探討癌症病人就醫經驗、信任醫師與更換醫師意向之關係

Exploring the relationship among cancer patient experience, trust in physician and intention of changing physician

張琬婷(Wan-Ting Chang)

指導教授 ： 鍾國彪

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2016年)

https://doi.org/10.6342/NTU201601606

摘要

背景與目的：自1982年起，癌症已連續33年高居國人死因首位，且發生和死亡的速率皆有增加的趨勢，對國人的健康一直存在威脅。WHO(2000)、IOM(2001)和OECD(2006)提出回應民眾需求及病人為中心為健康照護體系的要素，此兩要素逐漸成為全球醫療品質發展的趨勢，且近年來醫療品質的測量也轉向發展病人觀點或就醫經驗的調查，成為品質改善的重要依據。而信任是建立良好醫病關係的重要元素，會受到病人就醫經驗的優劣所影響，且病人信任度在醫療過程中也會造成許多正負面的影響(如健康結果、更換醫師等)。因此本研究欲了解就醫經驗、病人信任和更換醫師意向三者間的關係，找出影響因素以提升病人對醫師的信任度，進而降低病人更換醫師的可能性。
研究方法：本研究為橫斷性研究，採自填式結構問卷進行調查，收案對象為在醫院接受照護的六大癌症(乳癌、結腸直腸癌、子宮頸癌、肺癌、口腔癌和肝癌)病人，研究工具採用癌症病人就醫經驗問卷(CPES)和信任腫瘤科醫師量表(TiOS)作為調查問卷，收案期間為2015年11月16日至2016年6月8日，共得有效問卷為277份。在就醫經驗的部分將癌症病人在醫療過程中實際接受到的經驗換算成構面的正向經驗比率，代表該構面醫療品質的優劣；信任醫師的部分採Likert五點尺度作為程度高低的分數計算，再以加總分數代表病人信任度；而更換醫師意向則以二分法區分為不想或想。本研究使用SPSS20.0和IBM SPSS Amos 21.0，將收集到的資料以因素分析、描述性分析、獨立樣本T檢定、單因子變異數分析、卡方檢定、皮爾森積差相關、複迴歸和羅吉斯迴歸分析等方法進行資料分析。
研究結果：年齡和種族為影響癌症病人信任度的因素；其中、年齡亦會影響癌症病人更換醫師意向。在控制其他變項後，癌症病人就醫經驗七構面(以病人為中心的照護、醫病間溝通情形、癌症資訊的給予及支持、情緒支持、參與治療決策及照護計畫、照護的連續性、財務及工作支持)皆會顯著影響其對醫師的信任程度。而癌症病人信任度會顯著影響其更換醫師意向。除財務及工作支持外，其餘的癌症病人就醫經驗六構面皆會顯著影響病人更換醫師的意向，且此癌症病人就醫經驗六構面與更換醫師意向間的關係，皆會受到病人信任度的完全中介影響。
結論：癌症病人在以病人為中心的照護、醫病間溝通情形、癌症資訊的給予及支持、情緒支持、參與治療決策及照護計畫、照護的連續性、財務及工作支持構面中的就醫經驗愈好，病人信任度就會愈高；提升癌症病人的信任度，可降低其更換醫師的可能性；此外，除了財務及工作支持構面，其餘六構面的癌症病人就醫經驗愈好，而其更換醫師的可能性會愈低，且此六構面會透過病人信任度來影響其更換醫師的意向。進一步分析發現醫病溝通對於癌症病人是否會更換醫師而言是相當重要的影響因素，建議醫療院所可將溝通技巧納入教育訓練課程中，提升醫師的溝通能力，讓醫病溝通能更有效率及效益，也建議醫師在看診時可與個管師做搭配，讓病人得以獲得更詳細的說明。

關鍵字

病人報告為結果的測量 ； 醫病關係 ； 癌症病人就醫經驗 ； 病人信任 ； 更換醫師

並列摘要

Background and aims: Since 1982, cancer has been ranked top of death cause for 33 years, also the rate of occurrence and mortality have been increased. It had become a threat to the health of population. WHO, IOM and OECD indicated that responsiveness and patient-centered were the key elements of health care system. These two elements have gradually become the trend of medical quality development. Recently, the measure of medical quality has turned to develop the survey of patient perspective or experience which become the critical basis for quality improvement. Trust is the crucial element of building good physician-patient relationship, and is affected by patient experience. Patient trust will cause many positive and negative results, such as health outcomes, changing physician etc. This study attempts to explore the relationship among patient reported experience, patient trust and the intention of changing physician, and find out the influential factors to increase the degree of patient trust and reduce the possibility of changing physician.
Method: This is a cross-sectional study and adopt self-report questionnaire to collect the data. The subjects of study include six kinds of cancer patients that receive care in hospital. The questionnaire adopt Cancer Patient Experience Survey (CPES) and Trust in Oncologist Scale (TiOS) as investigative tools. There were 277 valid samples with collection period from November 16th 2015 to June 8th 2016. In CPES, the cancer patient during a medical procedure practical experience, is converted into a percentage calculated under dimensions. In TiOS, using the sum of Likert five-point scale as the scores of high and low degree. The part of change physician is to divide into two sections. The data is analyzed by methods of factor analysis, descriptive analysis, independent-sample T test, one-way ANOVA, chi-square test, Pearson Product-Moment Correlation, multiple linear regression and logistic regression.
Results: Age and race are the factors of influencing cancer patient trust, and age also affects the intention of changing physician. In the part of medical treatment experience, controlling for other variables, the patient receives patient-centered care experience in the process, communication experience with physicians, providing cancer information, providing emotional support, patient involvement in treatment-related decision-making and care planning, continuity of care, financial and work support are significant with patient trust. Patient trust will significantly affect the intention of changing physician. Except for financial and work support, the rest six dimensions will also significantly affect the intention of changing physician, and the relation between these dimensions and the intention of changing physician will totally intermediate by patient trust.
Conclusion: The better the cancer patient experience in the dimensions of receiving patient-centered care experience in the process, communication experience with physicians, providing cancer information, providing emotional support, patient involvement in treatment-related decision-making and care planning, continuity of care, and financial and work support, the higher degree of patient trust. Increasing the degree of patient trust will reduce the possibility of changing physician. Except for financial and work support, the better the rest six dimensions of cancer patient experience, the lower the possibility of changing physician. Furthermore, these dimensions will affect the intention of changing physician through patient trust. After further analysis, communication experience with physicians is the most important dimension. It is recommended that hospitals could include communication skill in education training to improve the ability of physicians and let communication more efficient and beneficial. In addition, it is recommended that physicians could cooperate with case managers during the outpatient service to help cancer patients to obtain more elaborate explanations.

並列關鍵字

patient-report outcome measure ； physician-patient relationship ； cancer patient experience ； patient trust ； change physician

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