| 摘要: | 論文名稱：外科加護病房靜脈營養支持對使用呼吸器病人之醫療品質及資源耗用探討
研究所名稱：臺北醫學大學醫務管理學系碩士在職專班
研究生姓名： 王鈺婷
畢業時間： 103 學年度 第 2 學期
指導教授：楊哲銘 臺北醫學大學醫務管理學系暨研究所 教授
前言: 長期以來，外科加護病房重症病患使用呼吸器佔有大量資源耗用於全國總醫療費用。重症病患往往無法達到代謝壓力和復原所需的熱量和營養素需求，當腸道營養無法符合需求或腸道不能使用就要儘快給予靜脈營養支持。儘快給予靜脈營養支持是否影響外科加護病房使用呼吸器病人之醫療品質及資源耗用的預後差異。
目的:本研究藉由2010年健保資料分析探討靜脈營養支持的介入是否改善使用呼吸器之外科加護病房病人的醫療品質及資源耗用。
方法: 本研究以國家衛生研究院釋出之全民健康學術研究資料庫LHID 2010版往前串2003年往後串2012年10月31日止之住院醫療費用清單明細檔(DD)、醫事機構基本資料檔(HOSB)、專科醫師證書主檔(DOC)、醫事人員基本資料檔(PER)等資料，以回溯性方法，採兩組長期追蹤性研究設計，分析外科加護病房使用呼吸器病患有無使用靜脈營養支持介入模式下之醫療品質與資源耗用的差異。
結果:在病患特質方面分為(一)男性病患會顯著增加住院花費。(二)病患年齡會顯著增加呼吸器天數、顯著減少住院天數、顯著減少住院花費、顯著增加死亡率、顯著增加手術30天感染率。(三)主診斷血管病變顯著減少呼吸器天數、顯著增加加護病房天數、顯著減少住院天數、顯著增加死亡率、顯著增加手術30天感染率。主診斷癌症顯著增加住院花費、主診斷顱內損傷、併有顱骨骨折者除外顯著減少住院花費。(四)有氣切的病人顯著增加加護病房天數、顯著增加住院花費。(五)鼻胃管灌食天數會顯著的增加呼吸器天數、顯著增加加護病房天數、顯著增加住院天數、顯著增加住院花費、顯著下降死亡率、顯著增加手術30天感染率。(六)疾病嚴重度增加顯著減少呼吸器天數、顯著下降死亡率、顯著增加30天感染率。
在醫療院所特質方面，(一)健保分局:南區分局顯著增加呼吸器天數、顯著減少住院花費。東區分局顯著增加呼吸器天數、顯著減少住院花費。北區分局顯著減少加護病房天數、顯著減少住院天數。中區分局顯著減少加護病房天數、顯著減少住院天數、顯著減少住院花費。高屏區分局顯著減少住院花費。(二)醫院權屬別: 在私立醫院就診的病人顯著增加手術30天感染率。在財團法人醫院就診的病人顯著減少呼吸器天數、顯著增加住院花費。 (三)醫療院所層級別: 在區域醫院就診的病人顯著增加加護病房天數、顯著增加住院天數、顯著增加住院花費。在醫學中心就診的病人顯著增加住院天數、顯著增加住院花費。 (四)住院科別:神經外科的病人顯著減少呼吸器天數、顯著減少住院天數、顯著減少住院花費。在耳鼻喉科就診的病人顯著減少呼吸器天數、顯著減少加護病房天數、顯著減少住院天數、顯著減少住院花費。在心臟血管外科顯著增加呼吸器天數、顯著增加住院花費、顯著增加手術30天感染率。在消化外科的病人顯著增加30天感染率。在醫師特質變項中，男性醫師顯著減少呼吸器天數。醫師年齡會顯著增加住院花費。
結論:在醫療品質部份，給予靜脈營養支持組顯著的增加2.02倍死亡率和顯著的增加1.75倍手術30天感染率。在資源耗用部份，給予靜脈營養支持組有顯著的增加呼吸器天數8.15天、顯著的增加加護病房天數6.60天、顯著的增加住院天數14.29天、顯著的增加住院花費279,454元。我國一直以來，對於有需要靜脈營養支持的重症病患，採取及早給予支持的觀念。然而，近幾年來國外大型研究現重症病患進入加護病房一星期，晚期給予靜脈營養較早期給予靜脈營養有較佳預後，或許可參考此觀念改善加護病房靜脈營養支持的介入步驟及提升靜脈營養支持的可行性。
Title of Thesis：Medical Resource Utilization and Quality Outcome of Parenteral Nutritional Support and Mechanically Ventilated Patients in Surgical ICU
Author：Yu-Ting, Wang
Thesis advised by ： Professor Che-Ming, Yang
(Taipei Medical University, Graduate Institute of Health Care Administration)
Introduction: Mechanical ventilation therapy is considered a high financial burden for Taiwan's National Health Insurance; patients who receive ventilation therapy in the ICU contribute to the high cost in surgical ICU care. Early parenteral nutrition support is often used on patients whom caloric targets connot be met by enterral nutrition. This study uses data in National Health Insurance Reserch Database of National Health Research Institutes to calculate medical resource utilization and quality outcome of parenteral nutritional support and mechanically ventilated patients in surgical ICU.
Object: To explore the possible improvement of the outcome of patients in surgical ICU when using parenteral nutrition suppot. This study is based on the year: 2010 Taiwan's National Health Insurance Research Databases.
Methods: Retrospective and longitudinal study was used to investigate the outcomes of medical care. This research used data in Taiwan's National Health Insurance Research Databases, picking out DD, HOSB, DOC, and PER filses of parenteral nutritional support case to compare the difference of different parenteral nutrition care modes.
Results: The characteristics of patients in this research consist of six major factors, in including: 1) Sex: male patients have higher result than femail patients in admission expense. 2) Age: patients’ age significantly increased days of mechanical ventilator, mortality rate and infection; besides it decreased admission days and admission expense. 3) Primary diagnosis: angiopathy significantly increased the duration of living in surgical ICU, mortality rate and infection; besides it decreased days of mechanical ventilator and admission days. Cancer significantly increased admission expense.Fracture of skull with intracranial injury significantly decreased admission expense.4) tracheostomy: Patients with Tracheostomy significantly increased the duration of living in surgical ICU and admission expense. 5) Days of gavage feeding: significantly increased days of mechanical ventilator, the duration of living in surgical ICU, admission days, admission expense, and infection. 6) Severity of Disease: significantly increased infection. Besides, it decreased days of mechanical ventilator and mortality rate.
The characteristics of hospital in this research consist of four major factors, in including: 1) Bureau of national health Insurance: Southern Division significantly increased days of mechanical ventilator and decreased admission expense. Eastern Division significantly increased days of mechanical ventilator and decreased admission expense. Northern Division significantly decreased the duration of living in surgical ICU and admission days. Central Division significantly decreased the duration of living in surgical ICU, admission days and admission expense. Kaoping Division significantly decreased admission expense. 2) Hospital ownership: Private Hospital significantly increased infection. Non-Profit Proprietary Hospital significantly increased admission expense and decreased days of mechanical ventilator. 3) Hospital accreditation Level: Regional Hospital significantly increased the duration of living in surgical ICU, admission days and admission expense. Medical center significantly increased admission days and admission expense. 4) Division of hospital: Division of neurosurgery significantly decreased days of mechanical ventilator, admission days and admission expense. Division of otolaryngology significantly decreased days of mechanical ventilator, the duration of living in surgical ICU, admission days and admission expense. Division of cardiovascular surgery significantly increased days of mechanical ventilator, admission expense and infection. Division of digestive surgery significantly increased infection. Doctor factors: male doctors significantly decreased days of mechanical ventilator. Doctors’ age significantly increased admission expense.
Conclusions : Quality of medical care: patients in the parenteral nutritional support group significantly increased 2.2 times on the mortality rate and the infection increased 1.75 times. Medical resource utilization: patients in the parenteral nutritional support group significantly increased 8.15 days of mechanical ventilator, 6.60 days of living in surgical ICU, 14.29 days of admission days and NT$279,454 dollars in admission expense.
In Taiwan, we used to give early parenteral nutrition in critically ill adults whom caloric targets connot be met by enteral nutrition alone. However, there are some studies talking about that the late parenteral nutrition in critically ill adults is better than the early. Clinic team should pay attention to this tiopic to improve medical resource utilization and quality outcome of parenteral nutritional support.
Key word: Parenteral Nutrition, Mechanical Ventilators, Resource Utilization, Quality of Medical Care |
