- 學位論文
核心測量指標、醫院服務量與大腸直腸癌患者死亡、復發情形之探討
Association of Core Measure and Hospital Volume to Colorectal Cancer Mortality and Recurrence
摘要
研究背景與目的：雖然在許多疾病治療上皆有證據支持「服務量-結果」關係，但在國內外研究中，大腸直腸癌手術服務量與照護成效仍然無一致的結論。且過去文獻少以同時探討醫院服務量、照護過程面指標、照護結果三者之間的關係，因此本研究擴大「服務量-結果」的假設，除了再次驗證台灣醫院大腸直腸癌手術服務量與病人照護結果的關係，也探討大腸直腸癌核心測量指標達成度對於病人照護結果的影響，及大腸直腸癌核心測量指標對於「服務量-結果」關係的影響情形。 研究方法：本研究以2004年台灣癌症診療資料庫(TCDB)中大腸直腸癌新發診斷個案為研究對象，共4254位病人，分別於29家醫院進行手術治療。醫院服務量係以該院年平均進行的大腸直腸癌手術量計算，而照護過程指標則是以國內大腸直腸癌核心測量指標為依據。本研究以階層邏輯斯迴歸(Multilevel logistic regression)進行分析醫院服務量、核心測量指標對於病人死亡、復發風險的影響。 研究結果：在病人層次的核心測量指標達成率有效影響病人之死亡情形與復發情形。而醫院層次部分，在控制病人特性後，醫院核心測量指標達成率對於病人之死亡及復發情形不具有顯著影響效果，而醫院服務量則為病人的死亡情形的顯著預測變項，但並不影響復發情形。進一步分析得知，在指標達成率高的醫院，其醫院服務量對於病人死亡情形的影響效果較大，而在指標達成率低的醫院，其醫院服務量對於病人死亡情形的影響效果較小。 結論：根據研究結果，醫院服務量對於病人死亡情形仍具有顯著影響力，因此，本研究支持手術集中化策略，另外，本研究建議醫院可投入更多資源在增加病人的照護品質上：在照護品質好的醫院，透過增加服務量對於病人照護結果可產生綜效。
並列摘要
Background：Many studies have been conducted the relationship between hospital volume and outcome, however the relationship has not to be determined for resection of colorectal cancer in Taiwan. This study examines the association of hospital volume with mortality and recurrence in colorectal cancer patients.It also examines the associations of core measure with outcome and the impact of core measure on the relationship between volume and outcome. Method：All newly diagnosed with colorectal cancer registered at Taiwan Cancer Databased in the year 2004 were entered into the study. The population consisted of 4254 patients from 29 hospitals. Data was analyzed using multilevel logistic regression to adjust factors for different nested levels of patients and hospitals. Results：In patient level, the adherence of core measure has influence on the 5 year mortality and recurrence. In hospital level, the adherence of core measure does not have impact on outcome. And after controlling other fators, hospital volume significantly impacts on the 5 year mortality, but not on 5 year recurrence. Besides, the relationship between hospital volume and 5 year mortality is stronger in hospitals with high adherence of core measure than in hospitals with low adherence of core measure. Conclusion：According to the results, the hospital volume has impact on the 5 year mortality. This study supports the strategy of surgery centralization. This study also suggests that hospitals could invest more resources to improve the quality of care. In high quality hospital, by increasing hospital volume can have the synergy results.