| Summary: | 碩士 === 國立陽明大學 === 衛生福利研究所 === 101 === Background: Total knee replacement is one of the payment items of Tw-DRGs (Taiwan Diagnosis related groups) from National Health Insurance. Payments on the materials of artificial knee joints from National Health Insurance are about 1.1 billion New Taiwan Dollars (NTDs) in 2011. If adding the payments for the surgery costs, payments from National Health Insurance would reach 2.6 billion NTDs. From 2009 to 2011, there are about 20-thousand people who need to undergo total knee replacement per year on average in Taiwan and the trend indicates that the requirement for total knee replacement is increasing owing to the aging population society. Surgical site infection is one of the main complications after the surgeries and is also the main cause for the death and injury of patients as well as increasing medical expenses. However, it is still unclear whether the characteristics and features of the hospitals and doctors would affect the post-operative surgical site infection rate of patients undergone total knee replacement.
Purpose: Investigate the relation and correlation between the characteristics of hospitals and doctors and the post-operative surgical site infection rate of patients. Then analyze the factors that may influence the infections.
Methods: We adopted retrospective cohort study in this research. With Longitudinal Health Insurance Database published by National Health Research Institutes (NHRI) as our research material, we found 1648 patients who have undergone surgeries about total knee replacement from 2009 to 2010 as research subjects. In our study, the dependent variable is the situation of post-operative surgical site infection and we divide infections into two categories: superficial infection and deep infection to undergo investigation. There are 4 categories used to define the superficial infection. The first category is defined as using 3 days antibiotic after surgery, the second category is defined as using 14 days antibiotic after surgery, the third category is defined as operating debridement after surgery,and the forth category is defined as operating debridement with wounds no smaller than 5 cm after surgery as well as using antibiotic and operating debridement with wounds smaller than 5 cm after surgery. The independent variable could be divided into the characteristics of hospital and the characteristics of doctor and the control variable is the characteristics of patient. Binary logistic regression mode is used to undergo analysis in our study.
Results: For all sampled patients, the superficial infection rates under 4 different defined categories are 0.30%, 0.21%,1.22%, and 0.79% respectively and the deep infection rate is 0.06% after operating total knee replacement for 30 days; the superficial infection rates under 3 different defined categories are 0.72%, 0.61%,1.28%, and 0.85% respectively and the deep infection rate is 0.24% after operating total knee replacement for 90 days. Considering the factors, including the characteristics of hospital and the characteristics of doctor, that may influence the post-operative surgical site infection, those who undergoing operations in regional and local hospital (OR=1.72、1.51、1.95、1.41), under the government of the eastern division of National Health Insurance (OR=2.43、2.13、2.43、2.13) , the lower amount of surgeries operated by the hostpital per year (OR=1.39、1.45、2.41、1.45),and the lower amount of surgeries operated by the doctor per year (OR=1.31、1.58、2.51、1.65) bear the significant higher risks of post-operative surgical site infection. Moreover, in the aspect of patient charicteristics, the older patients (OR=1.57、1.62、1.45、1.82) and patients with cerebrovascular disease (OR=1.24、1.35、1.64、1.35), rheumatic diseases (OR=1.74、1.59、1.36、1.47), diabetes (OR=1.49、1.87、1.68、1.69), kidney disease (OR=1.41、1.36、1.41、1.39) comorbidities are found with higher risks of post-operative surgical site infection.
Conclusion: The accreditation level of hospitals, the division of the business in National Health Insurance, and the amounts of surgeries operated by doctors and hospitals are all the related factors that may influence the post-operative surgical site infection of total knee replacement. We recommend the central competent health authority to enforce the monitoring on hospitals and doctors for the ensuring the quality after the surgeries. For patients who are older than 65 years old or with serious comorbidity, it should be more careful while the medical and healthcare processes to decrease the risks of infections.
Key Words: total knee replacement, post-operative infection, superficial infection, and deep infection
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