台灣醫院別癌症照護資源與內容之分析

An Analysis of Hospital Cancer Care Resources and Contents for Cancer Inpatients in Taiwan

呂雅雲(Ya-Yun Lu)

指導教授 ： 鍾國彪

共同指導教授 ： 賴美淑(Mei-Shu Lai)

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2007年)

https://doi.org/10.6342/NTU.2007.10166

摘要

確保癌症照護品質是各國在癌症控制上所一致努力的方向，英國1995年發表” Calman-Hine report ”癌症照護政策報告，藉由建構完整癌症照護網絡、制訂診療指引等方式，以改善癌症存活率偏低、診斷與治療延遲等問題；美國則由智庫IOM在1999年發表”確保癌症照護品質”報告，認為多數癌症病人並未得到適當且高品質的照護，醫療機構間所提供的癌症照護有變異存在，應加強醫療提供者在癌症照護上的責任。國民健康局自90年補助醫院成立癌防治中心，癌症防治法亦自92年頒佈施行，醫院配合國家政策投注相當人力、資源於癌症照護以持續提升診療品質。本研究目的為進行評鑑等級為地區醫院以上之組織設備、照護內容、癌症照護量之描述性分析，主要針對乳癌、子宮頸癌、肝癌、大腸直腸癌、肺癌及口腔癌等六種癌症，探討影響醫院癌症照護量的相關因素。

　　本研究為一橫斷性研究，以醫院為研究對象共寄發297份結構式問卷，含常設組織、人力、科別、設備、多專科醫療團隊、臨床試驗、診療指引、病友團體、專業人員的教育訓練、癌症病人追蹤或治療結果紀錄等題項；之後使用93年健保住院資料、92年癌症登記資料計算癌症照護量之癌症住院人數、住院人日、平均住院日及新診人數，進行資料連結。本研究使用SAS 8.2軟體進行統計分析，以次數分配、百分比呈現癌症照護現況調查結果，以t檢定、ANOVA、卡方檢定及複迴歸等探討醫院特性、組織設備及癌症照護內容與醫院癌症照護提供之相關情形。

　　問卷回收共76份，整體回收率為25.59%，以44份有效問卷納入分析；其中醫學中心及區域醫院共回收36份問卷，回收率佔所有醫學中心及區域醫院之42.86%。研究結果如下：（一）醫院設有多專科醫療團隊的比率為59.09%；參與並執行臨床試驗計畫的比率為56.82%；訂有診療指引的比率為68.18%；成立病友團體的比率為62.79%，並以乳癌團體數最多；醫院曾舉辦或參與專業人員的教育訓練活動的比率為90.91%；醫院進行追蹤率紀錄、死亡率紀錄、存活率紀錄的比率分別為45.45%、47.73%及43.18%；（二）醫院特性之「層級別、教學別、權屬別、是否為TCDB填報醫院、是否為TCOG會員醫院」及「醫院科別設置數」與醫院癌症照護量達顯著相關，癌症照護內容之「臨床試驗、診療指引、追蹤或治療結果紀錄」與醫院癌症照護量達顯著相關；（三）癌症住院人數、住院人日、平均住院日、癌症新診人數均呈現右偏分佈，多數癌症病人由少數醫院提供癌症照護服務，但散佈於各醫院。癌症防治法推動實施後，醫院開始重視多專科醫療團隊、診療指引遵循、追蹤及治療結果紀錄等癌症照護內容，致力於確保癌症診療品質。

　　根據以上研究結果，建議衛生主管機關明訂醫院之監督、賞罰及回饋機制，並加強各層級癌症照護機構功能之宣導；建議醫院落實院內癌症照護管理組織之功能，加強診療指引、多專科醫療團隊、追蹤及治療結果紀錄等癌症照護內容之實質運作；建議後續研究者可增加其他資料之連結，以豐富癌症照護現況的描述。

關鍵字

癌症照護 ； 醫院特性 ； 多專科醫療團隊 ； 臨床試驗 ； 診療指引 ； 癌症照護量

並列摘要

Ensuring cancer care quality is an international concern of cancer control. In England, NHS structured the cancer care network and published guidances to improve the cancer survival rate and reduce the delay between diagnosis and treatment. The Institute of Medicine considered that most cancer patients in the United States do not receive appropriate cancer care, and the providers should take responsibility for ensuring quality cancer care. In Taiwan, “Cancer Control and Prevention Centers” were set up to provide comprehensive cancer care and collect detailed clinical data since year 2001, and the Cancer Control Act was promulgated in year 2003. The hospital-based cancer care data is lacking and could be applied to the evaluation of cancer care provided from specific hospital types.

　　The purposes of this study include: (1) To understand the description of hospital cancer care in Taiwan, including the cancer care volume, organization, specialties, equipment, and the cancer care contents for cancer inpatients. (2) To analyse the diversity of cancer care volume among hospitals with different characteristics or cancer care contents.

　　All hospitals of research interests are accredited above district hospitals in Taiwan and provide at least six kinds of cancer including the breast, cervical, liver, colonrectal, lung and oral cancer care. A structural questionnaire was developed and mailed to 297 hospitals. The total response rate is 25.59 percent ( 76/297 ) , and response rate at medical centers and regional hospitals is 42.86 percent ( 36/84 ). Hospital characteristics and the cancer care volume including the number of inpatients, days of stay and average length of stay were calculated from National Health Insurance Research Database, and the number of new diagnostic patients was calculated from Taiwan Cancer Registry Database.

　　The major findings of this study are as follows:
(1) The rate hospitals managing cancer patients by multidisciplinary teams was 59.09% ; the rate hospitals providing clinical trials information and accruing patients was 56.82% ; the rate hospitals formulating or adhering to cancer clinical practice guidelines was 68.18% ; the rate hospitals with cancer support group was 62.79%, and breast cancer support group is the most general one ; the rate hospitals offering cancer-related educational activities was 90.91% ; the rate hospitals with follow-up , mortality and survival documents were in sequence 45.45% , 47.73% , and 43.18% .
(2) Cancer care volume was significantly related to hospital characteristics, such as accredited level, teaching status, ownership, submitting cancer care data to Taiwan Cancer Data Base (TCDB) , membership of Taiwan Cooperative Oncology Group (TCOG) and the arrangement of specialty division. It was also significantly related to cancer care contents inclusive of clinical trials, clinical practice guidelines and documents of patients’ follow-up and surveillance.
(3) The distribution of the cancer care volume was skewed to the right. Hospital cancer care service was concentrated at medical centers and regional hospitals but spread around. After the Cancer Control Act came into effect, hospitals are paying more attention to cancer care contents and improving the quality of cancer care.

　　According to the research results, we recommended that the health authorities should monitor the quality of cancer care, approve well-performed hospitals and announce to the public the function of cancer centers. The health care providers should enhance the practical operation of clinical practice guidelines, multidisciplinary teams, and the documents of patients’ follow-up and surveillance. Future researchers could explain the cancer care service in Taiwan by other source of data, for instance using Taiwan Cancer Data Base (TCDB) to attain the stage data and explore the patterns of cancer care, and using the accreditation data to attain more hospital characteristics.

並列關鍵字

cancer care ； hospital characteristics ； multidisciplinary team ； clinical trial ； clinical practice guideline ； cancer care volume

參考文獻

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