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標題: 探討某醫學中心糖尿病住院病患出院後之死亡率及死亡預測因子
Mortality and Predictors of Mortality from Discharged Hospitalized Diabetic Patients in a Medical Center
作者: 吳玫君
Wu, Mei Chun
關鍵字: 糖尿病;diabetes mellitus;粗死亡率;標準化死亡比;預測因子;crude mortality rate;standardized mortality ratios (SMRs);predicting factors
出版社: 生命科學院碩士在職專班
目標:針對台灣某醫學中心的糖尿病住院病患,探討其出院後之死亡率、死亡原因、標準化死亡比(standardized mortality ratio,SMR),及嘗試找出預測死亡之可能因子。
研究設計及方法:本研究是採前瞻性的世代研究(cohort study),收集西元1996年至2002年期間某醫學中心新陳代謝科的糖尿病住院後之出院病患,總計1792位。我們將此糖尿病患之名單連結至全國之死因檔,找出出院後在2002年12月31日前死亡之患者。其死亡證書上的死因是依據國際疾病分類碼第九版(ICD-9)而來,而標準化死亡比(SMR)則是以台灣一般人口當做參考組。以Kaplan-Meier方法作存活曲線並使用Cox的之單變量及多變量分析來探討可能因子對死亡風險之預測性。
結果:在1792位糖尿病住院病患中,男性為999位,女性為793位。平均年齡為62.4±15.0歲。全體總追蹤的人年數為4,399.2,男性患者的追蹤人年數為 2,404.8,女性為1,994.4。平均追蹤時間為29.5±21.0個月,中位數為27.0個月(2〜67個月),追蹤期間之死亡人數共有410位,男性為250位,女性160位,粗死亡率為93.2/1000人年。死亡率隨著年齡之增加而升高,糖尿病男性患者的死亡風險雖高於女性,但在各年齡層間無統計上之差異性。全體的標準化死亡比(SMR)為2.98(2.71〜3.28),其中男性為2.58(2.28-2.92),女性為3.80(3.25- 4.43),被歸類為糖尿病的標準化死亡比為14.92(12.76〜17.46),心血管疾病的標準化死亡比為1.97(1.57〜2.49)。糖尿病患的原死因百分比依序為:糖尿病、惡性腫瘤、心肺疾病、感染、中風、消化道疾病、腎病變、事故傷害、自殺、動脈小動脈和微血管的疾病,各個的死因比率分別為38.0,13.2,9.5,7.8,7.6,6.8,5.1,2.0,0.5,以及0.2%。從 Cox proportional hazard regression models的多變量分析發現糖尿病住院病患的年齡較長、高血壓罹病時間愈長、肌酸酐清除率較低、24小時蛋白尿較高者,是導致糖尿病住院病患後續死亡的獨立預測因子。

Background: Diabetes mellitus has been the fourth leading causes of death in Taiwan. Currently, there is no long term follow-up report with regarding to diabetic inpatients in Taiwan. In order to understand the mortality rate of diabetic inpatients after discharge from hospital and to find the possible predictors, we collected the clinical data and following causes of death in a group of diabetic inpatients.
Objective: To investigate the mortality rate, causes of death, and standardized mortality ratio (SMR), and further to identify the significant predicting factors of mortality from discharged hospitalized diabetic patients in a medical center at Taiwan.
Research design and methods: A prospective cohort study was carried out with 1792 discharged diabetic inpatients in a medical center during the years 1996-2002. These 1792 subjects were linked to the national mortality database to ascertain the diabetic subjects who died before Dec. 31, 2002. Underlying causes of death were determined from death certificates coded according to the 9th revision of the International Classification of Diseases. Excess mortality in this cohort study was evaluated by calculating standardized mortality ratios (SMRs) in relation to those of the general population. Predictors of mortality were assessed by Kaplan-Meier survival curves and by uni- and multivariate Cox survival analyses.
Results: A total of 1792 patients were studied, with 999 male and 793 female. The mean age was 62.415.0 years. The total follow-up person-years were 4,399.2 (2,404.8 for males, 1,994.4 for females), The mean follow-up period was 29.521.0 months, and the median was 27.0 months (ranged 2-67 months). During this period 410 patients died (250 in males, 160 in females) with the crude mortality rate was 93.2/1,000 person-years. The overall SMR was 2.98 (2.71-3.28), with 2.58(2.28- 2.92) in men and 3.80(3.25-4.43) in women. SMR caused by diabetes was 14.92(12.76-17.46), by cardiovascular SMR was 1.97(1.57-2.49). The percentage of causes of death ascribed to diabetes, cancer, cardiopulmonary disease, infection, stroke, digestive diseases, nephropathy, accidents, suicide, and disease of arteries, arterioles, and capillaries were 38.0, 13.2, 9.5, 7.8, 7.6, 6.8, 5.1, 2.0, 0.5, and 0.2 %, respectively. The independent predictors of mortality were older age, longer duration hypertension, increased 24h proteinuria, and decreased creatinine clearance, which were obtained by multivariate Cox proportional hazard regression models.
Conclusions: In general discharged hospitalized diabetic patients had about threefold excess mortality than the general population. The predictors of mortality included older age, longer duration hypertension, increased 24h proteinuria, and decreased creatinine clearance.
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