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標題: | 腦中風病人社經地位、急性後期照護與照護結果之關係 The Relationships Among Socioeconomic Status, Post-Acute Care and Outcome of Stroke Patients |
作者: | 許雅惠 Ya-Hui Hsu |
指導教授: | 董鈺琪 Yu-Chi Tung |
關鍵字: | 腦中風,急性後期照護模式,病人為中心照護,社經地位,功能性殘疾,復健,再住院, stroke,post-acute care model,patient-centered care,socioeconomic status,functional disability,rehabilitation,readmission, |
出版年 : | 2023 |
學位: | 博士 |
摘要: | 研究背景與目的:腦中風是世界第二大死亡原因,也是導致成年人殘疾,造成失能最常見的原因,復健是增進功能恢復主要的關鍵因素。過去一些研究發現腦中風病人社會經濟地位(socioeconomic status, SES)對照護結果有影響,研究結果大都支持社經地位較高的腦中風病人,照護結果是優於低社經地位者。然而,社經地位對腦中風病人照護結果之影響機轉,仍舊缺乏強而有力的證據。同時有關急性後期照護(post acute care, PAC)與照護結果之研究結果發現PAC可降低腦中風病人死亡風險,過去研究也發現有約30%的病人拒絕接受PAC服務,針對腦中風病人及家屬為中心的觀點探討選擇PAC模式(包含住院復健醫院、技術性護理機構、居家護理及門診復健等)的因素研究闕如。因此,本研究是以回溯性世代研究為研究設計,利用代表全國性人口之資料庫,探討社經地位對於腦中風病人30天再住院之影響,及急性後期照護是否為30天再住院之中介因素。另外透過質性深度訪談以探討腦中風病人及其家屬對於PAC服務及模式的選擇存在那些影響因素。
研究方法:以回溯性世代研究,透過衛生福利部衛生福利資料科學中心(Health and Welfare Data Science Center, HWDC),以2016年32,822位初次缺血性中風住院之出院病人進行追蹤分析。使用廣義估計方程式(Generalized Estimating Equation, GEE)進行多變項迴歸分析,在控制病人特質、住院復健、住院醫療利用及醫院特質後,探討缺血性腦中風病人社經地位、急性後期復健與30天再住院率之間的關係。另外,使用半結構式訪談大綱針對台灣北中南4家醫院之21位腦中風病人與家屬進行深度訪談,並以內容分析作為質性研究分析的方法以決定腦中風病人及家屬選擇PAC的影響因素。 研究結果:以具全國人口代表性資料進行分析研究結果發現,低個人社經地位及居住在低社經地位地區的缺血性腦中風病人,出院後接受復健的機率較低(低收入:OR= 0.77; 95% CI= 0.63-0.94, P =0.012;鄉村: OR= 0.88; 95% CI= 0.82-0.94, P <0.001);並且低個人社經地位及出院後未接受復健之缺血性腦中風病人其30天再住院的風險較高(低收入:OR= 1.28; 95% CI= 1.04-1.59, P =0.020; 急性後期復健:OR= 0.46; 95% CI= 0.41-0.52, P <0.001));低社經地位之缺血性腦中風病人可以透過急性後期復健降低30天再住院的風險,急性後期復健對於社經地位與30天再住院之間的影響具有部分中介效果。而以質性訪談確認腦中風病人及家屬選擇PAC的影響因素之研究指出,專業醫療人員的建議、健康照護資源可近性、照護連續性及協調性、病人與親友的意願及過去經驗、經濟因素是影響腦中風病人選擇PAC的模式的5個重要因素。 結論:根據本研究結果,缺血性腦中風病人在急性期治療後,積極接受復健治療確實可以改善病人再住院的風險。專業醫療人員的建議、醫療照護資源可近性、照護連續性及協調性、病人與家屬的意願及過去經驗、經濟因素是影響腦中風病人選擇PAC的模式的5個重要因素。 Objectives: Stroke is the second leading cause of death in the world, and it is also the leading cause of long-term disability in adults. For surviving stroke patients, follow-up rehabilitation therapy is the key to restoring lost functions. In the past, some studies have found that the socioeconomic status (SES) of stroke patients has an impact on the outcome of care, and most of the findings support that stroke patients with higher SES have better outcomes than those with lower SES. However, there is still a lack of strong evidence on the effect of SES on the outcome of stroke patients. Previous studies on PAC and care outcomes have found that PAC reduced mortality risk, and there are nearly one-third of the elderly in-patients had declined them. However, there has been limited investigation on the factors of stroke patients in choosing PAC service (inpatient rehabilitation hospital, skilled nursing facility, home health, and outpatient rehabilitation) using a person-centered approach. Therefore, this study was designed as a retrospective intergenerational study to examine the effect of socioeconomic status on 30-day readmission of stroke patients and whether post-acute care is a mediator of 30-day readmission using a national population-based database. In addition, this study conducted in-depth interviews to explore the factors that influence the choice of a post-acute care (PAC) model among stroke patients and their families. Methods: A retrospective generational study was conducted through the Health and Welfare Data Science Center (HWDC) of the Ministry of Health and Welfare (MOHW) to follow up on 32,822 discharged patients who were hospitalized with initial ischemic stroke in 2016. Multivariate regression analyses were conducted using the Generalized Estimating Equation (GEE) to examine the relationship between socioeconomic status, post-acute care, and 30-day readmission rates for ischemic stroke patients, and controlling for patient characteristics, inpatient rehab, inpatient healthcare utilization, and hospital characteristics. In addition, we conducted semi-structured, in-depth interviews with 21 stroke patients and their families at four hospitals in Taiwan. Content analysis was used in this qualitative study. Results: Analysis of nationally representative data found that ischemic stroke patients with low individual SES and those living in low neighborhood SES areas had a lower chance of receiving post- acute rehabilitation (low income: OR= 0.77; 95% CI= 0.63-0.94, P = 0.012; rural: OR= 0.88; 95% CI= 0.82-0.94, P < 0.001); and ischemic stroke patients with low individual SES and no post-discharge rehabilitation had a higher risk of 30-day readmission (low-income: OR= 1.28; 95% CI= 1.04-1.59, P = 0.020; post-acute rehabilitation: OR= 0.46; 95% CI= 0.41-0.52, P < 0.001)); Patients with ischemic stroke of low individual SES had a reduced risk of 30-day readmission through post-acute rehabilitation, which the partially mediated effect of SES on 30-day readmission. In a study using qualitative interviews to identify the factors influencing the choice of PAC by stroke patients and their families, and results revealed five main factors that influence respondents’ choice of PAC: (1) medical professionals’ suggestions, (2) health care accessibility, (3) continuity and coordination of care, (4) willingness and prior experience of patients and their relatives and friends, and (5) economic factors. Conclusion: According to the results of this study, positive rehabilitation of ischemic stroke patients after acute treatment can indeed improve the risk of readmission, and the advice of medical professionals, the accessibility of health care resources, the continuity and coordination of care, the willingness and past experience of patients and their relatives and friends, and economic factors were five important factors that affected the selection of PAC models for stroke patients. Follow-up studies should extensively explore the impacts on different cases based on the five main factors identified in this study. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/90419 |
DOI: | 10.6342/NTU202303211 |
全文授權: | 同意授權(限校園內公開) |
顯示於系所單位: | 公共衛生碩士學位學程 |
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