乳癌病患延遲治療時間相關因子和對預後影響之探討

背景與動機：乳癌在世界各國都對女性健康造成重大威脅，為促進乳癌女性健康，國內外著重早期診斷與早期治療的重要性，故而提出治療延遲的概念，並對此進行許多相關研究，研究顯示延遲治療對於病患的預後（存活、診斷期別、總醫療費用）會有重大影響。2015年Neal等人的針對癌症相關研究進行系統性回顧，指出過去的研究結果缺乏一致性，且探討相關因子面向過於侷限，由於延遲治療對於乳癌病患的健康存在影響，該回顧提出應再針對醫療機構特性因子進行分析，且應遵循2012年Weller等人提出的指引。本研究期望能透過資料庫分析，去針對過去探討較少的醫療機構特性因子進行分析，另外，使用大型資料庫探討對預後的影響。研究目的：本研究目的有二，其一為瞭解相關因子中醫療機構特性因子對延遲治療時間的影響，其二則是探討延遲治療的時間影響乳癌預後的情況。研究方法：本研究將利用健保資料庫結合癌症登記檔進行資料分析，使用SAS 9.4，分析方法採用T-Test、ANOVA、卡方、多變量迴歸進行資料分析。研究結果：分析結果顯示乳癌病患平均診斷延遲天數為9.45天（±11.75天），平均治療延遲天數為13.94天（±18.08天）。醫療機構特性因子當中，初次確診乳癌服務量對診斷延遲天數呈現顯著相關，每增加一個確診服務量，會增加0.000203天的診斷延遲天數，醫院權屬別則對診斷延遲天數和治療延遲天數都呈現顯著相關，在診斷延遲天數部分，公立醫院的平均天數為8.76天（±11.21天），非公立平均天數則是9.96天（±12.11天），而在治療延遲天數部份，公立醫院的平均延遲天數為14.12天（±18.88天），非公立醫院的平均天數為13.82天（±17.79天）。本研究依據延遲治療時間的平均值作為切點，將診斷延遲天數與治療延遲天數切為兩組，結果顯示診斷延遲天數較長的病患其在各個診斷期別都有較高的風險存在。診斷延遲天數對存活的影響上，兩組間存在顯著差異，高於平均值的組別其OR值為1.095，而治療延遲天數對存活的影響上，兩組亦存在顯著差異，高於平均值的組別其OR值為0.977。結論與建議：本研究發現到醫療機構特性對延遲治療時間存在影響，而延遲治療時間也與病患預後有著相關性，根據研究結果，針對政策、實務與未來研究三個面向分別給予建議，政策方面建議衛生主管機關可以利用診斷延遲天數來做為癌症照護的過程指標，並且應對現行的癌症改善規畫重新思考。實務方面建議醫療提供者可使用資訊系統來協助監測診斷延遲天數，此外，建議區域醫院和地區醫院應針對治療流程改善，幫助病患儘早獲得治療，最後，未來研究建議可針對其他種癌症疾病進行分析，並將醫院評鑑等級和權屬列入分析考量。

關鍵字

延遲治療；乳癌；醫療機構特性因子；延遲治療時間長度；區段迴歸

並列摘要

Background：Breast cancer threats the whole world women’s health, so many countries emphasis the concept, ‘Early diagnosis and early treatment’, to improve the health outcomes of breast cancer patients. Under this circumstance, researcher put their attention on ‘Delay treatment’, which measured the time of diagnosis and treatment, and has impact on patient’s outcomes (such as survive, stage and expense). In 2015, Neal and his team systematic reviewed the researches of Cancer delay treatment, pointed out that the studies’ results without consistency and the studies of relevant factors still lacking. Delay treatment is one of the important factors influenced patient’ health, they suggested the future researcher should focus on the hospital factors’ relationship and follow the guideline of Weller, which posted in 2012. This research expects to use database analyze exploring the relationship between hospital factors and delay treatment, moreover, understanding the delay treatment effect on patient’ health outcomes. Purpose: There were two purposes of this study, first, understanding the hospital factors’ relation to delay treatment, second, exploring the delay treatment effect to patient’ health outcome. Method: This research used the National Health Insurance Database and Cancer Registry Database to analysis. Version of SAS is 9.4. Statistic methods contain T-test, ANOVA, Chi-square and regression. Results: The results showed breast cancer patient’ average diagnosis delay is 9.45 days (±11.75 days), average treatment delay is 13.94 days (±18.08 days). In Hospital factors’ relation with delay treatment, the amount of first time diagnosis has significant correlation with diagnosis delay, the amount raise 1 unit, the diagnosis delay will increase 0.000203 days. The hospital ownership has significant correlation with diagnosis delay and treatment delay. The average diagnosis delay of public hospital is 8.76 days(±11.21 days), besides the average of non-public hospital is 9.96 days (±12.11 days). The average treatment delay of public hospital is 14.12 days(±18.88 days), besides the average of non-public hospital is 13.82days (±12.11 days). We seperated the delay time according the average point to two group, and found that longer diagnosis delay group significantly has higher risk to get serious stage than shorter delay group. Besides, the longer diagnosis delay group also has higher risk to die, and the OR is 1.095. However, the longer treatment delay group has lower risk to die, and the OR is 0.977. Conclusion：Our findings suggest that the effect of diagnosis delay should be considered in formulation or revisiong national health policy. Besides, the hospital should use information system to monitor their patients’ condition of delay treatment, and improve their treatment process to help patient get therapy. Last, the effect of delay treatment in other cancers is unknow, we suggested the future research can focus on other cancer, and consider the effect of hospital character in the study.

並列關鍵字

Delay Treatment ； Breast Cancer ； Systematic Factors ； Length of Delay Treatment Time ； Quantile Regression

參考文獻

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乳癌病患延遲治療時間相關因子和對預後影響之探討

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