肝癌患者經導管動脈化學栓塞治療標準流程之建立及其效益評估

Evaluation of the Implementation of Clinical Guidelines for Transcatheter Arterial chemo-embolization of Patients with Hepatocellular Carcinoma

黃凱琳(Kai-Lin Hwang) ； 蘇維文(Wei-Wen Su) ； 孫茂勝(Maw-Soan Soon) ； 吳順生(Shun-Sheng Wu) ； 陳洋源(Yang-Yuan Chen) ； 陳美如(Mei-Ju Chen)

《台灣公共衛生雜誌》 24卷4期 (2005/08) Pp. 284-295

https://doi.org/10.6288/TJPH2005-24-04-02

摘要

目標：本研究之目的爲評估肝癌病患經導管動脈化學栓塞治療標準流程建立及其效益。方法：本研究採前後期實驗對照研究法於彰化基督教醫院肝膽胃腸科進行，比較動脈化學栓塞治療標準流程建立前後之各項指標。共分三個階段：流程未實施前爲對照期、流程宣導及試行期、與路徑實施後三個月之實驗期。結果：於對照期及實驗期各收錄57名患者進行評估。兩組住院天數雖無顯著差異，但路徑實施後較實施前略降0.4天（3.3比2.9天，p=0.23），患者對大部份項目的服務滿意度在路徑實施後均較實施前有所提升，其中「護理人員對可能發生狀況的說明」(77.4%vs.94.6%, p=0.01)與「對發燒的處理」(78.8% vs.96.8%, p=0.04)之滿意／非常滿意的比例在路徑實施後顯著增加。路徑實施前之平均醫療費用（±標準差）爲NT$57,736.1(±11,197.7)，實施後爲NT$53,824.3(±10,332.6)，降幅爲6.8%(p=0.07)；前後兩次門診總醫療費用由NT$14,135.5(±5,143.9)降爲NT$12,2695(±4,670.7)，降幅達13.2%(p=0.05)。除了對減少工作負擔的同意率略低外(63.9%)，醫護人員對各項指標的支持度都在83%以上，尤以對照護品質提升的認同率最高達100%。結論：肝癌病患之肝動脈化學栓塞治療臨床路徑，除了對患者與醫護人員的滿意與支持度略有提升外，亦有減少醫療費用之傾向，值得繼續鼓勵與推動。但在實際應用上，仍需視個案實際情況由主治醫師依醫療專業給予最適當的處置與治療。

關鍵字

化學栓塞治療 ； 標準治療流程 ； 效益評估 ； 滿意度

並列摘要

Objectives: To evaluate the effectiveness of clinical guidelines for transcatheter arterial chemo-embolization (TACE) of patients with hepatocellular carcinoma (HCC). Methods: Pre- and post-implementation evaluations were performed at the Division of Gastroenterology and Hepatology, Changhua Christian Hospital. There were three study periods, control (3 months prior to implementation), construction and practice, and trial (3 months after the implementation). Results: Fifty-seven patients were recruited into each of the pre- and post-study periods. The average hospital stay was shortened (0.4 days, 3.3 vs. 2.9 days) for pre- and post-periods, respectively, p=0.23). Patients had a higher satisfaction of most of the services provided after the guidelines had been implemented. Among them, ”instruction of expected events” (77.4% vs. 94.6%, p=0.01) and ”treatment of fever” (78.8% vs. 96.8%, p=0.04) had significant higher rates of ”satisfied/very satisfied” ranking compared with those from the control period. Average (±standard deviation) overall medical expenditure was reduced from NT$57,736.1 (±11,197.7) to NT$53,824.3 (±10, 332.6); a reduction of 6.8% (p=0.07). The average medical expenditure for the outpatient visit prior to and after the TACE hospitalization was reduced from NT$14,135.5 (±5,143.9) to NT$ 12,269.5 (±4,670.7); a reduction rate of 13.2% (p=0.05). All health professionals agreed that the guidelines improved the quality of care, more than 83% supported additional advantages. However, only 63.9% agreed that workload decreased. Conclusions: The clinical pathway of TACE for patients with HCC was effective in terms of both patient's and health-care provider's satisfaction and tended to control medical expenditure. Still, it is strongly recommended that physicians provide the most appropriate treatment to patients based on professional judgment.

並列關鍵字

transcatheter arterial chemo-embolization ； clinical guidelines ； effectiveness evaluation ； satisfaction

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