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系統識別號 U0026-0707201921585000
論文名稱(中文) 跌倒史對FRAX台灣模式預測骨鬆性骨折信度之影響--兩世代(雲林縣/田寮鄉)追蹤串連健保資料庫研究
論文名稱(英文) The incorporation of falls into FRAX on the prediction of osteoporotic fracture in Taiwanese cohorts-Data from Yunlin and Tianliao cohorts
校院名稱 成功大學
系所名稱(中) 老年學研究所
系所名稱(英) Institute of Gerontology
學年度 107
學期 2
出版年 108
研究生(中文) 劉依亭
研究生(英文) I-Ting Liu
學號 TC6064063
學位類別 碩士
語文別 英文
論文頁數 59頁
口試委員 指導教授-吳至行
共同指導教授-王新台
召集委員-張家銘
口試委員-梁富文
中文關鍵字 骨質疏鬆  骨折  跌倒  十年骨折風險評估  健保資料庫 
英文關鍵字 FRAX  osteoporosis  fracture  fall  NHIRD 
學科別分類
中文摘要 背景:隨著世界老化浪潮,台灣的老年人口於2018年超過14%邁入高齡化社會。骨質疏鬆、跌倒、骨折在老年族群有高盛行率,且為老年失能的重要成因,因而近年來越來越受到重視。世界衛生組織於2008年推出十年骨折風險評估工具(FRAX)以篩檢40歲以上成年人之高風險族群。台灣FRAX工具於2010年由成大團隊建立並獲得世界衛生組織納入,由於此公式簡易便利且同時又是源自台灣本土資料庫所推估建立因此被廣泛使用,然而仍須完整世代追蹤資料以驗證2010年FRAX公式的預測性。

目的: 驗證台灣FRAX模式於人口中之骨折預測力。此外,在加入跌倒史後對於此模式的影響並計算跌倒史的加權指數。

方法: 自2009-2010之田寮及斗六雙世代研究中總計有 40歲以上932位男性及1044 位女性與2008-2016年健保資料庫成功連結。骨密度及FRAX相關臨床骨折風險因子於收案時皆予以評估。過去一年之跌倒史 於收案時同步記錄之。.計算FRAX 10年風險機率於7年追蹤期間之主要骨鬆骨折及髖骨骨折發生之間效準程度。Cox 比例風險回歸模式以計算跌倒史是否在調整FRAX原有因子後仍為骨折的預測因子。跌倒史於預測骨折的加權指數也同時計算之。所有資料以 SAS 9.4 軟體分析。

結果: 全部個案總計追蹤6.8±1.1 年中共有157 次骨鬆性骨折發生。 研究發現台灣FRAX模式之風險機率可獨立預測主要骨鬆骨折 (HR:1.06, 95% CI: 1.05-1.07, p<0.001) 及髖骨骨折 (HR: 1.07, 95% CI: 1.05-1.09, p<0.001)。由此證實台灣FRAX模式於7年之主要骨鬆骨折結果之預測校準能力。當調整FRAX分數後,跌倒史仍可顯著的預測主要骨鬆骨折 (HR: 1.47, 95% CI: 1.04-2.07, p=0.027);重複跌倒可顯著預測男性主要骨鬆骨折 (HR: 2.470, 95% CI: 1.220-5.001, p=0.012),但於女性則未達顯著 (HR: 1.322, 95% CI: 0.713-2.454, p=0.376)。 然而,跌倒對於75歲以上老年人的影響則較不顯著。最後,本研究計算出跌倒史的修正風險機率(加權指數)於一般跌倒史者為1.47,於重複跌倒史者為1.70,以此提升FRAX預測骨折的精確性。

結論: 台灣FRAX模式驗證結果具有可信度。跌倒尤其是重複跌倒是男性全身性骨折的顯著影響預測因子,女性則無。跌倒史對於年輕老年人之骨折預測影響性較高於年老老年性 。若使用原有的FRAX模式,則整體跌倒史的加權指數為1.47。
英文摘要 Background: FRAX® is an algorithms to calculate age- and gender-specific fracture probabilities from obtained clinical risk factors (CRFs) and femoral neck bone mineral density (BMD) developed in 2008 by the WHO Collaborating Centre for Metabolic Bone Diseases. In fact, the CRFs for fracture were identified based on serial meta-analyses of substantial population-based cohorts. According to the literature, there are still other risk factors that may have contribution to osteoporotic fracture not been included such as falls. The incorporation of falls into FRAX has been requested with increasing evidence. A country-specific Taiwanese FRAX model has been available since 2010, however, large prospective cohort studies are needed to validate the model.

Aims: To assess the clinical utility of Taiwan FRAX scores in prediction of incidence proportion of hip fracture/MOF using time to event data. In addition, weighted index of history of falls on Taiwanese FRAX will be calculated for further incorporation of falls into our FRAX Model.

Methods: A total of 932 men and 1044 women, aged 40year-old and over, from Yunlin and Tianliao cohorts in Taiwan during 2009-2010, were identified and successfully connected with the 2008-2016 National Health Insurance (NHI) databank. BMD and FRAX associated clinical risk factors (CRFs) for osteoporotic fracture were assessed initially. Prior fall history was also assessed at enrollment. The calibration between observed MOF/hip fracture over 7 years and FRAX 10-year probability were examined. Cox proportional hazards regression was conducted to assess whether falls is a predictor of time to incident fracture, adjusted for FRAX or its CRFs. Weighted index of history of falls on the prediction of incident fracture were calculated subsequently. Data were analyzed using SAS 9.4 software.

Results: During the average 6.8±1.1 years of follow-up period, 157 Incident osteoporotic fractures were identified. The present study revealed FRAX probability from Taiwan FRAX model was independently predictive of incident major osteoporotic fracture (HR:1.06, 95% CI: 1.05-1.07, p<0.001) and hip fracture (HR: 1.07, 95% CI:1.05-1.09, p<0.001). The observed majors osteoporotic fracture outcomes of 7 years showed good calibration for Taiwan FRAX. After adjusting FRAX scores, history of falls remains a significant predictor for incident MOF (HR: 1.47, 95% CI: 1.04-2.07, p=0.027). Repeated falls is also a significant predictor for incident MOF (HR: 2.470, 95% CI: 1.220-5.001, p=0.012) in man, not in women (HR: 1.322, 95% CI: 0.713-2.454, p=0.376). However, the influence of falls on incident fracture risk was not observed in subjects aged ≧75 years old. Finally, our data showed a modified risk probability (weighted index) by multiplying 1.47 for subjects ever fell in previous year and 1.70 for those with repeated falls, which may make the fracture prediction more accurate in fallers.

Conclusions: The Taiwan FRAX model is well-validated. Fall. especially, repeated falls are significant predictors for incident MOF in man, but not in woman. Falls play a more important role on the prediction of incident fractures in the young old than the extreme old. Our study concluded with a 47% increased risk for each fall adjusting as a weighted index while incorporating with FRAX score.
論文目次 三、目錄
1. 中文摘要 ………………………………………………………….........……I
2. 英文摘要 ……………………………………….......……….………..III
3. 目錄 ……………………………………………...……………..…….......V
4. 圖目錄 ……………………………………………...……………........VII
5. 表目錄 ………………………………………………...……………........IX
6. 研究背景及動機.........................……….1
7. 研究目的 …………….......………………………………………………...4
8. 研究方法 …………….......………………………………………………...4
9. 結果 ……………………………………………………………...….........10
10. 文獻查證 /討論 …………...………………………………..………..14
11. 結論 ……………...……………………………..………………….......20
12. 未來研究方向 ……………..............………….……..20
13. 研究限制 ……………..........……………………….……………….21
14. 參考文獻 ………..……………….………….......…………………….22
15. 附錄 ……………………...………………………………...…......……31
16. 圖表 …....………………...……………………………………......…36
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