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Synthesis and Optoelectronic Properties of 2,5-Disubstituted of 1,4-dihydropyrrolo [3,2-b] pyrrole
No full textSynthesis and Characterization of Star-shape Polymer and derivatives
No full text聚胺酯(Polyurethane，PU)材料，是一種用途十分廣泛的高分子材料，該材料製備主要是由NCO官能基與含活性氫化合物反應，藉由氫原子移轉之逐步加成聚合而形成的反應。在反應物中選擇不同數目以及不同結構類型的官能基團化合物、以及不同的合成方式，即可製備出性能優異、各式各樣型態成品的聚胺酯材料。例如:發泡體型材料、彈性橡膠、合成纖維、黏著劑以及具有細胞組織的相容性佳所發展的人體組織結構材料…等等。在這項研究中以合成聚氨酯為主要結構的高分子，藉由改變異氰酸酯的種類和多元醇的類型的新穎材料，最終的目的是提供生物醫學材料在黏著、保護、止血與高度生物相容性等方面生醫材料的需求。 本文是分為三個部分：part A是合成星狀聚胺酯感壓膠性質與研究。主要是利用polypropylene glycol triol先與IPDI進行聚合形成星狀結構之核心，再提高溫度讓IPDI進行選擇反應連結poly(1,4-butylene adipate) diol而形成最終的星狀聚胺酯高分子。 part B是合成聚胺酯液態繃帶材料性質與研究。要是利用Poly(oxytetramethxlene) glycol(PTMG) diol先與IPDI進行反應形成高分子的主錬段，再加入poly(1,4-butylene adipate) diol提供密著作用力與疏水性；再使用IPDI（trimer）增加高分子的交聯密度提供高分子的硬度。由於輕微的交聯度導致高分子依舊可以溶解於溶劑中，提供使用時可以依照物體的表面起伏而形成包附良好的薄膜。 part C是合成外科手術用之聚胺酯發泡體。使用polypropylene glycol triol 、polyethylene glycol diol 、HDI成為聚胺酯海綿的原材料，利用HDI快速反應與抗黃變能力與PEG的親水性能力與PPG triol提供整體高分子的交聯密度，最後賦予生醫材料聚胺酯泡棉形成親水、具有良好機械性質且不黃變
Synthesis and Applications of Thermally Stable Polyimide Electrode with High Optical Transparency
No full text本論文分成四個章節，第一張為總體序論。第二章節包含高長徑比奈米銀線、透明無色聚醯亞胺以及可撓式透明導電電極之製備及改善。第三章節為透明奈米銀線電極之電致變色元件與除雪裝置的應用。第四章節為結論。此研究探討並且有效提升奈米銀線與透明無色聚醯亞胺的製備及光電學性質，以製備兼具高透明度、高導電度及高耐熱度之可撓薄膜，因此文中也探討高長徑比奈米銀線的最佳化製程。在本研究中所使用的聚醯亞胺基材不但展現極高熱穩定性、高穿透度之光學性質，且有機抗化性佳，適合做為奈米銀線的黏著劑以利於嚴苛使用環境及後處理製程。第三章的部分，為了驗證第二章所製備的透明導電薄膜之應用價值，也製備兩段式電致變色元件與除雪裝置等等的應用元件，以展現奈米銀線電極應用之穩定性。This study has been separated into four chapters. Chapter 1 is the general introductions of transparent flexible electrodes. Chapter 2 includes the synthesis and improvement of silver nanowires (AgNWs), colorless polyimides and the preparation of highly flexible transparent electrodes. Chapter 3 depicts the applications such as electrochromic and snow-cleaning devices based on AgNWs-PI transparent electrode. The last chapter is the conclusions. In this study, both transparent and flexible electrode with highly thermal stability was successively prepared by the coating technique of silver nanowires (AgNWs) and polyimides (PI). In order to enhance the optical and electrical properties of hybrid film, the synthetic of higher aspect ratio AgNWs also have been discussed in particular. Because of the introduction of high performance polyimides as substrate and protector, the AgNWs conductive networks not only exhibited good adhesive property and bendability, but showed excellent thermal stability. Owing to the high glass transition temperature (Tg) of polyimides, the resulted AgNWs-PI electrode could maintain conducting property at high temperature environment. Thus, the hybrid electrode provided extremely high potential to operate at harsh working environment or further post processing. In addition, the optimized processing parameters were then used for applications of electrochromic and snow-cleaning devices which have been discussed in chapter 3. The devices fabricated by silver nanowires and colorless polyimide hybrids also showed excellent long-term stability
The Effect of City-County Consolidation on Mortality Difference Between Original City and Original County
No full text研究目的：臺灣在2010年底經歷行政區的重劃。其中，三個縣市區域個別合併成三個新的市：臺中市、臺南市，以及高雄市。本研究欲探討縣市的合併是否會縮小原縣、市居民間的死亡率差距。 研究方法：本研究的全年齡、0-4歲以及65歲以上死亡率資料來自衛生福利部，除了粗死亡率以外，也計算出年齡標準化死亡率進行分析。本研究利用hp濾波器分離出時間序列資料的長期趨勢，並使用複迴歸分析解釋縣市合併對於原縣、市之間居民死亡率差距的影響。 研究結果：縣市合併之後，不管是粗死亡率還是年齡標準化死亡率，原縣、市之間的全年齡及65歲以上死亡率的差距都增加，但僅有在65歲以上粗死亡率的分析中達到統計的顯著意義(β=142.2, p=0.000)。而0-4歲死亡率差距雖然在合併之後有稍微縮小，但並未達到統計顯著水準。 結論：本研究無法證實縣市合併對於原縣、市居民間死亡率差距的影響。 關鍵字：都會區治理、縣市合併、死亡率、死亡率差距、hp濾波器Objective: An administrative rezoning occurred in Taiwan in 2010. As a result, three city county duals were consolidated into three new cities: Taichung City, Tainan City, and Kaohsiung City. This study aims to investigate whether the consolidation would reduce the city-county mortality gap. Methods: Data on city/county mortality in total population, children aged 0-4 years, and adults aged 65 years and over, were obtained from Ministry of Health and Welfare. In addition to crude mortality rates, we also calculated age-standardized mortality rates. The Hodrick–Prescott filter was further used to separate long-term trends from time series data. The multiple regression was applied to examine the consolidation effect on mortality rate difference. Results: After the consolidation, the differences in both crude and age-standardized mortality rate between original city and original county have increased for total population and adults aged 65 years and over, but only the effect on the difference in crude mortality rate for adults aged 65 years and over was statistically significant (β=142.2, p=0.000). The difference in mortality rate for children aged 0-4 years has slightly declined after the consolidation, which was not statistically significant. Conclusions: There was no evidence that the consolidations had affected the mortality gap between original city and original county
Exploring the Relationship Between Patient Experiences of Breast Cancer Survivors and Follow-up Care
No full text目的：乳癌五年存活率提升，使得乳癌存活者增加，對癌症追蹤的需求也增加；過去少有研究收集由病人報告的乳癌存活者就醫經驗、癌症追蹤情形。由乳癌存活者觀點出發，藉由調查臺灣乳癌存活者就醫經驗與癌症追蹤情形，以NCCN乳癌追蹤指引符合情形，及以病人觀點探討乳癌存活者，對癌症追蹤照護品質的感受及看法。 方法：本研究問卷整合英國國民保健制度(NHS)的Cancer Patient Experience Survey 2014，以及自美國國家癌症研究院(NCI)的Follow-up Care Use Among Survivors (FOCUS) Survey: SECTION B. Follow-Up Care After Cancer選取13題。收案期間自2015年3月14日至6月30日，與乳癌病友協會以及全台12家醫院合作，以郵寄問卷的方式回收405份癌症病人就醫經驗和癌症追蹤情形。 結果：癌症病人就醫經驗問卷中的「以病人為中心的照護」、「共同決策與治療計畫」兩構面之就醫經驗越正向，與符合NCCN乳癌追蹤指引建議頻率有負向關係；癌症病人就醫經驗問卷中的「以病人為中心的照護」、「及時轉診與治療」、「醫病溝通」、「病程資訊提供」、「心理支持」、「共同決策與治療計畫」、「連續性照護」、「社會福利資訊」以上7個構面之正向經驗，與病人主觀認為的癌症追蹤品質癌症追蹤品質有正向關係。 結論：乳癌存活者多數都有進行癌症追蹤，因此合適的癌症追蹤，對於促進乳癌存活者的健康照護品質相當重要，理想的狀況是能夠由乳癌專科護理師，利用乳癌追蹤指引為每一位乳癌存活者，制定最適化的癌症追蹤，其中包括癌症追蹤頻率。71.27％乳癌存活者主觀認為過去2年的癌症追蹤品質為好，顯示台灣的癌症追蹤照護品質普遍良好。癌症病人就醫經驗問卷中的7個構面，為影響癌症追蹤品質的重要因素；以病人為中心的照護，將有助於提升乳癌存活者的癌症追蹤照護品質。Objective: The five-year survival rate for female breast cancer patients in Taiwan has increased to more than 86% in recent years. Appropriate follow-up care is important for improving the future health of breast cancer survivors (BCSs). This research focuses on findings related to the cancer patients experience survey, the general compliance of breast cancer follow-ups with the NCCN Breast Cancer Guidelines for follow-up care, and BCSs’ perspectives on the quality of their own follow-up care. Methods: This research used the questionnaire from the Cancer Patient Experience Survey (CPES) 2014, a national postal survey of patients with cancer treated in England and section B of the Follow-up Care Use among Survivors (FOCUS) Survey. The survey questionnaire included evaluative questions that covered patient experience along the care pathway of patients with cancer, encompassing experience of presentation, diagnostic testing, treatment decisions, doctor and nurse communication, informational integration between hospital and community services after discharge, experience of chemotherapy and radiotherapy treatment, and outpatient follow-up care. Also, this research was a result of cooperation with both the Taiwan Breast Cancer Association and 12 hospitals in Taiwan. Data was gathered from March 14th to June 30th, 2015, and 405 responses were received by mail. Results: The CPES included two dimension: patient-centered care and shared decision-making and care planning. The more positive these two dimensions were in terms of seeking medical treatments, the lower the likelihood that the treatment met the NCCN breast cancer follow-up frequency guidelines. The seven dimensions of patient-centered care, timely diagnosis and treatment, communication, information and support, emotional support, shared decision-making and care planning, continuity of care and financial and work support also had a positive correlation with the objective quality of the BCSs’ follow-up care. Conclusion: Because most BCSs have cancer follow-up care, providing appropriate follow-up care tailored specifically for each patient and ensuring the frequency of follow-up care are important for improving health outcomes in BCSs. Overall, 71.27% of breast cancer survivors said that their follow-up care was excellent or very good over the past two years, which demonstrates that Taiwan''s cancer follow-up care quality is generally good. The CPES 7 dimensions all are important qualities which affect the standard of follow-up care; thus, a more patient-centered approach will be helpful in improving the overall quality of BCS’s follow-up care
The Local Social Networks and Implementations of Promoting Community Health by A Hospital: A Field Observation in Jinshan, New Taipei City
No full text背景與動機：健康促進(health promotion)是公共衛生界不斷努力的目標。近年來，除了對個人行為介入，也強調社區健康促進所扮演的角色和功能。對醫院而言，渥太華憲章揭示「重新定位健康服務」(reorient health service)的行動綱領，期盼醫療機構自原有疾病診斷與治療，進一步擴增了其健康促進的功能，讓醫療機構(medical care organization)成為名副其實的健康照護組織(health care organization)，肩負在其環境與社區中倡議健康促進與改變的媒介。臺灣政府部門自1999年開始推行社區健康營造， 2012年近一步推動醫院以被保險人健康為目標的論人計酬(capitaion)試辦計畫。這些措施，都導引醫院正視自身在社區健康促進的角色。然而，現階段仍缺乏研究探索醫院在社區健康促進的背景成因，也尚未釐清醫院與社區在健康促進事務上的分工與整合，更缺少對醫院執行健康促進實務的探討。綜合前文所述，本研究之目的有三：（一）瞭解醫院推動社區健康促進的背景與原因；（二）分析醫院在社區健康促進的內容和與社區之整合；及（三）剖析醫院在社區健康促進實務之經驗。 研究方法：本研究以新北市金山區為研究田野。金山區位於北海岸地區，與主要城市相隔，境內僅有國立臺灣大學醫學院附設醫院金山分院一家醫院，其不只承接社區健康促進計畫，更以區域整合模式參與健康保險署論人計酬試辦計畫，使金山成為回答前述問題最適宜的場域所在。本研究以田野研究的方法，透過參與觀察、深度訪談、非正式訪談與檔案分析等方式進行資料收集。 結果：金山分院以承接論人計酬試辦計畫及相關健康促進計畫，獲得政府額外資源挹注，增強其社區健康事務參與的動機。然而資源不充足，且相關規範缺乏整合，限制醫院在社區健康促進的發展。其次，醫院的社區健康促進會受制於地方政治脈絡與社區人際網絡。醫院雖可協助社區內對健康有自覺意識的社群，提供健康專業，以補足社區之不能。但是對於未能覺察自身健康促進需求的社群，則需透過非正式的人際關係奠基，才能獲得資訊，以協助社區民眾健康促進與改善健康問題。此研究結果指出，醫院在社區健康促進實務中，非制度化與非正式化的特質及其結構限制。 結論：本研究透過質化的分析，討論醫院投入社區健康促進的可能原因與限制。醫院－社區的合作與經營，需要人際情感為基礎，顯示合作關係的不確定性與脆弱性。本研究可供臺灣發展醫院為基礎的社區健康促進政策參酌。建議未來研究持續深化醫院社區健康促進實務與理論的對話，以期建構具可行性的醫院－社區整合之健康促進運作模式。Backgrounds: Health promotion is a key of improving the public’s health. In recent years, reorienting health care toward health promotion has been considered as a major challenge for health service providers. The Department of Health started the Building Healthy Communities Program since 1999 and the National Health Insurance Administration also introduced a 3-year pilot capitation payment program which is similar to the accountable care organization in the United States in 2011. With these policy incentives, participating hospitals are encouraged to improve or maintain the health status of their enrollees, and community health promotion approaches are usually adopted. Given this groundwork, the aims of this study are to (1) investigate the backgrounds of promoting health in the community by a hospital; (2) figure out the processes and structures of the hospital-community partnership; and (3) profile the implementation of health promotion tasks by a hospital in the community context. Methods: The National Taiwan University Hospital Jinshan Branch was established in 2010 and it was also the only hospital in the northeast district of Taiwan. After participating in the capitation payment program of the National Health Insurance Administration and health promotion programs led by the Health Promotion Administration, the Jinshan hospital initiated several community-based health programs. This study, a field research, collected data by participant observation, documentary analysis and open-ended interviews with hospital staffs, community residents and relevant stakeholders. Results: The hospital participated in the capitation payment program and health promotion programs for gaining more resources and incentives in order to perform community health services. Nevertheless, scarcity of resources and conflicts among institutions limited the development of the hospital’s community health promotion works. On the other hand, promoting health in the community was also subjected to local social networks. Facing those community groups with high perception of health, the role of the hospital was to provide specialized healthcare services to meet the demands. On the contrary, the hospital had to approach local social networks to learn the needs of community members and assist them in improving or promoting health. The results showed non-institutionalized and informal characteristics of the hospital-community partnership and the structure constrains influenced the hospital''s community-based health promotion implementations. Conclusions: Through qualitative approach, this study observed that the relationship between local community and the hospital is multi-faceted and dynamic. The results also provided first-hand information for future policy formulation. By exploring the real practices of hospitals’ community health promotion works will help develop a proper operation model
Exploring How HIV/AIDS Case Managers Manage Clients and Their Professional Relationship:Take Guiding Clients’ Self-Care as an Example
No full text背景：政府自1997年免費提供三合一高效能抗反轉錄病毒療法（highly active antiretroviral therapy，簡稱HAART，俗稱雞尾酒療法）讓愛滋病毒感染者（以下簡稱感染者）服用後，感染者在規律服藥的情形下，其平均餘命逐年增加，生活型態也與其他慢性病患者無異。近年來感染者面臨多樣且複雜的照顧與資源需求，也期望降低愛滋病毒合併梅毒或C型肝炎的傳染率，感染者的生活就成了公共衛生部門亟需關切與介入的對象。臺灣衛生福利部疾病管制署（以下簡稱疾管署）自2007年起實施愛滋病個案管理計畫（以下簡稱個管計畫），目前已有不少學術研究從結果面（如感染者的生理或健康狀態）來評估此計畫的成效。在此同時我們亦不能忽略個管師作為計畫中的能動者（agent）對感染者的影響。個管師如何從一開始與感染者建立關係，到後續輔導感染者的自我健康管理，都與個管師的技巧以及雙方間的專業關係息息相關。 目的：從微觀互動的層次來探索個管師與感染者互動時的策略或技巧，與既有行為理論中的哪些面向有所呼應。其次，了解雙方間關係的維繫除了理解專業關係如何影響感染者，也可知道該維繫怎麼樣的專業關係才有助於感染者的健康。 方法：本研究為針對個管計畫中個管師與感染者互動情形的探索型研究。我採取深度訪談法來收集研究資料，以滾雪球抽樣（snowball sampling）訪談了13位任職於北部地區愛滋病指定醫院或地方衛生局的愛滋病個管師，與10位居住在臺灣北部地區的感染者。訪談內容由研究者將錄音檔內容聽寫轉錄成逐字稿後，依據Strauss和Corbin（1997）提出的開放性譯碼（open coding）原則來分析資料。 結果：研究主要發現有：（1）個管師（特別是醫療院所）會運用大量的會談技巧來與感染者建立專業關係，初期建立專業關係時主要透過「噓寒問暖」、「開放式問句」、「反映式傾聽」與「建立框架」來獲取感染者的信任，並營造讓感染者願意訴說的環境。（2）在協助感染者行為改變與服用雞尾酒療法方面，個管師多著眼於強化感染者的認知。針對前者採取「利己觀」的立場，並以感染者的免疫或是疾病負擔作為訴求；服用雞尾酒療法則接近既有行為理論中的行為（學習）理論，藉由創造或形塑感染者的前因（antecedent）來讓感染者規律服藥（3）個管師與感染者間的專業關係會因為疾病的性質、藥物的發明等因素，使得專業關係的性質在時、空間、權力關係，以及信任程度面向較為彈性。（4）個管師與感染者間的專業關係會受到信任程度的影響而朝向親近或疏遠化發展。 結論：不論是哪一場域的個管師與感染者互動時都會運用大量的會談技巧，然而不同場域間的技巧純熟度有別，建議未來在個管師任職前應提供相關訓練。個管師在協助感染者提升服藥順從時的策略較為接近行為學習理論，不過感染者身體對藥物的感受或想法仍較少在共同討論藥物時獲得重視。雙方間的專業關係在性質與規範上會隨著互動情形與信任程度而彈性變化，特別是關係疏遠化時彰顯了個管師在個管計畫中的位置與重要性。Background: Since the highly active antiretroviral therapy (HAART, also known as ART: antiretroviral therapy) was introduced and freely provided for people living with HIV/AIDS (PLWH) by the government in 1997. People who take HAART on a regular basis have prolonged their life expectancy, and their lifestyles are similar to patients with other chronic diseases accordingly. Multiple and complex needs of care and resources of PLWH have been concerned and intervened by public health sector, along with the expectation of reducing transmission rates of HIV along with syphilis or hepatitis C virus. The HIV Case Management Program (HIVCMP) has been launched by Centers for Disease Control in Taiwan since January 2007, many research has been done to assess effects of this program’s outcomes (such as physical or health status of PLWHs). Simultaneously, we cannot neglect HIV case managers as important agents in the program and their influence on PLWHs. How HIV case managers establish contact with and assist PLWHs’ self-care management is closely related to HIV case managers'' skills and professional relationship. Objectives: This study is to explore strategies or skills when HIV case managers interact with PLWHs, and to examine behavior theories corresponding to these strategies. Furthermore, understanding how HIV case managers establish contact with PLWHs helps us to comprehend how professional relationship influences PLWHs, and what kind of professional relationship is beneficial for PLWHs’ health. Methods: This study was an exploratory study focusing on situations where HIV case managers and PLWHs interact. Data were collected by in-depth interviews. By means of snowball sampling, 13 case managers working in AIDS assigned hospitals and local health bureaus and 10 PLWHs living in Northern Taiwan were selected and interviewed. The sound-recording interview data were transcribed into verbatim draft and followed by open coding principle proposed by Strauss and Corbin (1997) to analyze data. Results: The main findings of this study as follows: (1) HIV case managers (especially those who work in AIDS assigned hospitals) use a great amount of interview skills to establish professional relationship with PLWHs. The skills of “social conversation”, “open question”, “reflexive listening “, and “providing framework” are used to at the initial stage to earn PLWHs’ trust and create an environment where PLWHs are willing to make self-disclosure. (2) HIV case managers concentrate on strengthening PLWHs’ cognition when assisting PLWHs’ behavior change and use of HAART. In assisting PLWHs’ behavior change, case managers adopt an egoistic-oriented standpoint, along with PLWHs’ immunity or disease burden as argument. HIV case managers create or form PLWHs’ antecedents to help them take HAART, which is similar to behavioral learning perspectives. (3) Due to the characteristics of HIV, the invention and effects of HAART, the professional relationship between HIV case managers and PLWHs is flexible in time, space, power relationship and degree of trust. (4) The professional relationship between HIV case managers and PLWHs becomes more intimate or remote depending on degree of trust in their professional relationship. Conclusion: HIV case managers use a great amount of interview skills in every field. However, the proficiency of skills varies within case managers in different field. Therefore, this research suggests that providing related training before working as a HIV case manager is crucial. The strategies that case managers use when assisting PLWHs’ use of HAART is similar to behavioral learning theory. However, the experience and ideas of PLWHs who take HAART receive less attention when case managers and PLWHs discuss about HAART. The property and norms of professional relationship between HIV case managers and PLWHs vary with interaction and degree of trust between them. When the professional relationship is remote, the importance and role of HIV case managers in the program is especially significant
The Relationship Among Service Quality、Perceived Value、Satisfaction and Loyalty – Example of LASIK Surgery
No full text台灣近視盛行率高，且近視發生的年齡層早，使的許多人從學生時代就開始戴眼鏡來矯正近視的問題，然而配戴眼鏡對日常活動有著許多不便，戴隱形眼鏡則有眼睛易乾澀、衛生感染、過敏的擾人問題。近視雷射手術從20多年前即開始發展，隨著醫療儀器與技術的進步，近視雷射手術的安全性大幅提升，以上種種原因讓選擇近視雷射手術來治療近視的人越來越多。隨著蓬勃發展，眼科醫療產業的競爭也越來越激烈，如何在競爭激烈裡脫穎而出為眼科醫療經營者需思考的課題。 本研究主旨在於探討近視雷射手術術後的服務品質、知覺價值、滿意度與忠誠度的關聯探討。主要研究目的為: (1)不同的顧客特質是否會影響近視雷射手術之知覺價值、滿意度與忠誠度? (2)探討近視雷射手術之服務品質是否會影響顧客的知覺價值? (3)顧客的知覺價值是否會影響顧客之滿意度與忠誠度? 本研究在連鎖眼科門診收集所需資料，以了解民眾對近視雷射手術的術後看法，並以統計軟體SPSS 18.0進行資料處理，運用單因子變異數分析、複迴歸方法來進行資料分析。 其研究結果發現服務品質與知覺價值之間存在著正向關係；知覺價值對滿意度與忠誠度也存在著正向關係；滿意度對忠誠度存在著正向關係。當診所提升服務品質時，知覺價值也會提高，同時也會提高滿意度與忠誠度。本研究之結果可提供相關單位作為未來欲發展眼科相關產業時之參考策略
Associations of Individual Income and Early Rehabilitation with Outcomes for Patients with Ischemic Stroke
No full text研究背景：腦血管疾病為我國第三大主要死因，個人收入、早期復健可能與中風照護結果有關。 研究目的；探討個人收入、中風出院後早期復健與照護結果之關係。 研究方法：本研究使用全民健康保險研究資料庫百萬抽樣承保歸人檔進行分析，以2009年至2011年台灣急性缺血性腦中風出院病人為研究對象，照護結果變項包括一年內再住院及一年內死亡。統計方法以Cox比例風險模式，分析個人收入、出院後早期復健與照護結果之間的相關性，並且控制病患及區域特性。 研究結果：研究樣本數為4150人，個人收入較高，有較低的一年內死亡與再住院的風險，中風出院後早期復健上，有接受早期復健的中風病人，一年內死亡風險較低。針對出院後接受早期復健的病患，於門診復健者，相較於住院復健者，有較低的一年內再住院與死亡風險，除此，在基層診所復健者，相較於醫院復健者，有較高的一年再住院風險。 研究結論：個人收入低、出院後未接受早期復建，與出院後照護結果差有關，再者，於門診復健相較住院復健者，有較佳的照護結果，以及在醫院復健相較診所復健者，有較低的1年再住院風險。Background：Cerebrovascular disease is the third most common cause of death in Taiwan. Personal income and early rehabilitation may be related to the stroke care outcome. Objectives：The objective of this study was to understand the relationship between individual income, early rehabilitation and outcomes after stroke. Method：This study analyzed samples of 1 million beneficiaries of the Longitudinal Health Insurance Database, a data subset of the National Health Insurance Research Database, to investigate discharged patients that experienced an acute ischemic stroke in 2009–2011. The variables affecting the stroke care outcomes included the risks of readmission within 1 year and death within 1 year. Through the Cox proportional hazards model, the correlations among personal income, early rehabilitation, and treatment outcome were determined. The control variables were the patient and local characteristics. Result：The patients with high personal income exhibited low risks of readmission or death within 1 year. The patients receiving early rehabilitation exhibited low risks of death within 1 year. Moreover, the patients receiving outpatient rehabilitation exhibited lower risks of readmission and death within 1 year than did those receiving inpatient rehabilitation, and the patients receiving rehabilitation in primary care clinics demonstrated higher risks of readmission within 1 year than did those receiving rehabilitation in hospitals. Conclusion： The patients with low personal income and without receiving early rehabilitation have poor outcomes after stroke. Moreover, the patients receiving outpatient rehabilitation are better than receiving inpatient rehabilitation, and the patients receiving rehabilitation in hospitals demonstrated lower risks of readmission within 1 year than did those receiving rehabilitation in primary care clinics
Exploring the Association Between Disease-Specific Composite Process Scores and Patient Outcomes in Patients with Acute Myocardial Infarction in Taiwan
No full text前言：為了更廣範及便利地呈現照護流程測量，以及機構間比較的需要，組合測量是一種新的評估照護品質的方法，正大量的被發展及應用。然而，臨床上應用時卻出現了部分缺點。一、不同的組合方式會導致不同的機構排名。二、組合分數和其他構面指標(例如結果)間的關係仍不清楚。 目的：探討病人層級及醫院層級急性心肌梗塞照護流程組合分數和病人短期預後間的關係，並比較不同方法醫院層級組合分數間的關係。最終希望能找出一種最好的組合分數方法能代表醫院在急性心肌梗塞的照護品質。 方法：資料來源為台灣國家健康保險研究資料庫2005年1月1日到2009年12月31日第一次急性心肌梗塞(國際疾病分類代碼，第9版，ICD-9-CM 410.xx，排院410.x2)的病人。組合流程分數是依據六個照護流程指標(包含阿斯匹靈使用，乙型阻斷劑使用，Statin類降血脂藥物使用，左心室功能評估，左心室心輸功能不良病人使用ACEI/ARB類藥物，純藥物治療病人使用Clopidogrel)所完成並分別計算出三種病人層級組合分數(包含病人平均patient average，70%標準，及全有全無All-or-none) 及四種醫院層級組合分數（包含全平均overall average，簡單權重平均simple weighted average，全有全無All-or-none，及因素分析Factor analysis）。預後則選用住院後30天內死亡及出院後30天內再住院。多因子羅吉斯迴歸用來檢驗病人層級組合分數和病人預後間的關係，而醫院層級組合分數和病人預後間的關係則利用多層次階層羅吉斯迴歸完成。 結果：於2006年1月1日至2009年9月30日，分別有31899及25119名病人資料分別用於住院後30天內死亡及出院後30天內再住院分析。全部的病人分佈於19間醫學中心、71間區域醫院及34間地區醫院。三種病人層級組合分數的表現均和病人住院後30天內死亡及出院後30天內再住院有關。全體醫院在四種醫院層級組合分數的表現分別為全平均0.57±0.17，簡單權重平均0.62±0.16，全有全無0.18±0.15，及因素分析0.61±0.17（平均±標準差）。醫院中心在四種組合分數的表現均明顯高於區域及地區醫院。四種組合分數間不論是原始分數或醫院排名上，均高度相關，但不同方法會導致醫院落入不同的等級分類。在多層次分析方面，當病人層級照護品質當成控制變項時，只有區域醫院間，在全平均、簡單權重平均、及因素分析這三種醫院層級組合分數表現較高的醫院，其病人的住院後30天內死亡機率較低。當病人層級組合分數或醫院評鑑層級被當成控制變項時，四種醫院層級組合分數均和病人出院後30天內再住院無關。 結論：醫療服務在價值競爭的觀點上，病人預後是個重要的決定因素。三種病人層級組合分數均能和病人短期預後有關。70%標準在病人層級對和病人預後的關係並不差於全有全無。然而，不同的醫院層級組合分數會導致機構不同的排名，若要在急性心肌梗塞疾病上要使用組合流程分數來當成公開資訊或是論質計酬基礎必須要相當謹慎。進一步發展新的醫院層級組合分數是必須的。Background: Composite quality-of-care measures have been increasingly developed and applied for public reporting and pay-for-performance initiative. However, some defects have been noted when composite measures were applied in a clinical setting. First, different methods of computing composite scores can lead to unfair ranking. Second, the relationship between the composite score and other indicators, such as patient outcomes, remains unclear. Objective: We explored the relationship between composite process scores, at the patient and hospital levels, and short-term patient outcomes and compared the differences types of hospital-level composite score. Ultimately, we intended to determine the composite score that most accurately represents the quality of hospital care for patients with acute myocardial infarction (AMI). Methods: All patients who were admitted for AMI (International Classification of Diseases, Ninth Revision, Clinical Modification 410.xx [excluding 410.x2]) for the first time in Taiwan between January 1, 2005 and December 31, 2009 were identified in the National Health Insurance Research Database. Six process indicators (ie, Aspirin usage, Beta-blocker usage, Statin usage, Left ventricle function evaluation, ACEI/ARB usage on left ventricular systolic dysfunction, and Clopidogrel usage on medical treatment) were used to assemble the composite process scores. Three methods for calculating patient-level composite scores (ie, patient average, 70% standard, and all or none) and 4 methods for calculating hospital-level composite scores (ie, overall average, simple weighted average, all or none, and factor analysis) were employed. The outcomes were 30-day mortality after hospitalization and 30-day all-cause readmission after discharge. Multivariate logistic regression was applied to examine the relationship of the patient outcomes to the patient-level composite process measures. A multilevel hierarchical logistic regression model was applied to examine the relationships between the patient outcomes and factors at the two levels. Results: Between January 1, 2006 and September 31, 2009, we identified 31 899 patients with 30-day mortality and 25 119 patients with all-cause readmission. The patients were distributed among 19 medical centers, 71 regional hospitals, and 34 district hospitals. All 3 patient-level composite scores were inversely related to 30-day mortality and all-cause readmission in the multivariate logistic regression. The mean ± standard deviation was calculated for each method for calculating hospital-level composite scores: overall average (0.57 ± 0.17), simple weighted average (0.62 ± 0.16), all or none (0.18 ± 0.15), and factor analysis (0.61 ± 0.17). The 4 hospital-level composite scores of medical centers were significantly higher than those of the regional and district hospitals. The 4 hospital-level composite scores, including both the raw scores and those determined according to hospital rankings, were highly correlated to each other, but using different methods caused the hospitals to be categorized into different categories. In the multilevel analysis, only the hospital-level composite overall average, simple average, and factor analysis scores for the regional hospitals were inversely associated with patient 30-day mortality when the patient-level quality of care was controlled for. The 4 hospital-level composite scores were not correlated to patient 30-day all-cause readmission when the hospital accreditation level or patient-level quality of care were controlled for. Conclusion: Because of value competition among medical services, patient outcomes are a critical factor. All 3 patient-level composite scores can be used to represent patient-level quality of care related to short-term outcomes for patients with AMI. 70% standard is not inferior to all-or-none in patient-level. The hospital-level composite scores were related to patient outcomes only under certain conditions, and using different composite scoring methods might lead to different rankings. Selecting methods for public reporting or pay-for-performance initiatives for patients with AMI should be considered carefully. Further research on developing new hospital-level composite quality scoring is warranted