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系統識別號 U0026-1208201703192700
論文名稱(中文) 運用空間分析方法探討台灣缺血性中風後致死率之相關因子
論文名稱(英文) Using spatial analysis to explore the factors related to fatality among patients with ischemic stroke in Taiwan
校院名稱 成功大學
系所名稱(中) 臨床藥學與藥物科技研究所
系所名稱(英) Institute of Clinical Pharmacy and Pharmaceutical sciences
學年度 105
學期 2
出版年 106
研究生(中文) 林彥君
研究生(英文) Yen-Chun Lin
學號 s66041010
學位類別 碩士
語文別 中文
論文頁數 131頁
口試委員 指導教授-鄭靜蘭
指導教授-陳奕奇
口試委員-高雅慧
口試委員-劉子銘
口試委員-黃千惠
中文關鍵字 空間分析  缺血性中風  致死率  台灣 
英文關鍵字 spatial analysis  ischemic stroke  fatality rate  Taiwan 
學科別分類
中文摘要 研究背景
缺血性中風是國人主要死因之一。國外研究指出,缺血性中風後死亡率存在地區間的差異,但國內卻缺少相關研究,更鮮少文獻以空間分析方法探討中風後死亡率之相關影響因子。

研究目的
本研究目的在於了解台灣缺血性中風後致死率與心血管用藥之空間分布與聚集情形,並運用空間迴歸模型探討缺血性中風後致死率的相關因子。本研究能提供實證結果以改善某些鄉鎮中風後藥品使用與醫療資源配置,以降低缺血性中風後致死率。

研究方法
本研究係一回溯性世代研究,運用2001年至2013年全民健保資料庫,納入2004年1月1日(含)之後,且出院日期於2012年9月30日(含)之前,首次住院之缺血性中風患者(ICD-9-CM: 433, 434)。接著,以鄉鎮為單位定義病人實際居住地,進一步排除年齡小於18歲者、前三年曾被診斷腦血管疾病者、前一年曾被診斷惡性腫瘤或於住院及追蹤期間發生惡性腫瘤者、90天內死亡或住院時間超過90天者,以及離島居民。
由全民健康保險資料庫估算各鄉鎮缺血性中風後致死率、與心血管用藥平均每人每天藥品耗用定義日劑量(Defined daily dose),並從各縣市政府開放性資料中收集各鄉鎮之社會環境變項:包含人口結構、社經地位、原住民鄉鎮與空氣汙染等。接著,運用區域型空間自相關分析LISA (Local Indicators of Spatial Association)了解各鄉鎮中風後致死率與心血管用藥之空間分布與群聚情形,並以空間迴歸模型spatial Durbin panel model (SDPM) 探討缺血性中風後致死率之相關因子。

研究結果
本研究共納入165,732位初次缺血性中風病人,平均年齡為67.5歲,男性約佔58.5%。超過9成病人居住於西部地區,而東部居民偏少,僅佔3.3%。空間自相關分析結果顯示,較高的缺血性中風後一年內致死率集中於偏遠鄉鎮。而空間迴歸模型分析結果顯示,血栓溶解劑(p<0.001)、抗血小板製劑(p<0.001)、抗凝血劑(p<0.001)及降血脂劑(p=0.015)與中風後致死率呈顯著負相關,而利尿劑(p<0.001)的使用與心房顫動(p<0.001)、心衰竭(p<0.001)等共病症,則和致死率呈顯著正相關。鄉鎮老年人口比例、社經地位等環境社會因子則與致死率無顯著相關性。

結論
本研究發現台灣缺血性中風後一年內致死率具有空間聚集特性,高致死率之鄉鎮多為偏遠鄉鎮,且多集中於屏東縣;另外,藉由空間迴歸模型分析結果了解,共病症如:心衰竭與心房顫動,中風後用藥如:血栓溶解劑(rt-PA)、抗血小板劑、抗凝血劑、降血脂劑(statins)皆為影響致死率具有空間分布差異之顯著相關因子。
偏遠地區醫療資源不足,尤其在緊急醫療部分更為缺乏。建議衛生主管機關強化偏遠鄉鎮(如屏東縣、東部地區)地區醫院之緊急救護能力,並搭配完善、快速且安全的轉診系統,以改善其用藥情形;另外,亦應加強民眾對於腦中風徵兆之認知,以免延誤就醫時間。
英文摘要 Many risk factors for stroke fatality have been known, however, there were few studies using spatial analysis to identify causal factors such as geographical inequalities of health care across and within country. We conducted a retrospective cohort study by using 2001-2013 National health insurance research database (NHIRD), involving the patients with first-ever ischemic stroke. We observed the cardiovascular drug utilization for the following 3 months. The outcome was 1 year all-cause fatality rate after ischemic stroke. Local Indicators of Spatial Association (LISA) were applied to detect the spatial clusters of fatality rate. In addition, spatial Durbin panel model was used to identify the factors related to fatality. A total of 165,732 patients were included, with a mean age of 67.5 years and 58.5% male. The LISA statistics showed a high fatality rate was clustered in rural areas. Results from spatial regression model found that use of diuretics (p<0.001), atrial fibrillation (p<0.001) and heart failure (p<0.001) are positively associated with fatality, while the utilization of thrombolytic therapy (p<0.001), antiplatelet agents (p<0.001), anticoagulants (p<0.001) and statins (p=0.015) have a significant negative association. Our finding indicated that townships with higher utilization of thrombolytic therapy and other cardiovascular medications had lower fatality rate, suggesting healthcare providers improve the utilization of these medications after ischemic stroke in rural areas.
論文目次 摘要 I
Extended abstract III
誌謝 V
目錄 VII
表目錄 IX
圖目錄 XI
第一篇、運用空間分析方法探討台灣缺血性中風後致死率之相關因子 1
第一章、研究背景 1
第二章、文獻回顧 2
第一節、缺血性中風簡介 2
第二節、影響缺血性腦中風長期死亡率之危險因子 5
第三節、心血管用藥與缺血性中風後死亡率 7
第四節、缺血性中風後死亡率與相關因子之空間分布差異 11
第五節、空間分析方法與應用 16
第六節、總結 20
第三章、研究目的 21
第四章、研究方法 22
第一節、研究設計 22
第二節、研究變項與操作定義 32
第三節、研究變項校正及排除條件之操作定義 38
第四節、社會環境因子解釋及其操作定義 40
第五節、資料處理流程 46
第六節、統計方法 47
第七節、空間分析方法 48
第五章、研究結果 52
第一節、居住地判別流程 52
第二節、研究對象納入與排除 54
第三節、研究族群之人口學特性 56
第四節、描述性空間分析與空間自相關分析結果 60
第五節、空間迴歸模型分析結果 71
第六章、研究討論 77
第一節、描述性空間分析與空間自相關分析 77
第二節、空間迴歸模型分析 79
第三節、缺血性中風後用藥與致死率相關性 81
第四節、缺血性中風後用藥與鄉鎮都市化程度相關性 89
第五節、環境社會因子與致死率相關性 94
第六節、研究限制 96
第七章、結論與建議 100
第一節、研究結論 100
第二節、研究建議 100
第八章、未來研究方向 101
第二篇、臨床藥事服務:藥師介入評估藥物皮膚過敏反應 102
第一章、服務緣起 102
第二章、服務目的與方法 103
第三章、結果 105
第一節、本服務與原評估通報流程之差異 105
第二節、藥師評估藥物皮膚過敏反應評估表 106
第三節、服務對象分析結果 109
第四章、感想與建議 113
參考文獻 115
附錄一、急性缺血性腦中風之血栓溶解治療檢查表 123
附錄二、2004-2012年各變項冷熱點之鄉鎮分布 125
附錄三、台灣地區鄉鎮都市化分層表 130
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