中文摘要
目的：
再住院的發生在現今龐大的醫療成本支出中占很重要的比例且再住院率亦為衡量醫療品質的一項重要指標，在國外再住院率是相當受重視的議題，但台灣針對再住院率的研究並不多。而老年人口則是花費大量健保醫療費用的醫療資源使用者，並為再住院病患中主要的一群，而慢性病往往是造成住院與再住院的主要疾病。故本研究針對氣喘(Asthma)及慢性阻塞性肺病(COPD)兩種國內盛行慢性病其老年住院病患發生再住院情形做描述。檢視其發生再住院時，醫療服務利用的成本是否較第一次入院高，了解再住院與第一次住院的醫療費用成長情形。探討在台灣健保制度下，慢性阻塞性肺病或氣喘的老年病患是否有因過早出院而提高再住院率之情形發生，以及第一次入院住院期間較短的病人是否會縮短發生再次入院的間隔時間？
方法：
本研究以中央健保局89年至93 年之全國住院醫療費用清單明細檔（DD）串聯醫事機構基本資料檔(HOSB)取得病人就醫資料，刪除非當年度住院及64歲以下之病患，並以國際疾病分類代碼(ICD-9)篩選出主診斷碼為氣喘(33,255人)以及慢性阻塞性肺病(92,546人)之患者，將患者區分為有發生再住院及沒有發生
再住院兩組。研究變項包含病人特性、醫療機構特性 、環境因素、醫療服務利用以及是否發生再住院，其中環境因素變項來自勞保局所區分的都市化程度以及環保署空氣品質監測年報中所紀錄之空氣品質。統計方法為T檢定、邏輯式回歸、複線性迴歸。
結果：
氣喘老年患者及慢性阻塞性肺病老年患者其再次住院所消耗的醫療資源較第一次住院時高。而於再住院發生機率方面，年齡、性別、疾病嚴重度、所屬健保分局、住院年度、空氣品質，以及第一次住院天數皆對氣喘及慢性阻塞性肺病患者之發生再住院機率有顯著影響。而住院醫院是否為教學醫院僅對氣喘患者之再住院發生機率有顯著影響。進一步針對發生再住院之病患其再住院間隔時間研究後，年齡、疾病嚴重度、醫療機構評鑑等級，以及醫院所屬健保分局別對於氣喘及慢性阻塞性肺病再住院老年患者之發生再住院間隔時間皆會有顯著影響，而地區都市化程度僅對慢性阻塞性肺病老年患者產生顯著影響。在控制病人特性、醫療機構特性、環境因素後，住院天數對於慢性阻塞性肺病或氣喘患者其發生再住院之間隔時間的影響皆達顯著統計差異(p＜0.001)，呈負向關係。
結論：
第一次住院天數較長的此兩種疾病患者，有較高的機率發生再住院，並且造成較短的再住院間隔時間，此可能與病患的疾病嚴重度有關。本研究可提供醫院了解控制再住院率即可降低龐大的醫療支出，並思索如何在全民健保評鑑及申報制度下，有效降低氣喘及慢性阻塞性肺病患者再住院率並提升醫療品質，盼能更落實疾病管理計畫，以獲得更大成效。
關鍵字
氣喘、慢性阻塞性肺病、再住院、醫療服務利用、住院天數、住院費用

Abstract
Objective:
Readmission is a big part of health care expenditure and recent studies suggested that hospital readmissions can be applied as an important indicator of quality of care within health care system. Furthermore elderly population usually costs the large amount health care expenses and is the main group in readmission. Moreover readmission is usually attributed to chronic diseases. Nevertheless, evaluations of hospital readmissions under universal health care coverage areas were not well-studied in Taiwan. Therefore this study aims to explore the associations between initial hospitalizations and probability of hospital readmissions in details.
Research method:
Patients aged 65 or older with primary clinical diagnosis of asthma or COPD based on ICD-9-CM for hospital admissions and readmissions in Taiwan.National claims of these two diseases were collected and analyzed from year 2000 to 2004. Population-based descriptive analyses of related health care utilizations were estimated. Multivariate logistic regressions were conducted to predict the probability of hospital readmissions. Controlled variables included patient factors, medical institutions’ characteristics, urbanizations, and air quality indicators.
Result:
Among asthma and COPD elderly patients, more health care utilizations were observed in the hospital readmissions than initial admissions. Multivariate logistic regressions indicated that age, gender, disease severity, hospital characteristics, and air quality were significant predictors of the probability of hospital readmission. Meanwhile, age, disease severity, and hospital characteristics also significantly affected the time interval between initial admission and readmission. In addition, longer length of stay in the initial admission will significantly shorten the time interval between initial admission and readmission (P<0.001).
Conclusion:
For Asthma and COPD elderly patients, longer length of stay in the initial admission will significantly shorten the time interval between initial admission and readmission and have higher probability of hospital readmission. This study provides the evidence of reducing the health care expenditure by controlling readmission rate. With more understandings of factors affecting hospital readmissions, we can improve the health care delivery and reduce unplanned readmissions in the future.


Key words:
Asthma, COPD, hospital readmission, health care utilization, length of stay, admission fees

目錄
致謝 -------------------------------------------------------------Ⅰ
中文摘要 ---------------------------------------------------------Ⅲ
英文摘要 ---------------------------------------------------------Ⅴ
目錄 ------------------------------------------------------------ Ⅶ
表目錄 -----------------------------------------------------------Ⅸ
圖目錄 -----------------------------------------------------------Ⅹ
第一章 緒論 ------------------------------------------------------1
研究背景與動機 --------------------------------------------------1
研究問題與目的 --------------------------------------------------3
第二章 文獻探討 --------------------------------------------------5
醫院再住院 ------------------------------------------------------5
氣喘 -----------------------------------------------------------10
慢性阻塞性肺疾病 (COPD) -----------------------------------------17
老年人口對於氣喘及慢性阻塞性肺病醫療費用的影響 -----------------25
文獻綜合討論 ---------------------------------------------------27
第三章 研究方法 -------------------------------------------------28
研究設計與架構 -------------------------------------------------28
研究假設 -------------------------------------------------------31
研究變項 -------------------------------------------------------32
研究材料與對象 -------------------------------------------------36
統計分析方法 ---------------------------------------------------40
第四章 分析結果 -------------------------------------------------41
氣喘或慢性阻塞性肺病患者再住院情形之現況-------------------------41
研究樣本之描述性統計 -------------------------------------------74
發生再住院情形之患者第一次住院與第一次再住院其醫療服務利用差異--107
影響再住院發生之探討 ------------------------------------------109
影響再住院間隔時間之探討 --------------------------------------116
第五章 討論 ---------------------------------------------------122
台灣因氣喘或慢性阻塞性肺疾病住院病人之再住院現況與趨勢 ---------122
探討醫療服務利用差異 ------------------------------------------127
影響再住院發生之探討 ------------------------------------------128
影響再住院間隔時間之探討 --------------------------------------132
第六章 結論與建議 ----------------------------------------------134
結論 ----------------------------------------------------------134
研究限制 ------------------------------------------------------138
建議 ----------------------------------------------------------140
第七章 參考文獻 ------------------------------------------------142
附錄一 勞保局都市化程度分級 ------------------------------------147
附錄二 環保署空氣品質年報PSI值 --------------------------------148

英文文獻：
1. Anderson, G.F. and E.P. Steinberg, Hospital readmissions in the Medicare population. N Engl J Med, 1984. 311(21): p. 1349-53.
2. Anderson, G.F. and E.P. Steinberg, Predicting hospital readmissions in the Medicare population. Inquiry, 1985. 22(3): p. 251-8.
3. Arshad, S.H., M. Stevens, and D.W. Hide, The effect of genetic and environmental factors on the prevalence of allergic disorders at the age of two years. Clin Exp Allergy, 1993. 23(6): p. 504-11.
4. Ashton, C.M., et al., Predicting readmission in veterans with chronic disease. Development and validation of discharge criteria. Med Care, 1987. 25(12): p. 1184-9.
5. Benbassat, M. and M. Taragin, MPH, Hospital Readmissions as a Measure
of Quality of Health Care:Advantages and Limitations. ARCH INTERN MED, 2000. VOL 160: p. 1074-1081.
6. Brand, C., et al., Readmission patterns in patients with chronic obstructive pulmonary disease, chronic heart failure and diabetes mellitus: an administrative dataset analysis. Intern Med J, 2005. 35(5): p. 296-9.
7. Brown, J. and C. CS., Stemming the Ride of Readmission: Patients, Practice, or Pactitioner? Reviews in Clinical Gerontology, 1998. 8: p. 173-181.
8. Corrigan, J.M. and J.B. Martin, Identification of factors associated with hospital readmission and development of a predictive model. Health Serv Res, 1992. 27(1): p. 81-101.
9. Crockett, A.J., et al., An association between length of stay and co-morbidity in chronic airflow limitation. Int J Qual Health Care, 2000. 12(1): p. 41-6.
10. Cydulka, R.K., et al., Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 1997. 156(6): p. 1807-12.
11. Dockery DW, et al., An association between air pollution and mortality in six U.S. cities. N Engl J Med, 1993. 329: p. 1753-1759.
12. Giuffrida, A., H. Gravelle, and M. Roland, Measuring quality of care with routine data: avoiding confusion between performance indicators and health outcomes. Bmj, 1999. 319(7202): p. 94-8.

13. (GINA), G.I.f.A. Global Burden of Asthma. 2005 [cited; Available from: http://www.ginasthma.com/.
14. Global Initiative for Chronic Obstructive Lung Disease Executive Summary
GOLD 2004
15. Hart, J.T., The inverse care law. Lancet, 1971. 1(7696): p. 405-12.
16. Hasan, M., Readmission of patients to hospital: still ill defined and poorly understood. Int J Qual Health Care, 2001. 13(3): p. 177-9.
17. health, U.S.P.H.S.S.a., Report of the advisory committee to the Surgeon General of the Public Health Service. U.S. Department of Health, Education and Welfare, Public Health Service, Center for Disease Control 1964, PHS Publication.
18. Hofer, T.P. and R.A. Hayward, Can early re-admission rates accurately detect poor-quality hospitals? Med Care, 1995. 33(3): p. 234-45.
19. Krumholz, H.M., et al., Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch Intern Med, 1997. 157(1): p. 99-104.
20. Librero, J., S. Peiro, and R. Ordinana, Chronic comorbidity and outcomes of hospital care: length of stay, mortality, and readmission at 30 and 365 days. J Clin Epidemiol, 1999. 52(3): p. 171-9.
21. Lyratzopoulos, G., et al., Factors influencing emergency medical readmission risk in a UK district general hospital: A prospective study. BMC Emerg Med, 2005. 5(1): p. 1.
22. Osman, I.M., et al., Quality of life and hospital re-admission in patients with chronic obstructive pulmonary disease. Thorax, 1997. 52(1): p. 67-71.
23. Patil, S.P., et al., In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease. Arch Intern Med, 2003. 163(10): p. 1180-6.
24. Price, D. and M. Duerden, Chronic obstructive pulmonary disease. Bmj, 2003. 326(7398): p. 1046-7.
25. Reznik, M., S.M. Hailpern, and P.O. Ozuah, Predictors of early hospital readmission for asthma among inner-city children. J Asthma, 2006. 43(1): p. 37-40.
26. Roe, C.J., et al., A methodology for measuring clinical outcomes in an acute care teaching hospital. J Qual Clin Pract, 1996. 16(4): p. 203-14.
27. Saynajakangas, O., et al., Length of stay and interval to readmission in emergency hospital treatment of COPD. Age Ageing, 2004. 33(6): p. 567-70.
28. Soeken, K.L., et al., Predictors of hospital readmission. A meta-analysis. Eval Health Prof, 1991. 14(3): p. 262-81.
29. Sullivan, S.D., S.D. Ramsey, and T.A. Lee, The economic burden of COPD. Chest, 2000. 117(2 Suppl): p. 5S-9S.
30. Thomas, J.W., Does risk-adjusted readmission rate provide valid information on hospital quality? Inquiry, 1996. 33(3): p. 258-70.
31. Wallace, J.C., C.E. Denk, and L.K. Kruse, Pediatric hospitalizations for asthma: use of a linked file to separate person-level risk and readmission. Prev Chronic Dis, 2004. 1(2): p. A07.
32. Weinberger, M., E.Z. Oddone, and W.G. Henderson, Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. N Engl J Med, 1996. 334(22): p. 1441-7.
33. Westert, G.P., et al., An international study of hospital readmissions and related utilization in Europe and the USA. Health Policy, 2002. 61(3): p. 269-78.
中文文獻：

34. COPD診治手冊: 慢性阻塞性肺病(COPD)病友會.
35. 慢性阻塞性肺疾診治手冊. 胸腔醫學, 1996. 第十一卷(附冊一 ).
36. 丁家鵬, 慢性阻塞性肺病 (Chronic Obstructive Lung Disease, COPD). 2000.
37. 王姿乃, 氣喘之環境與遺傳因素研究 醫學研究所. 2000 高雄醫學大學。碩士論文　
38. 王馨儀, 氣喘門診照護對可避免住院之影響, 醫療機構管理研究所. 2006, 臺灣大學。 碩士論文
39. 江哲超, 老人資本、自評健康與醫療資源使用相關性之研究, 社會學研究所. 2003, 南華大學。碩士論文　
40. 余秀芳, 台灣地區病人重複住院之分析, 衛生政策與管理研究所. 2003 國立臺灣大學。碩士論文　
41. 余金燕、潘德樑, 疾病分類實務. 合記圖書出版社. 2003: 合記圖書出版社.
42. 李宏銘, 健康行為變數與終身型住院醫療保險之關係, 風險管理與保險所. 2004, 國立高雄第一科技大學。碩士論文
43. 李曉詩, 醫療利用行為函數之估計 － 全民健保揉合資料之應用, 財政學系. 2002 國立台北大學。碩士論文
44. 沈鴻銘, 慢性阻塞性肺臟疾病 (COPD) 與代謝性基因多型性相關之研究, 職業安全衛生研究所. 2001, 高雄醫學大學。碩士論文　
45. 周昭宏, 全民健保疾病管理模式運用於氣喘病患連續性照護之成效評估---以南部某區域教學醫院為例, 公共衛生學研究所碩士在職專班. 2004 高雄醫學大學。碩士論文
46. 林谷峰, 以全民健保1996-2001年承保抽樣歸人檔分析氣喘病人之醫療利用, 醫療機構管理研究所. 2004 國立臺灣大學。碩士論文　
47. 林靜靜, 肺病診療室. . 天下文化書坊. 2001/05:
48. 邱玉娜, 台灣慢性阻塞性肺病醫療利用與診療型態分析初探, 健康管理研究所. 2005, 臺中健康暨管理學院。碩士論文　
49. 俞聖彥, 門診氣喘病患醫療資源耗用分析-以某區域健保分局資料為例, 醫務管理研究所. 2001 國立陽明大學。碩士論文
50. 振興醫學中心急診重症醫學部主治醫師胡健虎. 胸腔血管疾病防治. KingNet國家網路醫院 2003/01/04.
51. 張祐剛, 台北市青少年棄喘及肺功能相關因子之探討, 環境衛生研究所. 2001 國立臺灣大學。碩士論文
52. 張靜惠, 基市�抽煙人口過高 特約戒菸醫療院所增為22家, 東森新聞報. 2005/05/05.
53. 曹永杰, 空氣污染及其它相關危險因子對學童氣喘及肺功能之探討-南台灣為例, 公共衛生學研究所. 1997, 高雄醫學院。碩士論文
54. 許世芳, 台灣人口的慢性疾病生命表, 醫務管理學研究所. 2005, 長庚大學。碩士論文
55. 郭壽雄, Chronic Obstructive Pulmonary Disease (COPD) in Taiwan, 台灣慢性阻塞性肺病診治指引研討會. 2004.
56. 陳怡文, 慢性阻塞性肺病中醫證型問卷之發展及證型分析之研究, 中國醫學研究所. 2003 中國醫藥學院。碩士論文
57. 陳招式, 門診急性呼吸道感染及氣喘病患醫療資源耗用分析, 公共衛生學研究所. 2002 高雄醫學大學。碩士論文
58. 曾曉琦, 健康狀況變化對老人醫療服務利用的影響, 公共衛生學研究所. 1995, 國立台灣大學。碩士論文　
59. 黃璟隆, 學校氣喘兒童個案管理模式及氣喘學童健康評估. 2003, 國民健康局92年度科技研究發展計畫(報告編號：DOH92-HP-1117)，未出版.
60. 楊寶圜, 護理指導對氣喘學齡期兒童氣喘知識的提升與生活品質之相關性探討, 護理學研究所. 2001 國立臺灣大學。碩士論文　
61. 蕭光明. 世界慢性阻塞性肺疾病日 我國慢性阻塞肺疾之衝擊. KingNet國家網路醫院 2002
62. 中央健保局網站. 2001
http://www.nhi.gov.tw/.
63. 行政院衛生署. 氣喘診療指引. 2002,2005 http://www.chest.org.tw/edu/index2.htm.
64. 行政院衛生署. 衛生統計資訊網. 2004 http://www.doh.gov.tw/statistic/index.htm.
65. 行政院環保署. 1996
http://www.epa.gov.tw/.
66. 林偉傑. 煙槍增加慢性阻塞性肺病死因升至第七. 成大內科衛教園地 2005 http://dr.hosp.ncku.edu.tw.
67. 郭壽雄. 氣喘、棄喘200 問答集. 2003 : http://ntuh.mc.ntu.edu.tw/med/sections/chest/asthma_200q/.
68. 慢性阻塞性肺病(COPD)病友會. http://www.copd.org.tw.