外傷一直是十大死因之一。根據內政部統計年報，在台灣108年度11月65歲以上老人占總人口比率為15.21%。老人在台灣有越來越多的趨勢。這將會影響醫療的花費。
目前台灣中央健保署實施住院診斷關聯群支付制度(diagnosis-related group)。此制度為一種病一個給付費用。就外傷病人來說，只有針對受傷部位及種類分類，並沒有將年紀考量進去。而老人外傷理論上是有較差預後。本研究的目的是，探討老年人外傷的預後和其醫療資源使用分析。
本研究收集南部某醫學中心外傷登錄資料庫，自民國 104 年 1 月 1 日起至 106 年 12 月31 日止，分析資料期間共計三年。經外傷初步處置後住院共 6,246 位病患。排去資料闕漏個案以及小於 18 歲 病患後，共有5,185名病人。其中老人為1,743人。收集各變項使用t檢定、卡方檢定、單因子變異數分析、二元邏輯迴歸分析分析各變項對醫療資源之影響。
研究結果顯示，老年病人以女性較多，年輕病人則男性佔多數。以受傷機轉來說，老年人以鈍傷為主，其中以跌落最多。老年人平均住院天數較多。每人平均健保花費，老年病人較多。老年病人併發症機會較多，死亡率較高。以老人來說，死亡率會受年齡、GCS、外傷嚴重度分數≥16 、併發症、手術、到院低血壓等因素影響。併發症會受總住院天數、24小時輸紅血球、死亡等因素影響。總花費會受外傷嚴重度分數、住院天數、加護病房住院天數、手術、死亡、外傷嚴重度分數≥16、24小時輸紅血球、外觀簡易外傷分數≥3等因素影響。健保花費會受外傷嚴重度分數、住院天數、加護病房住院天數、手術、死亡、頭頸部簡易外傷分數≥3、胸部簡易外傷分數≥3、外觀簡易外傷分數≥3等因素影響。住院天數會受GCS、併發症、頭頸部簡易外傷分數≥3、外觀簡易外傷分數≥3、機轉為車禍等因素影響。加護病房住院天數會受GCS、併發症、手術、外觀簡易外傷分數≥3，加護病房住院天數院等因素影響。
我們的建議如下: 1.以老人外傷來說，其所需醫療費用相對於年輕人來說是較高的。建議相關單位在制定外傷給付相關政策時應將年紀考慮進去。2. 根據我們的研究結果，要降低醫療資源耗用可以從降低住院天數以及降低外傷嚴重度著手。降低外傷嚴重度部分可以考慮如何避免傷害或是降低傷害。像是限制老人駕照問題，降低違規駕駛行為。降低住院天數可以考慮下列方式:像是嚴重老人病患可以提早和家屬溝通預立不急救同意書。應藉由教育方式，教育大眾末期病人避免無效醫療。在老人外傷住院期間採取積極作為避免併發症發生。

Trauma has always been one of the top ten causes of death. According to the yearly statistics of the Ministry of the Interior of Taiwan, the proportion of adults over 65 years old was 15.21% in November 2019. This proportion is increasing in Taiwan. Furthermore, this population will affect the costs of medical care. At present, the National Health Insurance Administration Ministry of Health and Welfare in Taiwan implements the hospitalization diagnosis-related group payment system. For trauma patients, only the injury site and type are classified; age is not considered. Trauma in the elderly is theoretically a poor prognosis. The purpose of this study was to investigate the prognosis and use of medical resources for geriatric trauma.
In this study, the trauma registry database and National Health Insurance claim data of a Level I trauma center in southern Taiwan were used to retrospectively analyze all cases admitted after visiting the emergency room (ER) between January 2015 and December 2017. Besides cases that excluded missing data, 5,185 patients matched the study criteria; of these, 1,743 patients were elderly. At first, we compared the difference in medical resource usage for younger and elderly patients. Relevant factors such as character, trauma condition, and management were examined to investigate differences in mortality, complications, length of hospitalization, length of stay in the intensive care unit (ICU), and medical expenses.
The results showed that more elderly patients were women, and they tended to have more blunt injuries than younger patients. Accidental falls were the primary causes of medical situations involving the elderly. The length of a hospital stay (LOS) was longer for elderly patients than for other groups, incurring more National Health Insurance (NHI) costs, more complications, and a higher mortality rate compared with younger patients. There were significant differences among elderly patients who died while hospitalized, including cause of death, age, assessment of the Glasgow Coma Scale (GCS), an Injury Severity Score (ISS) ≥ 16, a need for blood transfusion(s) with packed red blood cells within the first 24 hours of admission, complications, surgery during hospitalization, and shock while in the emergency department. For elderly patients who had complications, there were significant differences in LOS, the need for blood transfusion(s) with packed red blood cells within the first 24 hours of admission, and even death. The elderly patients whose medical situations incurred higher total costs had significant differences in ISS, LOS, LOS in ICU, a need for blood transfusion(s) with packed red blood cells within the first 24 hours of admission, and surgery. For elderly patients whose medical situations resulted in higher costs for National Health Care Insurance, there were significant differences in ISS scores, LOS, LOS in ICU, surgery, death, and scores on the Abbreviated Injury Scale (AIS) of the head and neck ≥ 3, AIS of the thorax ≥ 3, and AIS of the external area ≥ 3. For elderly patients with longer LOS, there were significant differences in the GCS score, complications, AIS of head and neck score ≥ 3, score on AIS of the external area ≥ 3, and traffic accidents. Elderly patients who had a longer LOS in ICU had significant differences in GCS scores, complications, surgery, and scores on the AIS of the external area ≥ 3.
We suggest that NHI take age into account when formulating policies related to payments for trauma patients. To reduce the consumption of medical resources, the LOS and severity of trauma can be reduced. Consideration should be given on how to prevent injury or reduce injury severity among the elderly; ideas include restricting certain elderly people from the issuance of driver’s licenses and reducing illegal driving behaviors. To reduce LOS in the hospital, we can communicate with families to preestablish a Do Not Resuscitate order. More public education on end-of-life care is also needed. Further, we should take active measures to prevent complications during the hospitalization of elderly patients.

論文審定書……………………………………………………………i
誌謝……………………………………………………………………ii
中文摘要………………………………………………………………iii
英文摘要………………………………………………………………iv
目錄………………………………………………………………………v
表次………………………………………………………………………vi
第 一 章 緒論………………………………………………………1
第一節 研究背景及動機………………………………………1
第二節 研究目的………………………………………………1
第 二 章 文獻查證…………………………………………………3
第一節 台灣外傷概況…………………………………………3
第二節 外傷嚴重度分數定義……………………………………3
第三節 老人外傷定義……………………………………………4
第四節 老人外傷病人醫療資源使用…………………………5
第 三 章 研究方法……………………………………………………11
第一節 研究假設與架構………………………………………11
第二節 資料來源與收集程序…………………………………11
第三節 研究變項的操作型定義…………………………12
第四節 資料處理與分析方法………………………………15
第 四 章 研究分析與結果………………………………………16
第一節 描述性統計分析…………………………………………16
第二節 影響老年外傷病人死亡率因素之分析………………… 21
第三節 影響老年外傷病人併發症因素之分析…………………25
第四節 醫療資源使用與病人年紀及其他因素關係之分
析…………………………………………………… 28
第五節 研究結果摘要…………………………………………49
第 五 章 討論與建議……………………………………………… 53
第一節 研究討論………………………………………………53
第二節 研究限制………………………………………………… 58
第三節 建議…………………………………………………… 59
第四節 研究貢獻…………………………………………………60
參考文獻……………………………………………………………61

中文文獻
碩士論文
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