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系統識別號 U0026-2707201118042900
論文名稱(中文) 中台灣某醫學中心低衝擊性非脊椎骨折之中老年患者的骨質疏鬆症診斷與治療
論文名稱(英文) Diagnosis and Treatment of Low Impact Non-Vertebral Fracture among Middle and Older Aged Patients at a Medical Center in Middle Taiwan
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 99
學期 2
出版年 100
研究生(中文) 張欽凱
研究生(英文) Chin-Kai Chang
學號 TC696108
學位類別 碩士
語文別 中文
論文頁數 60頁
口試委員 指導教授-張家銘
口試委員-吳至行
口試委員-黃國淵
中文關鍵字 骨質疏鬆症  低衝擊性骨折  雙能量X光吸收儀 
英文關鍵字 osteoporosis  low impact fracture  DXA 
學科別分類
中文摘要 前言:台灣地區已於1993年邁入世界衛生組織所定義的高齡化社會。2008年老年人口更突破10%,醫療支出也隨之成長。銀髮族常見的慢性病,除了心血管疾患和糖尿病外,骨質疏鬆症更是一大隱形殺手。骨質疏鬆症並無明顯症狀,一旦發生低衝擊性的傷害,例如跌倒,常伴隨髖骨、脊椎、橈骨或身體其他各處的骨折。特別是髖骨骨折病患,術後往往因長期臥床,造成肌力下降,進而喪失自主功能。後續的併發症例如肺炎和泌尿道感染等,更是導致死亡的原因。健保資料顯示,發生髖部骨折的老人,女性一年內死亡率為15%,男性則高達22%。因骨折住院的平均醫療費用,每人至少10萬台幣以上,後續的復健及照護安養,金額勢必更驚人。
現階段治療骨質疏鬆症已經有很明確的準則。發生骨折後使用骨質疏鬆藥物更可大幅降低再次發生骨折的機率。然而據許多國外文獻研究指出,發生低衝擊性骨折後,被診斷出骨質疏鬆症並接受相關藥物治療的比率並不高。環顧台灣,類似的研究也不多見。
目的:了解中台灣某醫學中心,因低衝擊骨折開刀住院的中老年病患,術後骨質疏鬆的診斷率,骨質疏鬆藥物使用率,以及接受雙能量X 光吸收儀(DXA)的檢測率。並找出影響術後未使用藥物治療,未接受DXA檢測的預測因子。同時分析術後規則服用骨質疏鬆藥物與未規則服用藥物的差異所在。
方法:自西元2007年1月1日起至2008年12月31日止,以回溯性橫斷研究,透過病歷查閱方式,收集中台灣某醫學中心內因低衝擊骨折住院接受手術治療,年滿50歲以上中老年病患相關資料並進行分析。除去脊椎骨折、高衝擊性骨折、癌症、血液透析,以及甲狀腺機能異常等患者。收集資料內容包括:患者基本資料、主要共病症、骨折種類、術前有無骨質疏鬆症診斷及用藥、術後有無骨質疏鬆症診斷、術後是否接受DXA檢測、術後是否有骨鬆用藥及藥物種類、有無多重用藥、服用藥物順從性,以及開立藥物的醫師特性等。
結果:根據ICD國際疾病分類碼及日期搜尋,共383名患者,其中125人被排除。被排除的原因以高衝擊骨折病患最多,共83人。其餘258人納入研究,其中男性69人,女性189人。平均年齡男性73.4歲,女性75.5歲。骨折種類以下肢骨折最多,共211人(82%)。術後接受DXA檢測共41人(16%)。術後有骨質疏鬆症診斷共134人(52%)。術後接受骨鬆藥物治療共124人(49%)。開立的骨質疏鬆用藥以口服雙磷酸鹽最多共71筆(36%),其次為鈣片製劑68筆(35%),選擇性雌激素受體調節劑53筆(27%)。術後開立藥物的醫師共19人,科別以骨科最多,有17位(89%)。術後藥物服用超過六個月以上的患者達83人(67%)。術後再次骨折的患者共26人,以75歲以上居多。進一步以多變項邏輯式回歸模式分析,發現術後未接受骨鬆用藥的病人的三項預測因子為:男性、上肢骨折、術後未接受DXA檢測。至於術後未接受DXA檢測的病患的預測因子為:術前無骨質疏鬆診斷。
在術後回診取藥的順從性方面,與不規律回診取藥的患者相比,術後規律回診取藥的病患,在術前已診斷骨鬆症、術前已服用骨鬆藥物、術後被診斷骨鬆症,以及術後接受DXA檢測等因子上達顯著之差異。
結論:低衝擊骨折之中老年患者,術後接受骨質疏鬆藥物治療與DXA檢測的比率仍然未盡理想。男性、上肢骨折、及術前無骨質疏鬆診斷者更是容易被忽略的危險族群,值得做為日後制定骨質疏鬆症防治策略的重要參考。
英文摘要 In 1993, people aged 65 and over comprised more than 7% of the total population. The percentage had increased to over 10% in 2008. As the numbers of elders increase, medical costs are growing fast. In addition to common chronic disorders, such as cardiovascular disorders and diabetes, osteoporotic fracture represents a serious threat to the older people. Fractures of hip, distal radius, vertebra, or other sites may occur in elders who fall from just a standing height or even less. Decrease in muscle strength due to long-term bed ridden status after surgical interventions, especially hip fractures would lead to functional dependency and thus many complications, such as urinary tract infection, or pneumonia and death eventually. Mortality within the first year after hip fracture is around 15% in women and 22% in men. The average medical cost of hospitalization due to fracture was more than one hundred thousand NT dollars, not to mention the costs of rehabilitation and nursing care after discharge from hospital. The financial and social burden is huge.
There are therapeutic guidelines for osteoporosis. Calcium plus vitamin D, and some anti-resorptive agent can reduce the risk of future fractures. However, recent research revealed that osteoporosis management following low-impact fracture is inadequate, let alone the older population. There are no similar studies among the elderly in Taiwan. Therefore, a retrospective study was conducted at a medical center in middle Taiwan.
Objectives: (1) To identify rates of diagnosis, and treatment of osteoporosis among middle-and-older patients with low impact fractures after surgery. (2) To identify rate of DXA examination of these patients. (3) To identify predictors of those who did not receive medications, and those who did not receive DXA post surgery. (4) To clarify characteristics between patients with good or poor compliance to osteoporosis medications.
Methods: This is a retrospective chart review. From January 1st, 2007 to December 31, 2008, people aged 50 years and older who suffered from low impact fractures and were admitted for surgical intervention were included in the study. Patients who were high impact fracture, receiving hemo-dialysis, having cancer, and having hyper/hypothyroidism were excluded. Information in the medical chart were recorded, including demographics (gender, age, education, residential area), fracture types, comorbidities, the diagnosis of osteoporosis, anti-osteoporotic treatment and DXA examination before and after surgery, poly-pharmacy, and drug compliance after surgery, and characteristics of physicians.
Results: There were 383 patients found but 125 patients were excluded due to high impact fractures (82), hemo-dialysis (9), and cancer (32). A total of 258 patients were finally enrolled in the study. There were 69 men and 189 women, with mean average age of 73.4 and 75.5 years, respectively. There were 134 patients with diagnosis of osteoporosis (52%), 124 patients with anti-osteoporotic medications (49%), and 41 (16%) patients with DXA examination post surgery. The most common medications prescribed post surgery was alendronate, followed by the calcium products and SERM. Nineteen physicians prescribed anti-osteoporotic medications post surgery, and most of them are orthopedic surgeons. There were eighty three (67%) patients who took medications for at least 6 months or more post surgery. Twenty six patients suffered from another fracture episode after surgery. According to the adjusted multiple logistic regression models, predictors of patients without medications after surgery were: male patients, fracture over the upper extremity, and no DXA exams after surgery. The predictor of patients without DXA examinations after surgery was: no diagnosis of osteoporosis before the surgery.
As to the drug compliance after surgery, there were statistically significant differences in the following factors: pre-surgical diagnosis, pre-surgical medications, post- surgical diagnosis and DXA examinations.
Conclusions: The diagnosis and treatment of osteoporosis following low impact fracture at the medical center of middle Taiwan is sub-optimal. Male gender, patients with upper extremity fractures, and patients without diagnosis and DXA examinations after surgery were apt to be under-managed.
論文目次 第一章 緒論 1
第一節 研究背景 1
第二節 研究動機 1
第三節 研究目的 2
第四節 名詞定義 3
第二章 文獻查證 5
第一節 骨質疏鬆症的定義、診斷及危險因子 5
第二節 骨質疏鬆症的流行病學 7
第三節 骨質疏鬆症帶來的衝擊與影響 8
第四節 骨質疏鬆症的預防 8
第五節 骨質疏鬆症的治療 9
第六節 低衝擊骨折後,骨質疏鬆的診斷情況 10
第七節 醫師治療骨質疏鬆症的意願與行為探討 11
第八節 低衝擊上肢骨折的治療情況 13
第九節 老年男性骨質疏鬆症的診斷與治療 14
第十節 綜合研究 14
第十一節 國內相關研究 15
第三章 研究方法 17
第一節 研究設計 17
第二節 研究對象 17
第三節 研究架構 18
第四節 研究步驟 18
第五節 資料處理 22
第四章 研究結果 23
第一節 基本資料 23
第二節 術後骨質疏鬆症診斷情形 24
第三節 術後使用骨質疏鬆藥物情形 25
第五節 術後DXA檢測情形 28
第六節 醫師背景及年資調查 29
第七節 術後發生新骨折 30
第八節 敘述性統計分析 31
第九節 推論性統計分析 34
第五章 討論 38
第一節 術後骨質疏鬆症的診斷與用藥比率 38
第二節 術後DXA的檢測比率與結果 40
第三節 醫師開立藥物與檢測的觀察 41
第四節 找出預測因子 42
第五節 術後服藥順從性的探討 42
第六節 術後發生新骨折的探討 43
第六章 結論 45
第七章 研究限制 46
第八章 未來展望 48
第九章 參考文獻 49
附錄一 人體試驗委員會同意書 55
附錄二 一分鐘骨鬆風險測試問卷 56
附錄四 全民健康保險骨質疏鬆症治療藥物給付規定(2011/01/01) 58
附錄五 全民健康保險骨質疏鬆症檢查給付規定 60
表目錄
表2-1骨質疏鬆症的診斷原則 6
表4-1 258位患者基本資料 23
表4-2 134位術後有骨質疏鬆症診斷患者基本資料 24
表4-3 124位術後使用骨鬆藥物患者基本資料 25
表4-4 開立藥物種類及人次 26
表4-5 術後持續服用骨鬆藥物病患之基本資料 27
表4-6術後骨質密度檢測情形 28
表4-7術後DXA檢測結果正常患者相關資料 (依手術日期排列) 28
表4-8 主刀醫師術後處方藥物情況 29
表4-9主刀醫師術後開立DXA情況 30
表4-10術後發生新骨折患者統計 30
表4-11男性患者/女性患者特性分布 31
表4-12術後使用骨鬆藥物/未使用骨鬆藥物患者特性分布 32
表4-13術後未用藥在單變項邏輯式迴歸分析之勝算比 34
表4-14術後未接受DXA檢測在單變數邏輯式迴歸分析之勝算比 35
表4-15 術後未用藥在校正多變數邏輯式迴歸分析之勝算比 36
表4-16 術後未接受DXA檢測在校正多變數邏輯式迴歸分析之勝算比 37
表5-1 術後該使用骨鬆藥物而未用藥比率 39

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