全面性照護之缺血性腦中風臨床路徑發展與評估; Development and Evaluation of the Comprehensive Care of Clinical Pathway for Ischemic Stroke

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Title:	全面性照護之缺血性腦中風臨床路徑發展與評估;Development and Evaluation of the Comprehensive Care of Clinical Pathway for Ischemic Stroke
Authors:	張榕浚;Lung-Chun Chang
Contributors:	中國醫藥學院醫務管理研究所
Keywords:	全面性照護臨床路徑;缺血性腦中風;隨機臨床試驗;Comprehensive Clinical Pathway;Ischemic Stroke;Randomized Control Trial
Date:	1992
Issue Date:	2009-12-23
Abstract:	隨著醫學的進步醫療專科分工日益精細，病人缺乏全人的照護，醫療資源的重複使用，造成醫療浪費，醫界面臨相當大的成本和品質挑戰。全面性照護之臨床路徑主要特色為結合早期復健、復健衛教及出院準備計畫，提供一套以病人為中心之全面性照護標準。國內外的實證研究指出臨床路徑為一種同時兼顧醫療品質與醫療成本之照護模式，廣受各醫療院所使用。本研究之主要目的為發展缺血性腦中風病人全面性照護之臨床路徑並評估其有效性。本研究採雙盲臨床隨機試驗（Double Blind Randomized Control Trial），將個案醫院缺血性腦中風患者隨機分配至路徑組（實驗組），和常規醫療照護組（對照組），介入三個月後測量患者之狀況，以評估臨床路徑之效益。評估之指標，除醫療資源耗用外，醫療結果指標包括身體功能、心理功能和社會生活三個層面，以中文版「美國國家衛生院中風量表」（NIHSS）、中文版「生活功能獨立執行量表」（FIM）、中文版「巴氏量表」（BI）、「雷氏修正量表」（MRS）、中文版「中國人健康量表」（CHQ-12）、憂鬱量表程度、病患及主要照護者和提供者滿意度評估問卷，作為醫療結果之評估指標。研究結果顯示實施全面性照護之缺血性腦中風臨床路徑，除了降低平均住院天數之外，在控制病患之性別、年齡、入院之疾病嚴重度之後，醫療結果（FIM, BI, MRS, NIHSS）也有改善，且達統計上的顯著水準。病患主觀之整體醫療滿意度也比常規治療為佳。此外，在評估中風病患醫療結果之工具中，以生活功能獨立執行量表為評估病人身體功能改變狀態最敏銳之量表。; The characteristics of comprehensive ischemic stroke clinical pathway emphasizes early rehabilitation, health education, and discharge plan. Previous studies indicate that the practice of a clinical pathway can reduce the cost of treatment and improve patients’ outcome by providing high quality of stroke care with minimum cost so to develop an effective clinical pathway is the most urgent work of the current clinical practice.This experimental study consists of two aims. The first aim is to develop the evidence-based stroke clinical pathway. The second aim is to evaluate the effectiveness of stroke clinical pathway provided by China Medical College Hospital (CMCH). The study population consists of inpatients with diagnosis of stroke from emergency department of CMCH and their primary caregivers and careproviders. The eligibility criterion is the patient with a diagnosis of Stroke (ICD-9CM of 433,434). All individuals who were eligible during the study period were recruited as subjects, and then were randomly assigned into two groups: with and without the clinical pathway care. The recruitment period was conducted over 3-months period. Face-to-face interviews with trained interviewers were used to collect information about sociodemographic factors, National Institute of Health Stroke Scale (NIHSS), Functional Independence Measure (FIM), Barthel Index (BI), Modified Rankin Scale (MRS), Chinese Health Questionaire (CHQ-12), Short Form 36 (SF-36), etc.at the entry of the study as well as at discharge, and 3 months after discharge. The distributions of age, gender, race, education, occupation, the severity of disease of the 2 groups were comparable. The result shows that clinical pathway can effectively reduce length of stay (LOS) for Ischemic stroke patient. In addition, the group with clinical pathway significantly increases the improvement of inpatients’satisfaction and physical functioning measured by BI, FIM, MRS, and NIHSS compared to the group with regular care after controllong for age, gender, and the seversity of disease at baseline. Among instruments measuring physical functioning, FIM is the most sensitive one to detect the change of patients’ physical functioning.
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