沒有照片 作者: 許以霖
班別: 碩士班
畢業年度: 98
指導老師: 李中一
共同指導老師: 柯乃熒
論文題目: 探討台灣外傷流行病學及發展適宜的照護系統

[ 摘要 ]
<前言>
外傷每年在台灣及全世界皆造成很多人死亡。2017年意外事故是台灣的第六大死因,因為意外事故死亡而造成24.4及自殺造成23.8的人年損失(全部死因平均為15.3)。外傷是年輕族群最重要的死因,所以改善照護系統會拯救非常多的社會成本。良好的外傷照護系統將會降低外傷的死亡率。台灣於2007年開始實施醫院緊急醫療能力分級來標準化外傷照護。自2009年起我們經歷了國立成功大學醫學院附設醫院外傷照護新的里程,我們建立了外傷登錄系統及整合的外傷團隊,希望藉此來降低病患的死亡率。
<目的>
在這份論文裡,我們希望研究頭部外傷和髖部骨折的臨床表徵及分析外傷團隊對外傷病患死亡率的影響。
<材料及方法>
我們於2009年建立成大醫院的外傷登錄資料,並且比較外傷團隊成立前(2009~2010)後外傷病患死亡率的差別。我們使用連接點迴歸分析來找出是否外傷病患的死亡率是否和外傷團隊的設置有關係上的連結。我們也使用全民健保資料庫來探討2007~2008頭部外傷(醫院緊急醫療能力分級前)及2000~2012髖部骨折病患(較低的死亡率及需要較長的追蹤)的流行病學。並且使用二元邏輯迴歸模式來預估危險因子和死亡率的勝算比及95%信賴區間。
<結果>
2009~2013在成大醫院登錄的7433位外傷住院病患中,有266位死亡(3%)。2009~2010的病患比起2011~2013的有較高的死亡率(3.9% vs. 2.7%)。女性病患在隨著時間而死亡率下降比男性明顯。經過一些干擾因素的校正後,外傷團隊設立後的病患死亡勝算比似乎比較低,但是並不顯著(OR: 0.58, 95% CI: 0.16-2.12)。這樣的降低在ISS≧25的病患更為明顯。在全國的資料庫中,我們發現因頭部外傷住院的病患每十萬人中有215.3人,而在中度到重度頭部外傷則為每十萬人中105.9人。比起居住在城市的病患,居住在偏鄉的有較高的住院率(130.6 vs. 95.3 per 100,000, respectively; p<0.01)及較高的死亡率(14.2 vs. 9.2 per 100,000, respectively; p=0.005)。同樣的城鄉差距也在髖部骨折的老年人一年後的死亡率明確地呈現。居住在高收入的髖部骨折老年病患在一年後的死亡勝算比有顯著的降低(>Q1-Q3: OR: 0.91, 95% CI: 0.87-0.95; >Q3-Max.: OR: 0.80, 95% CI: 0.75-0.85)。
<討論>
整合的外傷團隊雖然非常重要,但是只呈現在非常嚴重的外傷病患有改善死亡的成效。這可能是因為輕度外傷的低死亡率特質或是已經具備良好的外傷照護。我們需要更進一步的研究來探討外傷團隊其他潛在的影響。台灣幾乎涵蓋全民的健保制度改善了社經地位不平等的因素,但是我們的研究仍然指出住在偏鄉及低收入導致高死亡率。所以我們必須進一步分析影響城市偏鄉背後的真正因素並提出解決辦法來有效地減少社經地位的不平等。
<結論>
外傷照護不單只是醫療的問題更是社經地位不平等的議題。良好的醫療照護系統依賴醫院的評鑑來維持並提供良好的照護品質。雖然台灣實施了涵蓋全民的健康保險大大地去除了健康照護的藩籬,但是進一步減少照護上的社經地位不平等是臨床醫護人員及政策制定者都需要考慮的議題。
 
[ 英文摘要 ]
Injuries bring many deaths every year in both Taiwan and globally. In 2017, accident is the 6th leading cause of the death in Taiwan. The average loss of life of years is 24.4 for accidental deaths and 23.8 for suicide compared with 15.3 in all deaths. The trauma is actually the most important cause of death in younger people and improvement of trauma care can save a large amount of years of life. Good trauma care system will decrease the mortality of trauma patients. Trauma care system was standardized by hospitals emergent ability accreditation in Taiwan since 2007. We experienced the new era of trauma care of National Cheng Kung University Hospital (NCKUH) since 2009. We built trauma registry data and setup an integrated trauma team and hope to decrease the mortality rate.

In this study, we have two objectives: investigating clinical characteristics of cases of head trauma and hip fracture; assessing of the influence of trauma team on survival of trauma patients.

We used the trauma registry data of NCKUH set in and thereafter 2009 and compared the mortality rate of trauma patients before (2009-2010) and after trauma team setup. We performed jointpoint regression to assess whether there is a reflection in mortality rate in relation to the setup of trauma team. We also used Taiwan’s National Health Insurance Research Database in 2007~2008 for head injury epidemiology (before hospitals emergency ability accreditation) and between 2000~2012 for hip fracture (because of low mortality and long term follow up) epidemiology. We used binary logistic regression model to estimate the odds ratios (ORs) and their 95% confidence interval (CI) of mortality in association with selected risk factors.

Among 7,433 patients trauma patients admitted to NCKUH in 2009-2013, 266 died (3%) in hospital, with a higher mortality rate in 2009-2010 than in 2011-2013 (3.9% vs 2.7%). The decline of mortality rate over time is more obvious in female patients than in males. After adjustment for potential confounders, patients admitted after trauma team set experienced a lower but insignificantly reduced odds of mortality (OR: 0.58, 95% CI: 0.16-2.12); and such reduced mortality odds was especially notable for those patients with Injury Severity Scores >=25. Based on the nationally representative sample, we found that the hospitalization rate for all head injury was 215.3 per 100,000; and for moderate-to-severe head injury, it was 105.9 per 100,000. We noted that patients who resided in rural areas had a higher hospitalization rate than those residing in urban areas (130.6 vs. 95.3 per 100,000, respectively; p<0.01). Similar rural-urban difference in in-hospital mortality rate was also noted (14.2 vs. 9.2 per 100,000, respectively; p=0.005). We also noted a clear rural-urban difference in 1–year mortality among elderly people admitted for hip fracture. Elders living in in higher quartiles of family income had significantly lower odds of 1-year mortality (>Q1-Q3: OR: 0.91, 95% CI: 0.87-0.95; >Q3-Max.: OR: 0.80, 95% CI: 0.75-0.85) .

Integrated trauma team is very important in a hospital but it appears that it only poses beneficial influence among very severe cases. It may be caused by low mortality rate of minor injury or well established trauma care in hospitals. We need more studies to find the other potential impacts of trauma team. The National Health Insurance covered all the Taiwan population and improve the socioeconomic inequality in health care, but we still found that low income and rural area were associated with higher mortality in head injury and 1-year of hip fracture. We need to investigate the underlying factors truly contributed to such urban-rural difference, and to formulate strategies that can effectively reduce such socioeconomic inequality.

Trauma care is not only a medical problem but also a socioeconomic issues. Good medical service is relied on hospital accreditation and provision of good quality of care. Although the implementation of universal coverage of health insurance has largely removed barriers to health care in Taiwan, further reduction of socioeconomic inequality in health care should be considered by both clinicians and health policy makers.
 
住址: 台南市大學路一號 1 University Road, Tainan, TAIWAN 701    TEL: 06-235- 3535 EXT 5561 or 5562    傳真: 06-2359033    email: em75561@email.ncku.edu.tw