- 學位論文
探討不同治療選項對下咽癌病人照護品質之影響與病人服務量導致治療結果之差異
Impact of Different Treatment Options on Quality of Care for Hypopharyngeal Cancer and Influence of Patient Volume of Hospitals on the Outcome
摘要
背景: 健保的財務日益艱困，個別醫院總額出現許多問題, Tw-DRG又已經開始施行。但是惡性腫瘤之治療並沒有納入DRG之控管，在癌症的診斷與治療方面，使用高科技所花費的經費卻越來越多；包括CT、MRI、顯微重建手術，伽瑪刀，PET，各種放射治療及化學藥物治療等等，在近幾年來快速及廣泛地被應用到口腔癌之診斷與治療，尤其是下咽癌更是如此。我們選擇下咽癌作為研究的對象，同時也是因為它的干擾因素最少，其存活時間通常是直接與疾病本身的控制相關。台灣的下咽癌之罹病率比外國高3.3 倍，治療以後的追蹤比外國容易及完整，但我們過去總是習慣性地因循著國外的方法，過分仰賴別人的研究成果，然而事實上國外之文獻在下咽癌的兩大主軸治療方式之間仍然存在很大的爭議。 目的: 分析台灣究竟對這些病患所做的治療結果其效益如何，選擇最適合我國醫療環境的治療方式，並檢視醫院治療病人之數量對治療後併發症的影響，以作為日後政策決定之參考。這研究的方式及成果甚至可供國內其他癌症管理之借鏡。 資料和方法： 下咽癌的診斷與治療在口腔癌當中是最困難的一種，診斷不易而且治療之難度很高。隨著科技的進步，許多以前認為是診療瓶頸的困難處逐漸被克服。下咽癌之治療方式可以分為兩大類（根治療法與保守療法），目前文獻的缺口就是這兩種治療理念之間的爭議懸而未決。因此我們將針對台灣這兩種治療方式去做深入的研究。由癌症診療資料庫 (CRS-long form) 結合國衛院健保資料庫(NHID) 及死因登記檔去分析2005至2009年之間下咽癌病人的治療方式以及客觀的存活時間、疾病復發、併發症、進食狀況(是否需要管灌飲食)及生活品質；來比較這兩大類治療方式之效益。根據以上資料及多層次分析，可以檢視不同層級的醫院治療病患之數量差異與費用及治療後之合倂症發生率之間的關係。由此可引申出如何控管醫院收治重難症之政策，以減少醫療資源之浪費。下咽癌與其他癌症不同之處是它位於一個樞紐的位置，其治療會造成特殊的問題；因此可以發展一組生理指標來做為客觀評估治療後之生活品質的基礎。 結果: (1) 整體而言，台灣的下咽癌以照護結果及治療後之主觀生活品質來評估都發現只用放化療 (器官保留療法)，比手術加輔助性放化療還要好，雖然存活時間比較短。(2) 我們以德菲法發展出一組客觀生理指標來評估下咽癌治療後之生活品質，以這組指標來檢視這兩種治療方式之差異，也是得到相同的結果。(3) 此外我們以多層次分析的統計，發現醫院之下咽癌服務量增加時治療費用有顯著之減少。其他統計方式之結果，顯示醫院之服務量增加時，下咽癌之復發率減少。醫院層級確實影響到治療之併發症的發生率，在醫學中心之併發症減少。 結論: 就目前台灣的醫療環境及我們過去在下咽癌之治療成效而言，建議對一般的下咽癌病患應首先考慮採用放化療；但為了醫學的發展，在醫學中心則可以考慮手術加輔助性放化療，希望我們也能發展到最好的美日水準，之後再普及到一般醫院。
並列摘要
Background: National Health Insurance has encountered a hard situation of financial difficulty in the recent years. Now the policies of global budget and Tw-DRG have been implemented. However, the diagnosis and treatment of malignant tumors are not under the control of Tw-DRG. A lot of medical resources especially advanced technologies ( including CT, MRI, various reconstructive procedures, gamma knife, PET, modern radiation modalities and chemotherapy, etc) have been extensively applied for detection and treatment of oral cancers, especially hypopharyngeal cancer (HPC). Among the oral cancers hypopharyngeal cancer is selected for study because it has minimal confounding factors due to its short survival, which is most closely related to the control of the malignancy. Taiwan has much higher incidence of HPC than the developed countries. However, we always follow the treatment proposed by the developed countries, even though there is still controversy between the two treatment strategies of HPC. The results of our HPC patients in Taiwan are actually unknown. Objects: A study should be carried out for evaluation and comparison between the two options of treatment, and find out the best strategy for our country. This model of research can be applied to improve the management of other cancers. Material and Methods: Hypopharyngeal cancer (HPC) is a special subcategory among oral cancers. It is the most difficult one in diagnosis, also has controversies in treatment. With the advancement in technology, many drawbacks have been overcome. From Taiwan Cancer Database (TCDB) and National Health Insurance Database (NHID) as well as death registry, the data of hypopharyngeal cancer from 2005 to 2009 can be analyzed concerning the differences of the two major treatment modalities (radical surgery with adjuvant chemoradiation, versus organ preservation-intended treatment ), and the efficacy is compared according to the length of survival, time before recurrence, rate of major complications, feeding mode,and subjective evaluation of quality of life. From the above data multilevel analysis can be used to find the relationship between the volume of HPC patients indifferent hospitals versus cost and the rate of major complications after treatment, which is the major source of cost. Because HPC is located at a strategic position, its treatment will cause specific physiologic problems. Thus a series of objective indices can be established as a base to evaluate quality of life. Results: (1) In Taiwan the quality of care and subjective quality of life after treatment of HPC showed better results when the patients were treated with chemoradiation (OPIT) instead of operation with perioperative chemoradiation. However, the time of survival is longer when the patients receive operation and peri-operative chemoradiation. (2)Using Delphi method we developed an objective measurement with 6 physiologic indices for evaluation after treatment of HPC. It showed the same result. (3) Multilevel analysis showed that when the patient volume was increased, the cost would become less. Other analysis showed that when the volume of patient is increased, the recurrence rate becomes less. The complication rate is less in the medical centers. Conclusions: Under the present healthcare situation of Taiwan, it is suggested that chemoradiation alone ( OPIT) should be considered as the first option for most of our HPC patients. However, for continuous development of medicine, operation with peri-operative chemoradiation can be considered in the medical centers, in order to reach the highest international level, then the best treatment can be extended to other hospitals.