目的：本研究旨在分析老年肺炎住院病人的特徵，並評估影響老年肺炎病人出院後非計畫性再入院的相關因素。
方法：本研究採回溯性世代研究設計，收集高雄某區域教學醫院2009年至2010年間341位肺炎住院病人為研究樣本，採用病歷查閱方法建立研究樣本資料檔後，區分為年滿65歲以上組（173人）與未滿65歲組（168人），利用多變項逐步邏輯斯迴歸分析模式，驗證老化因素對於非計畫性再入院的影響，並進一步針對65歲以上的老年肺炎住院病人，在控制各種可能的相關因素之後，篩選出與非計畫性再入院有關的影響因素。
結果：總體樣本341人中，男性190人、女性151人，平均年齡為61.9歲（標準差19.3歲），平均BMI為23.4 kg/m2（標準差4.5 kg/m2），ICD-9診斷碼為486者佔了95.6%，社區型肺炎患者比例達98.8%，入院來源以急診85.3%比例最高，92.7%的樣本入普通病房，總體樣本非計畫性再入院的比例依序為14天/30天9.1%、60天11.7%、90天15.0%，年滿65歲組在各種狀況的再入院率均顯著高於未滿65歲組。與14天再入院率顯著相關得單變項包括年齡、Hb、住院天數、高血壓、其他慢性疾病，將上述因素利用多變項邏輯斯迴歸分析的結果發現，僅有年齡與14天在入院有顯著相關（年滿65歲組14天再入院的粗OR為4.561，調整後OR為2.714，95%CI為1.002-7.353）。利用多變項逐步邏輯斯迴歸分析篩選與非計畫性再入院有關的因素發現，影響14天/30天再入院的因素為年齡（年滿65歲者OR為3.025，95%CI為1.159-7.897）、住院時WBC（高於10750 mm3者OR為2.917，95%CI為1.207-7.075）、住院時Hb（高於12.4 g/dL者OR為0.390，95%CI為0.159-0.953）。排除未滿65歲者後，分析影響老年肺炎病人再入院的因素結果發現，控制年齡因素後，與14天/30天再入院有關的因素為住院時WBC（高於10900 mm3者OR為4.024，95%CI為1.325-12.235）、住院時使用氣管內管（OR為5.084，95%CI為1.257-50.267），與60天再入院有關的因素為住院時使用氣管內管（OR為8.013，95%CI為2.169-29.597）、住院時CRP（高於86.3 mg/dL者OR為3.061，95%CI為1.209-7.753）、住院時Hb（高於12.0 g/dL者OR為0.346，95%CI為0.135-0.887），與90天再入院有關的因素為住院時使用氣管內管（OR為4.937，95%CI為1.411-17.278）、住院時Hb（高於12.0 g/dL者OR為0.399，95%CI為0.176-0.906）、住院時CRP（高於86.3 mg/dL者OR為2.369，95%CI為1.062-5.284）。
結論：肺炎病人的出院後非計畫性再入院情形的發生，與年齡老化的因素有強烈的相關性，建議醫療照護品質指標應進行調整後再行比較。影響老年肺炎病人非計畫性再入院的因素在本研究中篩選出住院時氣管內管的使用（與各項再入院狀況均有關）及住院時WBC（與14天、30天再入院率有關）、住院時CRP（與60天、90天再入院率有關）、住院時Hb（與60天、90天再入院率有關）等生理測量指標，國內針對肺炎住院病人再入院率相關影響因素以及鎖定老年肺炎病人所進行的實證研究並正式發表在國際學術期刊者不多，本研究的發現將有其參考價值。

Objectives: This Study wanted to analysis the characteristics of the elder adult who had hospitalized with pneumonia. We also evaluated the factors that will affect the unexpected readmission in elderly pneumonia patients.
Methods: This is a retrospective cohort study design. The study data was collected 341 pneumonia patients who have hospitalized in a general teaching hospital in Kaohsiung city from year 2009 to 2010. The study population was divided into two groups, the sample size of the old group (age >= 65yrs), and the young group (age < 65yrs) was 173 and 168, respectively. The methods of stepwise multiple logistic regressions were needed to evaluate the association between aging and different days of unplanned readmission in adult pneumonia patients.
Results: All the 341 adult pneumonia patients, we found 613 male and 926 female. The demography characteristic of the study subjects, the means of age was 61.9yrs (s.d. = 19.3yrs), and BMI was 23.4 kg/m2 (s.d. = 4.5 kg/m2). The percentage of ICD-9-CM that code 486 was 95.6%. Most patients were community-acquired pneumonia (98.8%), hospitalized from emergency room (85.3%), and admission in general wards (92.7%). The unplanned readmission within 14/30 days, 60 days, and 90days were 9.1%, 11.7%, and 15.0%, respectively. The significant factors that were associated with readmission within 14 days include age, Hb, hospitalized days, hypertension, and other disease. When we used the multiple logistic regression analysis to adjust the other variables, only age still significant with readmission within 14 days (the crude OR of the old group was 4.561, adjusted OR was 2.714, 95% CI of OR from 1.002 to 7.353). In the stepwise multiple logistic regression models, the variable that was associated with readmission with 14 or 30 days were age (>= 65yrs, OR = 3.025), WBC (>=10750 mm3, OR=2.917), and Hb (>=12.4 g/dL, OR=0.390). We remain the elderly subjects to evaluate the factor that will influence readmission states. In all the stepwise logistic regression models, we found the experience with used endotracheal tube in the hospitalized period were the significant increases the readmission rate within 14 or 30 days, 60 days, and 90 days.
Conclusion: In our study shows that the situations of unexpected readmission in pneumonia patients were strong association with aging. We suggest that the indicator of medical quality should be adjusted before we comparison the readmission rate in the different institute. The major factors that will be associated to affect the readmission states were endotracheal tube used (significant with 14 or 30 days readmission rate), CRP level (significant with 60 days and 90 days readmission rate), and Hb level (significant with 60 days and 90 days readmission rate).

論文審定書----------------------------------------------------------------------------i
誌謝--------------------------------------------------------------------------------------ii
中文摘要--------------------------------------------------------------------------------iii
英文摘要--------------------------------------------------------------------------------v
內文目錄--------------------------------------------------------------------------------vii
表次--------------------------------------------------------------------------------------viii
圖次--------------------------------------------------------------------------------------ix

第一章 緒論--------------------------------------------------------------------------1
第一節 研究背景-----------------------------------------------------------------1
第二節 研究目的-----------------------------------------------------------------7

第二章 文獻探討--------------------------------------------------------------------8
第一節 肺炎的類型--------------------------------------------------------------8
第二節 台灣老年人肺炎醫療利用趨勢--------------------------------------16
第三節 老化與疾病再入院的關連--------------------------------------------22

第三章 材料與方法-----------------------------------------------------------------26
第一節 研究設計與研究架構--------------------------------------------------26
第二節 研究對象與資料來源--------------------------------------------------27
第三節 研究變項操作型定義--------------------------------------------------28
第四節 資料處理及統計分析--------------------------------------------------31

第四章 研究結果--------------------------------------------------------------------34
第一節 基本資料分析-----------------------------------------------------------34
第二節 肺炎再入院單因子相關分析-----------------------------------------45
第三節 肺炎再入院多變項邏輯斯迴歸分析--------------------------------53
第四節 老年肺炎住院病人再住院多變項危險因子分析-----------------61

第五章 討論與建議-----------------------------------------------------------------65
第一節 研究樣本的代表性及肺炎病人再入院率與醫療品質評析-----65
第二節 老化因素與肺炎病人非計畫性再入院的關連--------------------70
第三節 影響老年肺炎病人再入院的其他因素-----------------------------75
第四節 結論與建議--------------------------------------------------------------79

參考文獻--------------------------------------------------------------------------------81

作者簡歷--------------------------------------------------------------------------------90

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