骨骼肌肉系統的肢體創傷是「重大外傷」中常見的傷害，也是重大外傷病患最常接受手術的原因，之前文獻顯示此類患者雖然死亡率較其他重大外傷患者為低，但常留存肢體部分後遺症。且國內外並未有研究針對此類族群的醫療資源使用情形作分析討論。
本研究使用南部地區某外傷中心暨醫學中心之外傷登錄資料庫與醫院向健保署申報資料，回溯性統計自民國104年1月1日起至105年12月31日所有急診外傷就診後住院病人，經排除資料缺漏部分後，符合重大外傷定義者共400人，其中合併有骨骼肌肉系統肢體創傷者有179人。首先比較有無肢體創傷對重大外傷患者的醫療資源使用差異，再進一步針對合併肢體創傷的重大外傷患者之所有病患特性、傷害處置、與傷害情況等相關因素，加以分析其呼吸器使用日數、加護病房住院日數、住院日數及醫療費用之差異。
結果發現，合併肢體創傷者進行手術的次數約為沒有肢體創傷者的兩倍，且急診費用和醫療總費用也都較高。進一步分析住院之重大外傷合併肢體創傷的病人，大多以男性為主，平均47.9歲，受傷機轉八成為車禍，四成由外院轉入。肢體外傷部位以上肢最多佔41.3%，而56.4%多為單一部位肢體創傷，肢體外傷嚴重度分數約一半為AIS＝2分，兩成是開放性骨折，發生併發症比率為6.7%，死亡率佔6.1%。八成病人有接受高階影像學檢查，約三分之一的病人有接受輸血，80％有進行手術治療。平均呼吸器使用天數為12.3日，住院日數是20.1日，平均加護病房住院日數8.6日，平均每次醫療費用總共需新台幣301,001.4元，其中急診費用平均為29,747.8元，住院花費平均為289,439.8元。影響呼吸器使用日數的相關因素為性別、住院死亡和合併併發症；影響住院天數之因素為住院死亡、接受手術和合併併發症；而影響加護病房天數者則是性別、合併併發症、和輸血等。影響總費用的因素為性別、住院死亡、輸血和接受手術等； 影響住院費用為性別、住院死亡、合併併發症、輸血和接受手術；影響急診費用有年齡、到院方式、肢體外傷部位總數、肢體外傷之部位、開放性骨折、輸血、高階影像學檢查和手術等多項因素。在各項相關因素中，以性別、住院死亡、有無併發症、是否輸血、以及是否曾經接受手術處置對醫療資源使用的影響較大。
本研究建議應整合建置全國性統一之外傷登錄資料庫，並加入健保申報費用及自費項目等變項，以利後續更深入及大規模之研究。政策面在考慮將重大外傷納入DRG支付制度時，應適當調整重大外傷同時合併骨骼肌肉系統創傷案件之給付，讓醫療資源的分配更加符合實務狀況，並將併發症列為外傷照護的品管指標之一，以樽節資源耗用。

Musculoskeletal limb injury is the common injury in “major trauma”and also the most common cause for patients of major trauma to receive operation. The previous studies indicated that the mortality rate of this group is lower, but often combined with comorbidity in extremities. In addition, previous researches did not focus on the usage of medical resources for this kind of group.
This study uses the trauma registry database and the National Health Insurance claim data of a level I trauma center in southern Taiwan to retrospectively analyze all the cases admitted after visiting ER between January 2015 and December 2016. Within the cases which excluded the missing data, 400 matched the criteria of major trauma, and 179 of them combined with limb musculosteletal injury. At first, we compared the difference of medical resource usage between cases with and without musculoskeletal limb injury. Furthermore, relevant factors such as characters, trauma conditions and management were examined to investigate the differences in length of ventilator use, hospital length of stay, ICU length of stay and medical expenses in those who with limb injury.
The results showed that those with limb trauma received around 2 times more operations than those who without limb trauma, as their ER cost and total cost are also higher. Further analysis revealed that these major trauma patients with limb injury are primarily male averaged 47.9 years old. 80% of the mechanism is traffic accidents, and 40% of the patients were transferred from other hospitals. The most common injury site is upper limb (41.3%), as 56.4% is single site limb injury. Half of these cases were measured as AIS=2 in extremity, and 20% is open fracture. The complication rate is 6.7%, and mortality rate is 6.1 %. 80% of the patients had ever received advanced image exams, 1/3 received blood transfusion, and 80% underwent surgical intervention. The average length of ventilator use is 12.3 days, length of hospital stay is 20.1 days, and the ICU stay is 8.6 days. The average cost for whole course is NT$ 301,001.4, in which emergency medical fee is NT$ 29,747.8, and the average cost for per admission is NT$ 289,439.8. Relevant factors that influenced the length of ventilator use include gender, hospital mortality, and complications; the factors influenced hospital stays are death during hospitalization, operations and complications; factors affect ICU stay are gender, complications, and blood transfusion. Factors with influence on total cost are gender, hospital mortality, tansfusion and operations. Factors relate to hospital cost include gender, death, complications, transfusion and operations. Besides, numerous factors affect emergency fees, including age, transferred from other hospital or not, amount of limb injury, limb injury sites, open fractures, tansfusion, and advanced image study. Among all the factors, gender, hospital mortality, complications, transfusion and operation impact medical resource usage significantly.
Our research suggests that Taiwan government should set up nationwide integrated trauma registry database, and the items should include health insurance claim fee and self-pay cost which would benefit further and larger scale researches. For policy consideration, the fee for such cases of major trauma combined with musculoskeletal injury should be adjusted appropriately in order to more compatibly align the distribution of medical resource with the clinical conditions. For the clinical care, complications rate shoulde be considered as part of the quality index for trauma care so as to mitigate the unnecessary cost.

論文審定書 ………………………………………………………………………….. i
誌謝 ………………………………………………………………………………….. ii
中文摘要 …………………………………………………………………………….. iii
英文摘要 …………………………………………………………………………….. v
目 錄 ………………………………………………………………………………. vii
表 次 .. …………………………………………………………………………….. ix
圖 次 ……………………………………………………………………………….. x
第一章 緒論 ………………………………………..……………………………… 1
第一節 研究背景及動機 ………………………………………………………. 1
第二節 研究目的 ………………………………………………………………. 3
第二章 文獻查證 ………………………………………………………………….. 4
第一節 重大創傷 ………………………………………………………………. 4
第二節 重大外傷中的骨骼肌肉系統肢體創傷…………………………………. 9
第三節 重大外傷之醫療資源耗用………………………………………………. 10
第三章 研究方法 ………………………………………………………………….. 18
第一節 研究假設與架構 ………………………………………………………. 18
第二節 資料來源與收集程序……………………………………………………. 22
第三節 研究變項的操作型定義………………………………………………... 25
第四節 資料處理與分析方法 …………………………………………………. 30
第四章 研究結果 ………………………………….……………………………….. 31
第一節 描述性統計分析 ………………………………………………………. 31
第二節 是否存在肢體創傷對醫療資源使用之分析……………………………. 38
第三節 病人特性與醫療資源利用之討論..…………………………..…………. 40
第四節 創傷情況與醫療資源使用之分析……………………..………………... 44
第五節 創傷處置與醫療資源使用之分析……………………. ………………. 55
第六節 研究結果摘要…………………………………………..………………... 58

第五章 討論與建議 ……………………………………………………………….. 60
第一節 研究討論 ………………………………………………………………. 60
第二節 研究限制 ………………………………………………………………. 68
第三節 建議 ……………………………………………………………………. 70
第四節 研究貢獻 ………………………………………………………………. 72
參考文獻 …………………………………………………………………………….. 73
一、中文文獻 ………………………………………………………………….. 73
二、英文文獻 ………………………………………………………………….. 74

中文文獻：

李卓倫、陳瑞杰、陳文意、梁亞文、陳慈純（2010）。中台灣嚴重外傷病患死亡率相關因素探討：對外傷登錄與外傷體系之意涵。醫護科技期刊，12(2)，96-108。
李卓倫、陳瑞杰、陳文意、梁亞文、陳慈純（2010）。嚴重外傷存活病患的失能影響因素。臺灣公共衛生雜誌，29(6)，518-527。
陳瑞杰（2003）。探討台灣外傷系統之設計-資料探勘分析法於健康資料庫之應用（碩士論文）。取自台灣碩博士論文知識加值系統。（系統編號 091TMC00674017）
黃勝堅、曹昭懿(2003)。台灣地區外傷事故之健保醫療費用分析:西元 1996~1999 年。台灣醫學，7，861-870。
黃睦舜、繆珣、李建賢（2000）。創傷登錄的實施及其重要性。榮總護理，17(2)，
119-124。
蔡卓城、陳瑞杰、蔡維謀、蔡宛真、謝屈平、劉永弘、邱文達（2003）。使用外傷登錄探討台灣都會地區之傷害型態：以六所醫院為例。中華民國急救加護醫學會雜誌，14(2)，47-56。
盧怡吟 (2012)。重大外傷住院病人之醫療資源使用分析－以南部某醫學中心為例。（未出版之碩士論文）。國立中山大學企管系醫管所。高雄市。
簡立建 (2005)。肝脾損傷住院病患之醫療資源耗用分析 （碩士論文）。取自台灣碩博士論文知識加值系統。（系統編號 093ISU05121117）

網頁資料
衛生福利部（2016）。105 年死因統計結果分析。取自衛生福利部檢附105年死因統計結果分析(含參考附表) 。2016-11-03取自https://www.mohw.gov.tw/cp-16-33598-1.html
衛生福利部統計處(2016)。105 年全民健康保險醫療統計年報。 2016-11-03
取自https://dep.mohw.gov.tw/DOS/np-3717-113.html

二、 英文文獻：
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Boyd, D. R., Rappaport, D. M., Marbarger, J. P., Baker, R. J., & Nyhus, L. M. (1971). Computerized trauma registry: a new method for categorizing physical injury. Aerospace medicine, 42(6), 607-615.
Banerjee, M. (2013) Epidemiology of extremity injuries in multiple trauma patients Injury, Int. J. Care Injured 44 ,1015–1021
Celso, B., Tepas, J., Langland-Orban, B., Pracht, E., Papa, L., Lottenberg, L., & Flint, L. (2006). A Systematic Review and Meta-Analysis Comparing Outcome of Severely Injured Patients Treated in Trauma Centers Following the Establishment of Trauma Systems. The Journal of Trauma and Acute Care Surgery, 60(2), 371-378.
Gallay SH, Hupel TM, Beaton DE, Schemitsch EH, McKee MD. (1998) Functional outcome of acromioclavicular joint injury in polytrauma patients. J Orthop Trauma 12,159–163.
Horst, K. (2015) Detecting severe injuries of the upper body in multiple trauma patients Journal of Surgical Research 199, 2, 629-634
Hemmila MR, Jakubus JL, Maggio PM, et al. (2008). "Real money: complications and hospital costs in trauma patients". Surgery. 144 ,2,307–316.
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National Association of Emergency Medical Technicians (NAEMT), (2010). Prehospital trauma life support
O'Keefe, G. E., Jurkovich, G. J., Copass, M., & Maier, R. V. (1999). Ten-year trend in survival and resource utilization at a level I trauma center. Annal of Surgery, 229(3), 409-415.
Pape H.C., Probst C., Lohse R., Zelle B.A., Panzica M., Stalp M., et al. (2010). Predictors of late clinical outcome following orthopedic injuries after multiple trauma. J Trauma ,69, 1243–1251.
Probst C., Richter M., Lefering R., Frink M., Gaulke R., Krettek C., et al. (2010). Incidence and significance of injuries to the foot and ankle in polytrauma patients—an anaylsis of the Trauma Registry of DGU. Injury , 41,210–215. 

Søreide K.et al. (2009). "Epidemiology of major trauma". The British Journal of Surgery. 96 ,7, 697–698.
Wafaisade A, Lefering R, Bouillon B, Sakka SG, Thamm OC, Paffrath T, et al. (2011). Trauma Registry of the German Society for Trauma Surgery. Epidemiology and risk factors of sepsis after multiple trauma: an analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery. Crit Care Med 39(April (4)),621–628.
Ziran B.H., Le, T., Zhou, H., Fallon, W., Wilber, Jack H. （1997）The Impact of the Quantity of Skeletal Injury on Mortality and Pulmonary Morbidity. Journal of Trauma and Acute Care Surgery. 43,6, 916-921



網路資料

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