目的：
本研究討論利用組合式照顧模式治療社區型肺炎患者，對於減少住院天數，醫療費用和醫療品質的影響。
方法：
選擇2016年7月至2016年10月南部某區域教學醫院，符合社區性肺炎診斷的患者72例，使用實驗法隨機分為一般組和照護組，每組36例，對照組根據一般醫療處置處理社區性肺炎，研究組則應用組合式照顧模式處理治療，統計兩組平均住院日、平均住院費用、治療效果、三日內再急診率、十四天再住院率以及出院回診次數及回診開立口服抗生素比例等作為評價指標，進行對比分析。
結果：
自收集2016年7月至10月社區性肺炎且肺炎嚴重程度CURB-65小於2分的患者，導入組合式照顧這組的患者與未導入組的患者之間在住院時間有明顯縮短(6.5 vs 7.8天95% CI [-2.000-0.000])；總住院費用導入組較未導入組低(24,670元 vs 29,169元；P=0.313)；而出院口服抗生素使用比例，導入組較未導入組多 (27.8% vs 5.6%；P=0.01)；出院後30天再住院及30日死亡率方面無顯著性差異。三日內再急診率及十四天再住院率亦無明顯差異。
結論：
導入組合式照顧於社區獲得性肺炎病患治療，可以明顯縮短平均住院日、降低平均住院費用，而不會增加患者的再回診率。但可能增加病人回診的次數及開立口服抗生素的比例。

Background: Community-acquired pneumonia (CAP) is the second leading cause of mortality worldwide; CAP-related mortality among hospitalized patients is as high as 13%. The effectiveness of prevention bundles on occurrence and mortality of ventilator-associated pneumonia has been evaluated in many studies. However, no similar bundles were available for CAP. This study aims to evaluate an alternative model of care designed to improve adherence to evidence-supported interventions, including early switch to oral antibiotics, early mobilization, chest physiotherapy, and routine malnutrition screening.
Methods: Patients hospitalized in a general internal medicine unit who met the standard case definition for CAP were included. Using concealed allocation, two general internal medicine units at one regional teaching hospital were randomized: (i) usual medical, nursing, and allied health care delivered according to existing organizational practice (usual service, n=36) or (ii) care supported by a dedicated “CAP service” (CAP service, n=36) multidisciplinary team that deployed algorithm-based implementation of a bundle of the four evidence-based interventions. Multivariable regression models were used to assess hospital length of stay (LOS), 30-day mortality, total hospital cost, and duration of oral antibiotic use after discharge.
Results: We used multivariate regression models after adjustment for age, gender, comorbidities, and severity of illness (using the Confusion-Urea-Respiratory Rate-Blood pressure-65 [CURB-65] scoring system) and for clustering within hospitals to compare LOS and outcomes between “usual service” and “CAP service” groups. LOS was significantly shorter in CAP service than in usual service (6.5 vs 7.8 days; absolute difference, 1.3 days; 95% CI [-2.000-0.000]); total hospital cost was also lower with CAP service than with usual service (24670 vs 29169 NTD; P=0.313). However, oral antibiotic treatment after discharge was prolonged in the CAP service group compared to the usual service group (27.8% vs 5.6%; P=0.01). There were no differences in 30-day mortality rates or recurrence rates within 14 days. Moreover, no differences were found in the rate of still ongoing clinical symptoms at 30 days.
Conclusion: Management by a care bundle approach reduced hospital LOS and
total hospital cost without causing adverse events, compared with the usual standard of care. However, prolongation of oral antibiotic treatment after discharge was noted with the care bundle approach in our study. Further studies are required to validate these findings for other large patient populations.

論文審定書 i
謝辭 ii
摘要 iii
Abstract iv
目錄 vi
圖次 viii
表次 viii
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第二章 文獻探討 4
第一節 社區型肺炎介紹 4
第二節 組合式照護對於肺炎照顧影響 8
第三節 實證醫學治療肺炎的因素 10
第三章 研究方法 13
第一節 研究設計與架構 13
第二節 研究樣本與資料來源 21
第三節 研究分析工具與方法 22
第四章 研究結果與分析 24
第一節 研究樣本人口學特質 24
第二節 兩組平均住院天數及醫療費用差異 28
第五章 討論 31
第一節 使用組合式照護可減少住院天數及醫療花費 31
第二節 對於老人肺炎及多共病的病患應小心評估使用組合式照護 35
第六章 結論與建議 36
第一節 結論 36
第二節 研究限制 37
第三節 研究建議 39
第四節 研究貢獻 40
參考文獻 41

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