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系統識別號 U0026-2308202017355300
論文名稱(中文) 中醫利用降低骨鬆性骨折風險
論文名稱(英文) The utilization of Traditional Chinese Medicine decrease the risk of osteoporotic fracture
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 108
學期 2
出版年 109
研究生(中文) 鄭秝丞
研究生(英文) Li-Cheng Zheng
學號 TC6074076
學位類別 碩士
語文別 中文
論文頁數 101頁
口試委員 指導教授-邱靜如
共同指導教授-吳至行
口試委員-梁富文
口試委員-徐之昇
中文關鍵字 骨質疏鬆症  骨質疏鬆性骨折  中醫  風險  利用 
英文關鍵字 osteoporosis  osteoporotic fracture  Traditional Chinese Medicine  risk  utilization 
學科別分類
中文摘要 研究背景
骨質疏鬆症是最常見的肌肉骨骼系統疾病之一,在全世界有普遍高的盛行率,隨著世界人口的老化其盛行率也隨之增加。骨質疏鬆症最嚴重的併發症之一為骨鬆性骨折,造成嚴重的疼痛、失能、甚至是死亡,危害生活品質,也是造成龐大醫療費用負擔,因而成為重要的公共衛生議題。台灣是亞太地區二十五國中唯一被列為髖關節骨折風險極高的國家,台灣女性髖骨骨折發生率是亞洲地區排名第一,全世界排名第九。近年來台灣政府致力於推動全民骨鬆之防治,除了常規之西醫療法之外,其他療法的需求也日漸增加。中醫近年在世界各國成為熱門的輔助及替代性醫療,在台灣更是唯二納入全民健康保險給付的醫療系統之一,中醫的應用深植於華人的文化和生活,也因全民健保提供給付,近十年來健保中醫利用的人口逐年增加,約由總納保人口的25%上升至30%。中醫對於骨質疏鬆症相關的預防和治療也越來越受到重視,先前之研究指出中醫療法經由增加骨生成、減少骨質破壞、影響賀爾蒙、增加肌肉質量及強度、改善平衡以及減少跌倒風險等多種機轉來治療或預防骨質疏鬆症及其相關性骨折。

研究目的
本研究之目的旨在探討健保中醫利用對於骨鬆性骨折風險的影響。

研究方法
本研究為雙世代追蹤串連健保資料庫研究,雙世代資料收集來自台灣雲林及田寮兩地區,於2009年至2010年間以骨密度檢測及問卷調查收集40歲以上成人共932位男性及1044位女性樣本,排除1位問卷資料不齊全者後,串連2008-2017年健保資料庫,連結樣本之就醫紀錄以及死因統計等資訊,以分析追蹤期間中醫健保門診就醫紀錄與骨鬆性骨折風險之相關性。研究中將骨密度檢測日訂為檢測日,以檢測日隔日起一年內之中醫就診次數作為分組依據,中醫就診次數≥5次者為中醫利用者,0次者為非中醫利用者,並自2012年1月1日起持續追蹤至2016年12月31日止,以COX迴歸模型分析兩組之骨鬆性骨折風險,並進一步以年齡、性別、社經地位、查爾森共病指數、檢測日前一年中醫就診次數以及追蹤期間中醫就診次數以上共變項進行風險的校正。另外,對於有發生骨鬆性骨折之樣本進一步分析兩組於骨折後死亡率之差異。

研究結果
本研究之分組中中醫利用者組共347人(22.65%),其中男性148人(42.65%),女性199人(57.35%),平均年齡為61.12歲;非中醫利用者組共1185人(77.35%),其中男性611人(51.56%),女性574 (48.44%),平均年齡為67.21歲。中醫利用者傾向於女性、中高社經地位,大於80歲以上者比例偏少。在五年追蹤期間骨鬆性骨折之發生率中醫利用者為6.05%;非中醫利用者為7.85%,以卡方檢定統計量,結果得χ2 = 1.257,p值= 0.262。以COX迴歸模型分析兩組樣本之骨鬆性骨折風險比(Harzard Ratio, HR),與非中醫利用者相比,未校正前之中醫利用者骨鬆性骨折HR為0.858 (95%CI:0.512 -1.437),p值= 0.5597。將控制變項包含年齡、性別、社經地位、查爾森共病指數、檢測日前一年中醫就診次數以及追蹤期間中醫就診次數加入迴歸模型,計算中醫利用者之校正後骨鬆性骨折HR為1.248 (95% CI:0.637-2.444),p值= 0.518。在骨鬆性骨折後死亡率方面,追蹤期間中醫利用者死亡率為19.05%,其中骨折後一年內死亡率為14.29%;非中醫利用者死亡率為10.75%,其中骨折後一年內死亡率為6.45%。利用卡方檢定統計量,骨折後死亡率結果得χ2 =1.094,p值= 0.498,骨折後一年內死亡率結果得χ2 = 1.446,p值= 0.451。


結論
以一年之健保中醫就診次數大於等於五次定義之中醫利用與非中醫利用者相比其骨鬆性骨折風險無顯著差異,且在骨鬆性骨折後死亡率以及骨折後一年內死亡率亦無顯著影響。
英文摘要 Fracture is the most serious complications of osteoporosis. This study aims to explore the relationship between the utilization of TCM and the risk of osteoporotic fracture. This is a two-cohort study derived from Yunlin and Tianliao in 2009-2010 and connected with the 2008-2016 National Health Insurance database. A total of 932 males and 1044 females aged 40 y/o and over, were collected. According the number of NHI medical visits of TCM during one year after the exam date, the visit number of TCM ≥ 5 was defined as TCM users and those of TCM =0 was non-TCM users. The hazard ratio of osteoporotic fracture between two groups was analyzed. The TCM users tend to be female, middle-high socioeconomic status and less proportion in over 80 year-old. After adjusting the age, sex, socioeconomic status, Charlson Comorbidity Index and the visit number of TCM by regression model, there are no statistical differences on the incidence of fracture and total mortality between TCM and non-TCM users. Using strictly criteria of TCM user by adjusting with the major covariates, the utility of TCM have no significant effect on the incidence of osteoporotic fracture.
論文目次 中文摘要 ---------------------------------------------------------------------------------------------Ⅰ
Abstract ----------------------------------------------------------------------------------------------- Ⅳ
致謝 ------------------------------------------------------------------------------------------------- Ⅶ
第一章 緒論 ----------------------------------------------------------------------------------------1
第一節 研究背景與動機 -------------------------------------------------------------1
第二節 研究目的與問題陳述 -------------------------------------------------------3
第三節 研究重要性 -------------------------------------------------------------------3
第四節 名詞解釋 ----------------------------------------------------------------------4
第二章 文獻查證 ----------------------------------------------------------------------------------6
第一節 骨質疏鬆症與骨質疏鬆性骨折的流行病學 ----------------------------6
第二節 骨質疏鬆性骨折之臨床危險因子 ----------------------------------------8
第三節 骨折風險預測因子與預防方法 ------------------------------------------14
第四節 中醫與中醫使用者 ---------------------------------------------------------18
第五節 中醫療法與骨質疏鬆症 ---------------------------------------------------21
第六節 中醫作為補充或替代性療法與骨鬆性骨折之相關性 ---------------23
第七節 研究契機 ---------------------------------------------------------------------27
第三章 研究方法 ---------------------------------------------------------------------------------28
第一節 研究設計 -------------------------------------------------------------------- 28
第二節 研究假設與研究架構 ----------------------------------------------------- 29
第三節 研究對象與資料收集 ----------------------------------------------------- 31
第四節 研究變項 -------------------------------------------------------------------- 38
第五節 研究流程 -------------------------------------------------------------------- 47
第六節 倫理考量 -------------------------------------------------------------------- 48
第七節 資料統計與分析 ----------------------------------------------------------- 48
第四章 研究結果 -------------------------------------------------------------------------------- 49
第一節 健保中醫利用率 ----------------------------------------------------------- 49
第二節 人口學及共病 -------------------------------------------------------------- 50
第三節 FRAX十二變項 ----------------------------------------------------------- 58
第四節 骨鬆性骨折發生率與風險 ----------------------------------------------- 62
第五節 骨鬆性骨折後死亡率 ----------------------------------------------------- 74
第五章 討論 -------------------------------------------------------------------------------------- 77
第一節 雙世代之中醫利用率 ----------------------------------------------------- 77
第二節 雙世代之人口學變項及共病 -------------------------------------------- 78
第三節 FRAX之十年骨折機率 -------------------------------------------------- 79
第四節 骨鬆性骨折風險 ----------------------------------------------------------- 81
第五節 與先前文獻之比較 -------------------------------------------------------- 82
第六節 雙世代與健保資料庫分析之優缺點比較 ----------------------------- 85
第七節 研究結果之臨床解讀與應用 -------------------------------------------- 86
第六章 結論
第一節 研究發現 -------------------------------------------------------------------- 87
第二節 研究貢獻 -------------------------------------------------------------------- 87
第三節 研究限制 -------------------------------------------------------------------- 87
第四節 未來研究方向 -------------------------------------------------------------- 88
參考文獻 ---------------------------------------------------------------------------------------------89
中文文獻 -------------------------------------------------------------------------------- 89
英文文獻 -------------------------------------------------------------------------------- 90
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