| 摘要: | 本研究希望藉由全民健康保險研究資料庫糖尿病特定主題檔，分析台灣地區民國九十年糖尿病非創傷性截肢者的總人數、申報健康保險局之住院費用；進而連續追蹤三年查看多少存活個案發生再截肢、存活個案申報健康保險局之門診與住院費用；探討影響糖尿病非創傷性截肢者發生再截肢、醫療利用之相關因素為何？
擷取住院申報檔ICD-9 -CM編碼同時有糖尿病編碼與手術編碼為下肢足趾截肢條件者，去除因外傷原因截肢，找出中華民國九十年糖尿病非創傷性截肢者為研究對象。以SAS 8.0版軟體進行統計。先經單變項分析如性別、年齡等，找出對當次住院天數、當次住院費用、手術當次死亡、後續三年醫療利用與後續多次截肢等依變項有統計意義的變項。再以多變項廻歸及邏輯斯迴歸方法探討對以上依變項有影響之因素。
結果顯示，中華民國九十年糖尿病施行非創傷性足趾截肢共有2,202人（扣除10人性別不詳者）。男女性別分佈（1.4:1）。性別並未影響當次住院醫療費用、後續三年醫療費用與再截肢頻率。年齡愈高當次住院醫療費用、後續三年醫療費用與再截肢機會愈高，但不影響當次住院死亡。此類手術主要集中在大於50歲年長者（80.25%）。有5.86%合併接受血液透析治療。
在醫學中心施行手術者佔所有手術的45.46%，區域醫院佔35.20﹪。初次施行足趾截肢手術平均住院22.55天，平均住院費用111,458點，平均每日住院費用5,121點。手術當次住院死亡2.05%，小於30歲以下當次手術住院時無人死亡。術後三年存活者門診平均次數20.89次，中位數9次；住院平均次數2.88次，中位數2次；平均總住院天數42.25天，中位數21次。總醫療費用256,395點、總門診費用37,091點、總住院費用219,304點。存活者41.4%三年內發生再截肢，平均再截肢2.48次。
對當次住院醫療費用有影響之因素為合併接受血液透析、高血壓、腦血管阻塞、冠狀動脈粥腫樣硬化、週邊動脈血管阻塞、年齡、醫院評鑑級別。地域別及醫院評鑑級別不影響當次住院醫療費用。對後續三年醫療費用有影響因子為合併高血壓與年齡增長。
對後續三年再截肢機會有影響之因素為年齡、合併接受血液透析與合併週邊動脈血管阻塞。合併接受血液透析比無接受血液透析者有2.05倍之後續三年再截肢機會。合併週邊動脈血管阻塞比無合併週邊動脈血管阻塞有2.54倍之後續三年再截肢機會。
此研究提供臺灣地區首次有關糖尿病施行非創傷性足趾截肢之訊息，以利後續相關之研究。
We have used The National Health Insurance Research Database focusing on diabetes mellitus, which includes ambulatory care expenditures by visits and inpatient expenditures by admissions to investigate the annual number of non-traumatic diabetic-related toe amputee and their inpatient claim fee in Taiwan in the year 2001. We then followed up a three year period to realize how many patients have survived and received re-amputation along with the total claim fee (including inpatient and outpatient). Furthermore, we analyzed the factors that had influenced the claim fee and the re-amputation.
We initially selected our research subjects with ICD-9-CM code 84.11 to represent the toe amputation patients. Then, we exclude the traumatic cause by E code. The cases which received 84.11 in the year 2000 were excluded. The subjects’ data were connected to the data base between the years 2001-2004 to find out more about the survivors after three years. We exclude subjects who died during hospitalization. The Statistics used the SAS 8.0 edition to analyze the total toe amputation and re-amputation number, inpatient claim fee, outpatient claim fee along with the independent factor which influences both the fee and re-amputation. Multiple regressions and logistic regressions were used.
The result showed non-traumatic diabetic-related amputee subjects（exclude 10 non-gender patients）was 2,202 in year 2001. Male ratio was 1.4. The mean age was 62.5 years old. 80.5% of the subjects were older than 50 years old. Subjects whom received hemodialysis were 5.86%.
There were 45.46% subjects that received amputation at Medical center. Regional hospital included 35.20%. The mean of length of stay was 22.55 days. The mean inpatient claim fee was 111,458 points. The mean hospitalized fee per day was 5,121 points. 2.05% of the patients died during hospitalization. None of the patients that were younger than 30 years old died during hospitalization.
During the next 3 years; the mean and median of the survivors’ outpatient visits were 20.89 times and 9 times. The mean and median of subjects being hospitalized were 2.88 times and 2 times. The mean and the median of total hospitalization days were 42.25 days and 21 days. Total claim fee was 256,395 points (total clinic and hospitalization fee were 37,091 points and 219,304 points respectively). Survivors who had to be re-amputated were 41.4%. The mean of re-amputation was 2.48 times.
Gender hadn’t affected hospitalization claim fee or the frequency during the 3 years claim fee and re-amputation. The older the subjects the higher the hospitalization claim fee, the 3 years claim fee and re-amputation would be. But it didn’t affect death during hospitalization at that time.
Variables that affected hospitalization claim fee were hemodialysis, hypertension, cerebral vascular accident, peripheral arterial occlusive disease, coronary arterial atherosclerosis, hospital accreditation level and age. There were no regional and hospital accreditation level differences in the hospitalization claim fee.
During the 3 years both hypertension and age were variables that affected the hospitalization claim fee.
In the next 3 year’s time; age, hemodialysis and peripheral arterial occlusive disease all affects the chance of re-amputation. The odds ratio of being re-amputated, compared with the subjects who have hemodialysis and no previous history of hemodialysis, was 2.05.
Subjects who have peripheral arterial occlusive disease had 2.54 times higher the risk of being re-amputated compared with subjects with no previous history of peripheral arterial occlusive disease.
This research is the first to evaluate on The National Health Insurance Research Database about the non-traumatic diabetes-related toe amputee in Taiwan. The outcome results may provide information to the people who are interested in treating diabetes-related toe amputee. |
