研究目的︰
慢性阻塞性肺病(COPD)經常合併多重慢性疾病，每年耗費健保將近13億元，由於對肺部造成持續性傷害，因此患者的精神狀態、醫療品質與日常生活都會受到極大影響，這些擁有多重慢性疾病的患者以老年人為主，常見的合併症主要是憂鬱症和焦慮症，盛行率最高可達80%與74%，然而，在治療過程中兩者的症狀常受到忽略，或是歸咎於老化，國外有許多針對這類病人的研究，但國內則較少討論，這也突顯了國內在探討多重慢性病之醫療品質上的不足。因此，本研究目的為針對慢性阻塞性肺病患者合併發生憂鬱症與焦慮症，分析其在醫療資源使用情形以及對於醫療品質的相關影響。
研究方法︰
本研究是以中央健保局2002年至2006年的門診處方及治療明細檔(CD) 串聯住院醫療費用清單明細檔(DD)與醫事機構基本資料檔(HOSB)，並以國際疾病分類代碼(ICD9 CM)篩選出主診斷碼為慢性阻塞性肺病、憂鬱症與焦慮症之65歲以上患者，除了探討患者門住診的使用情形，並藉由Charlson Co-morbidity Index來檢視患者在罹患精神疾病時出現合併症的情形並探討其醫療品質，本研究採用描述性統計並使用卡方檢定與複迴歸來進行資料分析。
研究結果︰
描述性統計顯示慢性阻塞性肺病合併憂鬱症與焦慮症的患者以75歲以上未滿79歲的男性患者(52.13%)，此類型的病患多於私立醫療機構(38.30%)、教學醫院(67.43%)、區域醫院(36.19%)為主要就醫地點。針對其他合併症進行分析時，發現慢性阻塞性肺病患者罹患精神疾病後與未罹患精神疾病者相比較有達到統計上的顯著意義(p<0.05)，在醫療資源使用的部分，以藥費最為明顯，合併發生精神疾病後，患者的用藥費用約為未合併發生憂鬱症或焦慮症者的兩倍，且有達到統計上的顯著意義(p<0.001)。
研究結論︰
慢性阻塞性肺病會造成患者肺部持續性的退化，使其整體生活品質受到影響，除了本身受到威脅，對於家庭與社會都會產生沉重的負擔，且退化的狀況也會使得健保資源大量耗用。病患受到如此長時間的身心折磨，更會嚴重影響相關之醫療品質，衍生出的精神疾病也會使得患者疾病加速的惡化。因此，為了提升這群患者的醫療品質並保障其身心安全，應避免將這些精神症狀歸咎於老化，多多給予患者關懷與鼓勵，醫師也可視必要狀況開立抗憂鬱的藥物，減少患者的生命損失與醫療成本的耗費。

Research Objectives:
Chronic obstructive pulmonary disease (COPD) is a major cause of disability and death worldwide. The prevalence of depression and anxiety in COPD patients is generally higher than those reported in other chronic illnesses, and these mental diseases significantly affect the health expenditures and the course of the diseases on elderly COPD patients. The COPD patients with co-morbid depression, anxiety or other chronic diseases are more impaired and have 50% to 100% higher medical costs than those without depression and anxiety. COPD affects approximately 1.8 million people in Taiwan every year, however, little studies have examined the impacts of mental diseases on elderly COPD patients. This study aims to investigate the depression and anxiety status on COPD patients’ medical care utilizations and health outcomes.
Study Design:
This study analyzed the nationally representative research database from National Health Insurance program between 2002 and 2006 in Taiwan, by exploring outpatient visits, hospitalizations, and medical expenditures of COPD and its associated co-morbidities. The data analyses were carried out by Chi-square test, multiple linear regression and multivariate logistic regression.
Population Studied:
Patient aged over 65 with primary diagnosis of COPD and co-morbidity diseases based on ICD-9-CM in Taiwan. To investigate the complications in COPD patients, four diseases such as diabetes, hypertension, heart failure and ischemic heart disease were included in the analyses.

Principle Findings:
Among the 5,735 COPD patients (59.81%, male), most of them were aged over 80 (28.67%) , and lived in urban areas (62.28%) in northern Taiwan (43.71%). The results indicated that those who were suffered from depression or anxiety increased medical utilization and costs. Multiple linear regression model showed that age, and hospital level significantly affect the expenditures for medicine of COPD patients with depression or anxiety (p＜0.001). Multivariate logistic regression model presented that number of complications significantly affect the probability of hospitalization among the COPD patients with mental diseases (p＜0.001).
Conclusions：
COPD symptoms were usually getting worsen over time and depression or anxiety affect the COPD patients significantly, though the mental diseases are usually under-estimated. The study results demonstrated that COPD patients suffered from depression and anxiety increased the risks on longer length of stay, higher medical expenditures and more complications.
WHO predicts that COPD will become the third leading cause of death worldwide by 2030. Since mental diseases may worsen elderly COPD patients’ health outcomes, physicians are advised to pay more attention to these types of patients. With on time and appropriate treatments, thus may help to improve quality of care and reduce medical expenditures for these patients.

論文審定書----------------------------------------------------------i
致謝詞--------------------------------------------------------------ii
摘要--------------------------------------------------------------- iii
Abstract-------------------------------------------------------------v
目錄----------------------------------------------------------------1
圖目錄--------------------------------------------------------------3
表目錄--------------------------------------------------------------4
第一章 前言 ----------------------------------------------------- 5
第一節 研究背景 ------------------------------------------------5
第二節 研究目的 -----------------------------------------------7
第二章 文獻探討 -------------------------------------------------8
第一節 慢性阻塞性肺病之相關概念與流行病學------------------------8
第二節 老年憂鬱症與焦慮症之相關概念與流行病學-------------------14
第三節 憂鬱症與焦慮症對於慢性阻塞性肺病之影響探討---------------18
第三章 研究方法與過程---------------------------------------------24
第一節 研究設計 ------------------------------------------------24
第二節 研究對象-------------------------------------------------25
第三節 研究變項定義---------------------------------------------25
第四節 研究架構 ------------------------------------------------30
第五節 研究工具與資料來源---------------------------------------31
第六節 統計分析方法--------------------------------------------32
第七節資料處理過程---------------------------------------------33
第四章 研究結果 --------------------------------------------------36
第一節 老年慢性阻塞性肺病患者人口學變項與就醫特性---------------36
第二節 老年慢性阻塞性肺病患者罹患憂鬱症或焦慮症之描述性分析-----39
第三節 老年慢性阻塞性肺病患者罹患憂鬱症或焦慮症與人口學特性及就醫變項的相互關係-----------------------------------------------------44
第四節 老年慢性阻塞性肺病患者罹患憂鬱症或焦慮症後在住院方面的情形(推論性統計)------------------------------------------------------ 46
第五節 小結論------------------------------------------------- 62
第五章 研究討論 ------------------------------------------------- 63
第一節 老年慢性阻塞性肺病患者罹患精神疾病後於人口學變項之討論-- 63
第二節 老年慢性阻塞性肺病患者罹患精神疾病後對於醫療資源與醫療品質的影響------------------------------------------------------------ 64
第三節 研究限制------------------------------------------------ 66
第六章 結論與建議 ----------------------------------------------- 67
第一節 研究結論 ----------------------------------------------- 67
第二節 研究建議------------------------------------------------ 67
參考文獻 --------------------------------------------------------- 69

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