行政院國家科學委員會專題研究計畫 成果報告
初次缺血性腦中風病人住院醫療成效研究
計畫類別： 個別型計畫 計畫編號： NSC93-2416-H-110-031- 執行期間： 93 年 08 月 01 日至 94 年 07 月 31 日 執行單位： 國立中山大學企業管理學系(所) 計畫主持人： 曾美君 共同主持人： 張谷州，林慧娟 報告類型： 精簡報告 報告附件： 出席國際會議研究心得報告及發表論文 處理方式： 本計畫可公開查詢中 華 民 國 94 年 7 月 22 日
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初次缺血性腦中風病人住院醫療成效研究
中文摘要 過去二十年來，腦血管疾病一直高居我國十大死因之第二位；而超過七成的腦血管疾病 是屬於缺血性腦中風。腦中風往往需要昂貴的重症加護醫療、長期照護與復健，對病患、 病患家屬以及整體社會產生很大的影響。由於臺灣已經邁入世界衛生組織所謂的「高齡 化社會」，腦血管疾病罹病比例預期會持續增加，相關的醫療與長期照護需求亦將遽增。 腦中風醫療管理的重要性不容忽視。 在1996 年美國核准將靜脈血栓溶解劑（簡稱 rtPA）使用於治療缺血性腦中風之前，缺 血性腦中風並沒有真正有效的藥物治療。歐盟各國在2002 年核准該藥物後，我國衛生 署亦於2002 年 11 月核可使用。面對急性缺血性腦中風的治療進入新紀元的此刻，我們 對當前國內腦中風照護情況以及住院醫療成效與品質卻一無所知。本研究藉由探討初次 缺血性腦中風病患住院就診的醫療成效，填補腦中風醫療管理研究之不足，提供後續標 竿管理（benchmarking）的基本資料和資訊。研究中同時探討以入院當時之腦中風嚴重 度作為預測急性期中風之恢復程度之可行性，並分析年齡與急性期中風之恢復程度的關 聯。 關鍵詞：醫療成效研究、缺血性腦中風、中風嚴重度、急性期住院 AbstractStroke has been the second leading cause of death in Taiwan since 1983, with ischemic stroke accounting for about 70%. Stroke, requiring costly acute hospitalization care and
continuing inpatient/outpatient rehabilitation, consequently has a significant social and economic impact on patients, their families, and society as a whole. With an aging population, the number of strokes is projected to increase. That is to say, the enormous burden of stroke is likely to increase further in the future. Health care research is clearly warranted for a disease like stroke.
Little treatment existed for ischemic stroke until 1996, when the use of recombinant tissue plasminogen activator (rtPA) for the treatment of patients with acute stroke got approved in the United States. Following the approval granted by the European Union in 2002, the use of rtPA in patients with acute stroke becomes legitimately available in Taiwan after
November 2002. At the turning point in the acute stroke health care, however, little is known about the status quo of acute stroke care and quality of diagnosis and therapy. The
purpose of this study is to fill this gap by analyzing the treatment outcome of acute
hospitalization in patients with first-ever ischemic stroke. Through this observational study, we are able to provide a benchmark for the recovery outcome of acute hospitalization of patients with first-ever ischemic stroke. In addition, we identify the extent of stroke severity on admission to be predictive of outcome of acute hospitalization, and to clarify the
relationships between patient age and early recovery outcome.
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The main results of this study are summarized as follows.
Tseng MC., Chang KC (2005), “Acute Care of First-Ever Ischemic Stoke in Taiwan: Outcomes and Implications for Healthcare Resource Utilization,” presented at the 2005 iHEA World Congress in Barcelona, Spain.
Background and Purpose - To evaluate the effectiveness and the utilization of healthcare
resource of acute care in first-ever ischemic stroke.
Methods – A prospective study of 368 first-ever ischemic stroke patients consecutively
admitted to a medical center in Taiwan was conducted. Neurologic improvement was defined as an improvement of the NIH Stroke Scale (NIHSS) by ≥4 points or NIHSS ≤1 at discharge. Good functional outcome was defined as modified Barthel Index (BI) ≥19 (20=normal) at discharge. We analyzed the data using univariate methods and a logistic regression with the dependent variable of neurological improvement and good functional outcome, respectively.
Results - Of 360 patients (mean age, 64.9±12.5 years; 43% women; median NIHSS, 6;
median LOS, 7 days; median costs per patient, US$841), neurological improvement was observed in 150 (42%) patients, and good functional outcome in 126 (35%). Patients with neurologic improvement had shorter LOS (median, 6 vs. 8 days, P=0.017) and lower hospital charges (median, US$769 vs. $872, P=0.056), so did patients with good functional outcome (median, 5 vs. 9 days, P<0.001; US$639 vs. $1,050, P<0.001). In multivariable models, age (odds ratio [OR] = 0.97 per year; 95% CI, 0.95 to 0.99) and initial BI (OR = 1.08 per point; 95% CI, 1.02 to 1.15) were significantly associated with neurological improvement, while age (OR = 0.97 per year; 95% CI, 0.95 to 1.00), initial NIHSS (OR = 0.86 per point; 95% CI, 0.77 to 0.95) and initial BI (OR = 1.22 per point, 95% CI 1.12 to 1.33) were significantly associated with good functional outcome.
Conclusions - This study reported clinical outcomes and the extent of effectiveness of acute
care for first-ever ischemic stroke.
Chang KC, Tseng MC, Tan TY, YH, Liou CW (2005), Acute Hospitalization for First-Ever Ischemic Stroke — What Are the Data for Outcome at Discharge?
Background and purpose - Evaluating the potential utility of acute hospitalization after stroke
is valuable, but difficult. We sought to explore the outcomes of first-ever ischemic stroke patients during acute hospitalization, in terms of changes of neurological deficits and functional status during the period.
Methods - Data of first-ever ischemic stroke patients were prospectively collected. Patients
whose NIH Stroke Scale (NIHSS) score at discharge was ≥4 points less than at admission or was 0-1 were classified as neurologically improved, within 3 points of baseline was
considered neurologically unchanged, and ≥4 additional points or death was rated as neurological worsened. Our primary analysis regarding functional outcome, measured by Barthel Index (BI), at discharge was based on three categories: good (BI ≥95), moderate (60-90), and poor (0-55 or dead). We also explored the extent of change in BI over the period of acute hospitalization.
Results - There were 207 men and 153 women with mean age 64.9 ± 12.5 years. Mean
score of the initial NIHSS was 9.4 ± 9.4 (median 6.0). Median score of the initial BI was 60. Median length of stay was 7 days (mean 11 ± 14). In-hospital death was 8%. Overall,
41.7% of patients improved on the NIHSS, 41.4% remained unchanged, and 17% worsened or died during acute hospitalization. Good functional outcome was seen in 35% patients, moderate in 26.9%, and poor in 30.3%. Patients admitted with severe stroke seldom had good or moderate functional outcome at discharge.
Conclusions - Based on data from daily practice, our study provides a reference for recovery
of acute care of ischemic stroke, and may offer the fundamental step of evaluating the effectiveness of acute hospitalization of stroke patients.
曾美君、張谷州、林慧娟（付梓中），「短暫性腦缺血發作(TIA)之迷思」，台灣醫界。 摘要：陣發性腦缺血（transient ischemic attack，以下簡稱 TIA），一般又譯為「暫時性
腦缺血」或「短暫性腦缺血」，是一個使用久遠的神經學名詞；字面上容易引起不正確
的觀念聯想，誤以為TIA 是指「前兆」、「警訊」、「差一點就中風」，或誤以為 TIA 是指
「還沒中風」。這種似是而非的觀念，亟待針對一般民眾，醫療工作人員，甚至是腦中
風治療相關人員澄清。本文透過整理近年來國內外有關TIA 的研究，旨在釐清 TIA 這
個名稱與定義所可能引發的誤解，冀望能協助醫界建立正確觀念。
Self-Evaluation of the study
To the best of our knowledge, this was the first study in Taiwan to explore outcomes of acute care in patients with first-ever ischemic stroke. Our analysis therefore provides valuable information to healthcare decision-makers regarding clinical outcomes of acute
hospitalization of first-ever ischemic stroke. However, a great many things in outcomes and effectiveness research of stroke remain to be done so as to guide multiple healthcare
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