心臟衰竭是導致65歲以上老年人入院的主要原因，雖然台灣心臟衰竭的盛行率低，但是其醫療花費卻是相當高的。研究指出，經過住院治療後的心臟衰竭病患，其再入院的機率相當高，但卻有一半的早期再入院是可以預防的。在心臟衰竭常用藥物的部份，ACE inhibitors (Angiotensin-converting enzyme inhibitors)與ARB(Angiotensin receptor blocker)都能有控制血壓的效果，卻都有導致再入院的風險。因此藉由了解台灣心臟衰竭病患其再入院的影響因子，使政策的制定者未來能建立有效的疾病管理方案，來提升台灣整體的醫療照護品質有其必要性。
本研究的目的旨在利用全民健康保險資料庫 (National Health Insurance, NHI)，分析台灣中老年心臟衰竭病患之再入院的影響因子。採用回溯性研究法（retrospective cohort study）來對於心臟衰竭病患進行次級資料的分析(secondary data analysis)，研究時間將設定為2000年至2006年，研究樣本為國家衛生研究院全民健保資料庫之「心臟衰竭」50歲以上中老年病患。將全民健康保險資料庫中之心臟衰竭病患區分為實驗組(有發生14天內再入院、有發生15至30天、有發生30至180天以及有發生180天以上之再入院等四組)以及對照組(沒有發生14天內再入院、沒有發生15至30天、沒有發生30至180天以及沒有發生180天以上之再入院等四組)，分析人口學變項：包含年齡、性別及醫院特性：醫院層級、權屬別、教學醫院、城鄉等變項，及醫療資源使用，最後則分析其共病分數(Charlson Comorbidity Index)與使用藥物(ARB藥物、ACE inhibitors藥物)等對於再入院的影響。
共有2173名心臟衰竭病患住院，且有1920名(88.4%)病患發生心臟衰竭再入院，253名(11.6%)則沒有發生任何再入院。經過首次入院後，有821名(42.8%)病患因為主診斷碼為心臟衰竭而再入院，而有433名(22.6%)病患發生主診斷碼為心臟衰竭之六個月內再入院。在醫療資源使用的部分，有發生再入院的病患其平均住院費用、平均門診費用、總藥費、平均住院次數與門診次數皆顯著較高。而在所有再入院的分層中，年齡、Charlson分數大於二與兩種藥物的使用與再入院有顯著相關。
根據台灣衛生署調查，心臟相關疾病的死亡率在台灣逐年的攀升，藉由本研究可提供政策制定者的參考以建立有效的疾病管理方案，並可以提供未來醫療財政管理上的重要參考資料，以提升台灣整體的醫療照護品質。藉著了解影響心臟衰竭病患再入院的重要因素，可提供台灣各醫療機構對心臟衰竭病患進行持續性品質改善的有用資訊，使病患能夠獲得更完善的健康照護，進而減少醫療資源的浪費。

Research Objectives
Heart failure (HF) is a common condition in persons older than 65 years. Existing literature indicated that hospital readmission rates after discharge for heart failure patients are immensely high. However, previous studies showed that almost half of the early hospital readmissions could be prevented. Moreover, Angiotensin-converting enzyme (ACE) inhibitor and Angiotensin receptor blocker (ARB) are the commonly used medications for heart failure patients to control blood pressure. Nevertheless, studies indicated that these two medications could also cause the risk of hospital readmission. Little studies examined the associations of medication use and hospital readmission of heart failure patients in Taiwan. This study aims to investigate the influence factors of hospital readmissions among heart failure patients in Taiwan.

Study Design
We collected the data from National Health Insurance (NHI) database during the period from year 2000 to 2006. Based on the rule of Bureau of National Health Insurance in Taiwan, the 14-day readmission is considered as a poor quality indicator. We categorized readmissions into 4 groups (14-day, 30-day, 180-day and over 180-day) and evaluated each group’s demographic, hospital characteristics, medical resource utilization, Charlson Comorbidity Index and medication utilizations of ACE inhibitor and ARB. We conducted descriptive analyses by using chi-square and t tests and applied multivariate logistic regression analyses to estimate the probabilities of hospital readmissions of heart failure patients.
Population Studied
Patients aged 50 or older with heart failure were identified based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

Principle Findings
Among 1920 heart failure patients, 19.9% of them were readmitted within 14 days, 7.6% were readmitted within 30 days and 26% were readmitted within 180 days. The medical resource utilizations such as average inpatients cost per patient, average outpatients cost per patient, total medical cost, average of inpatients times per patient and average of outpatients times per patient were significantly higher in patients with readmissions than those without readmission. Age, Charlson Comorbidity Index, patients who had been treated with ACE inhibitors and patients who had been treated with ARB were significantly affected the probabilities of readmissions.

Conclusion
The heart failure patients with readmissions had significantly higher medical resource utilizations than those without readmission. The medication uses of ACE inhibitors or ARB were significantly affected the probabilities of hospital readmissions. By understanding more about the influence factors of readmissions among heart failure patients, we may provide continue improvements of quality of care and reduce unnecessary medical costs. This study results provide useful reference for policy-makers to establish effective disease management program and appropriate health care financing arrangement in the future.

致謝 I
摘要 II
Abstract IV
目錄 VI
圖目錄 VII
表目錄 VIII
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究方法與目的 2
第三節 預期研究成果 3
第二章 文獻探討 4
第一節 心臟衰竭之疾病介紹與相關研究 4
第二節 心臟衰竭再入院之相關研究 11
第三節 共病之相關研究 14
第四節 藥物之相關研究 16
第五節 文獻小結 17
第三章 研究方法 18
第一節 研究設計與架構18
第二節 研究問題與假設21
第三節 研究樣本與對象22
第四節 研究變項的操作型定義與資料庫串檔流程27
第五節 統計分析36
第四章 研究結果與分析37
第一節 描述性統計37
第二節 推論性統計49
第五章 研究討論67
第一節 研究結果討論67
第二節 研究假設驗證70
第六章 研究建議72
第一節 研究限制72
第二節 研究建議73
參考文獻 74

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