第六章 結論與建議
第二節 建議
一、對醫療院所與缺血性腦中風病人之建議
面對缺血性腦中風的患者的當務之急為如何在短時間內讓腦血管再暢通及 恢復正常灌流、穩定病情以及減少併發症，建議醫療院所可以建立一套高效的 臨床路徑(clinical pathway)，針對缺血性腦中風的病人發展最佳的照護管理模 式，以減少醫療照護延遲及資源不必要的浪費，不易因人員的素質差異，影響 到醫療品質的穩定。此外，對於帶有危險因子的病患(例如：吸菸)，醫院也應 制定適合的照護準則(例如：提供戒菸衛教)，以提升病患的照護結果。
病人則可以做好自身的健康管理，例如：定期的健康檢查、控制血壓、控 制血糖、控制血脂肪、規律適度的運動、控制體重、戒菸、飲酒勿過量、保持 情緒穩定、注意保暖、定期就醫以及規則服藥，此外，腦中風相關的危險因 子，如高血壓、糖尿病、高血脂症等，也與遺傳有明顯相關，因此若家族中有 腦中風的患者應更加注意腦中風的影響。
二、對未來研究者的建議
本研究僅以台北市台大總院(醫學中心)的患者為研究對象，研究結果發現 缺血性腦中風患者的30 天內非計畫性再住院，會受前次住院時病人層級照護重 點指標(過程面)的組合分數影響。建議未來除了可以收集不同層級醫院之資料 外，還能與全國性的健康資料(例如：健保資料庫)串連，以獲取更完整的病人 流向資料、用藥種類或持續開藥的狀況，若醫院內的護理師或個管師能對出院 的病患進行追蹤更佳(例如：電話追蹤)，便能詳細的紀錄病人出院後的情況(例 如：服藥規則)。另外，因本研究所使用的 NIHSS 是於病患剛住院時所給予的 評估，跟出院前的NIHSS 可能會有不少差異，建議之後能多看出院時的 NIHSS 或mRS 這兩個變項，也許能從中發現其與非計畫性再住院的關聯性。
此外，在樣本數擴大後，可進一步針對缺血性腦中風的病人特性或醫院特 性作分層分析，探討不同疾病嚴重度、不同年齡層、不同醫院層級別的分組對 於缺血性腦中風病人於前次住院時的照護過程組合分數與30 天內/ 90 天內非計 畫性再住院之影響是否有不同程度上的差異，也能再探討是否有其他因素影響
病人非計畫性再住院。再者，亦可以本研究之經驗為基礎，將觸角伸及出血性 腦中風或其他重要的疾病別，或是針對出院準備服務小組的功能作探討。
三、對衛生主管機關之建議
本研究中發現照護重點指標的組合分數與缺血性腦中風患者的30 天內非計 畫性再住院有關之結論，可提供主管機關界定高風險醫院之參考，對於中風照 護指標達成狀況越不好的醫院能予以輔導、加強監測，以減少患者於出院後30 天內非計畫性再住院的可能。
此外，本研究結果顯示缺血性中風患者注射血栓溶解劑的比率低，可能因 為血栓溶解藥劑在處方上有較高的風險與限制，建議應增加醫療提供者提供此 醫療照護之誘因，研擬更具影響力、更適切之配套措施，也應在醫療品質的指 標中，對於適用施打IV-tPA 的建議時間(3 小時內)及中風嚴重度的範圍應明確 的放入指標計算的定義中。最後建議未來可增加其他重要照護品質指標的規範 (例如：出血性中風的 P4P)，並鼓勵醫院參與相關的品質提升活動。
80
參考文獻
1. 衛生福利部統計處. 民國 104 年死因統計結果分析. 2016 [cited 2016;
Available from:
http://www.mohw.gov.tw/CHT/DOS/Statistic.aspx?f_list_no=312&fod_list_no
=6201.
2. Hsieh, F.-I., et al., Get With The Guidelines-Stroke Performance Indicators:
Surveillance of Stroke Care in the Taiwan Stroke Registry. Get With The Guidelines-Stroke in Taiwan, 2010. 122(11): p. 1116-1123.
3. Statistics, C.N.C.f.H. Deaths and Mortality. Leading Causes of Death 2016 [cited 2017; Available from:
https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf.
4. Mozaffarian, D., et al., Heart Disease and Stroke Statistics—2016 Update : A Report From the American Heart Association. Circulation, 2016. 134(13): p.
e1-e323.
5. Hsieh, F.-I. and H.-Y. Chiou, Stroke: morbidity, risk factors, and care in taiwan. J Stroke, 2014. 16(2): p. 59-64.
6. 衛生福利部. 醫院品質績效量測指標系統與落實品質改善第二階段計畫.
2015 [cited 2016; Available from:
http://www.mohw.gov.tw/MOHW_Upload/doc/%E9%86%AB%E9%99%A2%E
9. Landrum, L. and S. Weinrich, Readmission data for outcomes measurement:
identifying and strengthening the empirical base. Quality Management in Healthcare, 2006. 15(2): p. 83-95.
10. CMS., Measure Methodology. 2016, Centers for Medicare & Medicaid Services.
11. Mittal, M.K., et al., A population-based study for 30-d hospital readmissions after acute ischemic stroke. International Journal of Neuroscience, 2016: p. 1-9.
12. Li, H.-W., M.-C. Yang, and K.-P. Chung, Predictors for readmission of acute ischemic stroke in Taiwan. Journal of the Formosan Medical Association, 2011. 110(10): p. 627-633.
13. Bravata, D.M., et al., Readmission and death after hospitalization for acute ischemic stroke 5-year follow-up in the medicare population. Stroke, 2007.
38(6): p. 1899-1904.
14. Lakshminarayan, K., et al., Five-Year Rehospitalization Outcomes in a Cohort of Patients With Acute Ischemic Stroke Medicare Linkage Study. Stroke, 2011.
42(6): p. 1556-1562.
15. Lin, H.-J., W.-L. Chang, and M.-C. Tseng, Readmission after stroke in a hospital-based registry Risk, etiologies, and risk factors. Neurology, 2011. 76(5): p.
438-443.
16. Kurtz, S.M., et al., Hospital, Patient, and Clinical Factors Influence 30-and 90-Day Readmission After Primary Total Hip Arthroplasty. The Journal of
arthroplasty, 2016.
17. Reeves, D., et al., Combining multiple indicators of clinical quality: an
evaluation of different analytic approaches. Medical care, 2007. 45(6): p. 489-496.
18. 鍾國彪 and 游宗憲, 醫療品質指標發展的挑戰與展望: 我們還能做什麼?
臺灣公共衛生雜誌, 2009. 28(5): p. 345-360.
19. Peterson, E.D., et al., ACCF/AHA 2010 Position Statement on Composite
Measures for Healthcare Performance Assessment. Circulation, 2010. 121(15):
p. 1780-1791.
20. Shahian, D.M., et al., Association of National Hospital Quality Measure adherence with long-term mortality and readmissions. BMJ quality & safety, 2012. 21(4): p. 325-336.
21. Stefan, M.S., et al., Hospital performance measures and 30-day readmission rates. Journal of general internal medicine, 2013. 28(3): p. 377-385.
22. Fan, C.-M., 探討台灣醫院照護流程組合分數和病患預後之關係-以急性心 肌梗塞為例. 臺灣大學健康政策與管理研究所學位論文, 2015: p. 1-201.
23. 莊旺川 病人層級指標資料之分析與運用. 2015.
24. Lichtman, J.H., et al., Predictors of hospital readmission after stroke. Stroke, 2010. 41(11): p. 2525-2533.
25. Rao, A., et al., Systematic review of hospital readmissions in stroke patients.
Stroke Research and Treatment, 2016. 2016.
26. Ashton, C.M., et al., The association between the quality of inpatient care and early readmission. Annals of internal medicine, 1995. 122(6): p. 415-421.
27. Krumholz, H.M., et al., Randomized trial of an education and support intervention to preventreadmission of patients with heart failure. Journal of the American College of Cardiology, 2002. 39(1): p. 83-89.
28. Garcia-Aymerich, J., et al., Effects of an integrated care intervention on risk factors of COPD readmission. Respiratory medicine, 2007. 101(7): p. 1462-1469.
29. Kossovsky, M.P., et al., Unplanned readmissions of patients with congestive heart failure: do they reflect in-hospital quality of care or patient
characteristics? The American journal of medicine, 2000. 109(5): p. 386-390.
30. Burke, J.F., et al., Influence of hospital-level practices on readmission after ischemic stroke. Neurology, 2014. 82(24): p. 2196-2204.
31. NINDS. Stroke: Hope Through Research. 1999 [cited 2016; Available from:
http://www.ninds.nih.gov/disorders/stroke/detail_stroke.htm#1105_1.
32. Fatahzadeh, Mahnaz, and M. Glick, Stroke: epidemiology, classification, risk factors, complications, diagnosis, prevention, and medical and dental management. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 2006. 102(2): p. 180-191.
33. 許立奇. 腦中風的簡介與預後. 2016 [cited 2016; Available from:
82
34. Valery L Feigin, et al., Global and regional burden of stroke during 1990–2010:
findings from the Global Burden of Disease Study 2010. The Lancet, 2014.
383(9913): p. 245-255.
35. 廖建彰, et al., 2000 年台灣腦中風發生率與盛行率的城鄉差異. 2006. 25(3):
p. 223-230.
36. 臺北榮民總醫院腦中風防治中心, 醫護人員腦中風教育手冊. 2004: 臺北
40. Group, H.P.S.C., Heart Protection Study Collaborative Group MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20536 high-risk individuals: a randomised placebo-controlled trial. Lancet, 2002. 360: p. 7-22.
41. Sacco, R.L., et al., Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and
Intervention: The American Academy of Neurology affirms the value of this guideline. Circulation, 2006. 113(10): p. e409-e449.
42. 許擇良, 探討影響長期照護機構腦中風住民復健治療與成效相關因素之 研究, in 高雄醫學大學醫務管理學研究所碩士在職專班學位論文. 2010. p.
1-98.
43. Hou, W.-H., et al., Stroke rehabilitation and risk of mortality: a population-based cohort study stratified by age and gender. Journal of Stroke and Cerebrovascular Diseases, 2015. 24(6): p. 1414-1422.
44. Donabedian, A., Evaluating the quality of medical care. The Milbank memorial fund quarterly, 1966. 44(3): p. 166-206.
45. Lohr, K.N., Medicare: a strategy for quality assurance. Vol. 1. 1990: National Academies Press.
46. Nadzam, D.M., et al., Data-driven performance improvement in health care:
the Joint Commission's Indicator Measurement System (IMSystem). The Joint Commission journal on quality improvement, 1993. 19(11): p. 492-500.
47. AHRQ. About AHRQ. n.d.; Available from:
http://www.ahrq.gov/cpi/about/index.html.
48. NICE. About NICE. n.d.; Available from: https://www.nice.org.uk/.
49. 楊志良, et al., 健康保險. 四版 ed. 2016, 台中: 華格那企業有限公司.
50. 孫穆乾, 中風照護品質指標的發展. 臺灣醫學, 2013. 17(1): p. 76-83.
51. American Heart Association (AHA), American Stroke Association (ASA), and Brain Attack Coalition (BAC) for use by Disease-Specific Care (DSC). Stroke.
2016 [cited 2016; Available from:
https://www.jointcommission.org/stroke/.
52. Genentech USA, I. Stroke Quality Measures Now Reported to CMS. 2016;
Available from: https://www.activase.com/resource-center/cms-stroke-measures.
53. 林啟禎. 論質計酬. 2006 [cited 2017; Available from:
http://ortho.clmed.ncku.edu.tw/~cjlin/othernote/400.html.
54. QOF., 2015/16 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). 2015, BMA , NHS Employers, NHS England.
55. Doran, T., et al., Pay-for-performance programs in family practices in the United Kingdom. New England Journal of Medicine, 2006. 355(4): p. 375-384.
56. general practice quality and outcomes framework(QOF), General practice for quality improvement, and clinical commissioning group(CCG). Standards and Indicators：Stroke and ischaemic attack. n.d. [cited 2016; Available from:
https://www.nice.org.uk/standards-and-indicators.
57. 衛生福利部中央健康保險署., 全民健康保險急診品質提升方案(106.03.01 新增). 2017.
58. 衛生福利部中央健康保險署. 2015-2016 全民健康保險年報. 2015;
Available from:
http://www.nhi.gov.tw/Nhi_E-LibraryPubWeb/CustomPage/P_Detail.aspx?FType=8&CP_ID=153.
59. 胡曉珍, 內科病人非計畫性再住院相關因素探討-以癌症病人為例. 2011.
60. 王本仁. 出國報告(專題研究)：健保支付計畫成效評估方法之研究. 2015 [cited 2016; Available from:
http://www.dgpa.gov.tw/public/Data/68229301571.pdf.
61. Yale New Haven Health Services Corporation (YNHHSC) / Center for Outcomes Research & Evaluation (CORE). 2016 Condition-Specific Measures Updates and Specifications Report Hospital-Level 30-Day Risk-Standardized Readmission Measures. 2016 [cited 2016; Available from:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html.
62. National Health Service (NHS) The rate of unplanned readmissions to hospital.
2010 [cited 2016; Available from:
http://www.nhs.uk/Scorecard/Pages/IndicatorFacts.aspx?MetricId=6&OrgTyp e=5%3Cdiv.
63. Tseng, M.-C. and H.-J. Lin, Readmission after hospitalization for stroke in Taiwan: results from a national sample. Journal of the neurological sciences, 2009. 284(1): p. 52-55.
64. Andrews, A.W., D. Li, and J.K. Freburger, Association of rehabilitation intensity for stroke and risk of hospital readmission. Physical therapy, 2015. 95(12): p.
1660.
65. Marcantonio, E.R., et al., Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. The American journal of medicine, 1999. 107(1): p. 13-17.
66. Hsieh, C.-Y., et al., Stroke severity may predict causes of readmission within one year in patients with first ischemic stroke event. Journal of the
Neurological Sciences, 2016.
67. Bjerkreim, A.T., et al., Causes and Predictors for Hospital Readmission after Ischemic Stroke. Journal of Stroke and Cerebrovascular Diseases, 2015. 24(9):
p. 2095-2101.
68. Chuang, K.-Y., et al., Identifying factors associated with hospital readmissions
84
117-128.
69. Howrey, B.T., Y.-F. Kuo, and J.S. Goodwin, Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke.
Medical care, 2011. 49(8): p. 701.
70. Palmer, W.L., et al., Meeting the ambition of measuring the quality of hospitals' stroke care using routinely collected administrative data: a feasibility study. International journal for quality in health care, 2013: p.
mzt033.
71. Kfoury, A.G., et al., Incremental survival benefit with adherence to
standardized heart failure core measures: a performance evaluation study of 2958 patients. Journal of cardiac failure, 2008. 14(2): p. 95-102.
72. O’Brien, S.M., et al., Exploring the behavior of hospital composite performance measures. Circulation, 2007. 116(25): p. 2969-2975.
73. Chih, Y.-W., A Study of Mutual Fund Performance under Business Cycle in Taiwan. 2001.
74. 國立政治大學. 常用的資料採礦方法. [cited 2017; Available from:
https://nccur.lib.nccu.edu.tw/bitstream/140.119/33896/6/35401406.pdf.
75. 鄭建興, 腦中風的危險因子. 健康世界, 2004(217): p. 87-88.
76. Schlegel, D., et al., Utility of the NIH Stroke Scale as a predictor of hospital disposition. Stroke, 2003. 34(1): p. 134-137.
77. 梁蕙雯. 腦中風之障礙與失能評估量表簡介. 2009 [cited 2017.
78. Hsieh, F.-I., et al., Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke. PloS one, 2016. 11(8): p.
e0160426.
79. Prabhakaran, S., et al., Prehospital triage to primary stroke centers and rate of stroke thrombolysis. JAMA Neurology, 2013. 70(9): p. 1126-1132.
80. 台灣腦中風學會, 靜脈血栓溶解劑治療急性缺血性腦中風指引 2013. [cited 2017; Available from:
http://www.stroke.org.tw/newpaper/2011Mar/paper_2.asp.
83. McPhee, J.T., et al., Risk prediction of 30-day readmission after infrainguinal bypass for critical limb ischemia. Journal of vascular surgery, 2013. 57(6): p.
1481-1488.
84. 黃年富. 抽菸對身體的危害. 2009 [cited 2017; Available from:
http://www.tcmg.com.tw/paper/paper-980501.htm.
85. 周禎穎, 吸菸對心血管的影響. 血管醫學防治季刊, 2012(11): p. 4-5.
86. Goldstein, L.B., et al., Guidelines for the primary prevention of stroke. Stroke, 2011. 42(2): p. 517-584.
87. Meschia, J.F., et al., Guidelines for the primary prevention of stroke. Stroke, 2014. 45(12): p. 3754-3832.
88. Wolf, P.A., R.D. Abbott, and W.B. Kannel, Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke, 1991. 22(8): p. 983-988.
89. Lainay, C., et al., Hospitalization Within the First Year After Stroke. Stroke, 2015. 46(1): p. 190-196.
90. Waldo, A.L., Anticoagulation: stroke prevention in patients with atrial fibrillation. Medical Clinics of North America, 2008. 92(1): p. 143-159.
正本
檔 號：電語：
02-2312-3456轉
66554傳真：
02-2395-1950電子信箱：
ntuhrec@ntuh.gov. tw受文者：國立臺灣大學公衛學F完公共衛生學系董鈺琪副教授 發文日期：中華民國
105年
2月23日
發文字號：校附醫倫字第
1053700931號 逑別：音通件 prospective payments, and hospital strategies with use of medical services and outcomes of care」（本院
案號： 201601056RINB)純學術臨床試驗／研究案，符合簡易 審查條件及研究倫理規範，通過本院B研究倫理委員會審查，
六
、依據赫爾辛基宣言、 世界衛生維織及International
｀
第1頁 共2頁
附 件
doi:10.6342/NTU201701762