[[alternative]]Survival analysis and medical resource utilization of Patients with acute respiratory distress syndrome

[[abstract]]背景與目的:台灣地區急性呼吸窘迫症候群是高死亡率、高罹病率的疾病，許多研究致力於探討院內存活率及相關因子，卻缺少對於存活者的後續存活情形與預測因子、共病情形、醫療資源耗用。本研究的目是藉由存活分析，探討影響離院後的存活時間與預後因子，並瞭解罹患ARDS之後之共病分佈情形以及進一步分析ARDS醫療資源耗用情形與影響醫療費用之相關因子。研究方法:本研究以病歷回溯世代性分析，以台灣大學附設醫院為對象，收集自2004年1 月至2009 年12月在本院診斷為急性呼吸窘迫症候群，並接受加護病房治療後存活離院共200 人，以人口學特徵、病患的臨床數據以及資訊資料庫，與衛生署死亡檔作ARDS相關存活率及預後分析。研究結果:本研究結果以Kaplan-Meier 分析ARDS 70個月(5.8年) 的存活率為36%，可知第1個月的累積存活率為90.9％，第2個月的累積存活率為86.0％，第6個月的累積存活率為75.2％，第12個月的累積存活率為69.8％，第24個月的累積存活率為59.1％。以Cox proportion hazard model 分析影響預後的獨立因子分四個層面如下：基本特質獨立預測指標為「年齡分組(每10歲)」以及「疾病病史數」、入住加護病房時獨立預測指標為「住院前CCI」及「APACHE II」、經入住加護病房後獨立預測指標為「Post ARDS tracheostomy」、離院後獨立預測指標為「Malignancy」、「Renal」以及「離院後住所」，經確認為獨立預測因子都對預後和存活有影響，或是有相關性的。在ARDS發生之後的共病情形：入院時平均CCI為1.74±1.9出院後CCI為2.5±2.3，在疾病診斷分類上增加最多的疾病為腎臟疾病，共增加了18%，第二為神經疾病部份增加了15%，疾病診斷數目在ARDS發生前與ARDS發生後有很大的變化，住院時沒有任何疾病的有33%，而出院時只剩下11%沒有任何共病情形。醫療費用部份主要花費最多的為藥物費用，再來為病房包含護理費用，ICU LOS平均數為28.44±23.4，Hospital LOS為65.7±55.1。院內存活者相較於院內非存活者花費了更多費用，花費較多的相關因子包括：年齡較輕者、出院後死亡者、加護病房合併症數目越多者、APACHE II得分越高者、氣切患者。[[abstract]]Objective: Acute respiratory distress syndrome came with a high mortality rate as well as high comorbidity. Previous research has devoted the hospital survival rate and to identify high-risk factors associated with it. Little attention has been paid to long-term clinical outcomes and post ARDS comorbidity.The purpose of this study was to explore post ARDS hospital discharge which the prognostic factors and survival time .Further understand the distribution of comorbidity of ARDS patients after suffering from ARDS. Methods: This was a retrospective cohort study using survival analysis on 200 ARDS patients. Those patients who were diagnosed and hospital survived with ARDS after treated in Intensive Care Unit and survived upon discharge from hospital between January, 2004 and December, 2009 were included in this study. Data on the survival status from their discharge to June, 2010 were obtained via data bank of the National Health Insurance under the permission from the Department of Health. We calculated survival time in months, from 2004/1/1 to 2010/6/30 the number of months total of 78 months. Results: The findings from the Kaplan-Meier analysis of the results of the ARDS survivors indicated that 70 months (5.8 years) survival rate was 36%, 1-month cumulative survival rate 90.9%, 2-month cumulative survival rate 86.0%, 6 months cumulative survival rate 75.2%, 12-month cumulative survival rate 69.8%, and 24-month cumulative survival rate 59.1%. The result from Cox proportion hazard model analysis of prognostic independent factor in four dimensions were presented in the following: The basic characteristics of independent predictors included the age group (per10 years) and the number of disease history; the ICU admission independent predictor included pre-admission CCI and APACHE II; post ICU care independent predictors included Post ARDS tracheotomy; Hospital discharge independent predictors included Malignancy, Renal, and Discharge disposition. Those identified as independent predictors were significantly associated with the prognosis and survival.The comorbidity after ARDS were presented as follows: In admission the average CCI was 1.74 ± 1.9. Upon discharge the average CCI was 2.5 ± 2.3. During the post ARDS period, among the categorized diseases, kidney related conditions raised 18%, the highest increase for this group of patients. The neurological disease raised by 15% ranking as the second highest. There were 33% of the patients without any disease before being diagnosed with ARDS. There were only 11% of them without any comorbid disease at the post ARDS stage.Medical resource utilization and hospital costs were related to younger age, more ICU cormobidity and more severity of illness in ICU, Post ARDS tracheostomy, discharge from hospital and non-survival patient. The largest portion of hospital costs for a survivor of ARDS was the pharmacy costs and the second most important cost was nursing costs.The ICU LOS was 28.44±23.4 and Hospital LOS was 65.7±55.1