轉送(decentralization),建議將急性心肌梗塞病患送至立即可做心導管介入之醫院(心臟中心)。本研究也建議心導管量不是心臟中心的重要影響因子,但病患遵照準則用藥的品質指標才是影響病患存活較重要的因子。本研究建議衛生主管機關針對區域醫院加強急性心肌梗塞病患住院準則藥物使用的稽核。而健保局可針對心導管給付方式中增加要求品質相關指標。. 關鍵字: 緊急醫療,分級轉診,重大創傷,急性心肌梗塞 Miss Chiu’s event point out two major problems in our EMSS and the critical care systems. One is the ambiguous criteria for transferring patients, and another one is unknown evidence of inter-hospital transferring for the critical patients. In order to find out all the risk factors (including hospital levels) affecting the outcomes in the critical patients, we designed a research by using the one million beneficiaries data from the NHIRD during the year of 2005-2009. By using the ICD-9-CM code and ISS (Injury Severity Score), we included the patients with major trauma and STEMI. After adjusting all the variables like age, sex, triage classifications and comorbidities in the logistic regression models, we compared the risks for mortality and medical costs between centers and regional hospitals. After adjusting all the variables, we found the risk of mortality was lower in the centers for major trauma patients. But, there was no significant difference in STEMI patients. We also found there were no significant difference in mortality between the transferred and non-transferred patients in both diseases. In the subgroup analysis, we found a potential criteria for transferring major trauma patients to the medical centers. And, we also proved the compliance of pre-hospital trauma transferal guidelines and the compliance for using SWTG medications had greater influence for the mortality in the major trauma and STEMI patients. At last, we found that the SES was not the major factor for the inappropriate treatments (not-transferring to trauma centers, no primary PCI in the STEMI, poor compliance in STEMI guideline drugs). However, hospital levels, the public hospitals and other variables (like age and comorbidities) were the major factors for the inappropriate treatments. Our research provide evidence of “centralization” for the major trauma patients (especially for the patients older than 55, triage classification 1&2, and ISS>25), but “decentralization” for the STEMI patients. And, we also prove that volume is not the major issue for heart centers, compliance of the guideline medications (SWTG) is the major issue for outcome in STEMI patients. KEY WORDS: EMSS,tranferral,major trauma,STEMI |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/6429 |
全文授權: | 同意授權(全球公開) |
顯示於系所單位: | 健康政策與管理研究所 |
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