乳癌試辦計畫品質指標在第三期乳癌病人治療之效果評估

施長慶(Chiang-Ching Shih)

指導教授 ： 郭震坤

共同指導教授 ： 陳國泰

國立臺灣大學/管理學院/會計與管理決策組/碩士(2006年)

https://doi.org/10.6342/NTU.2006.10291

摘要

乳癌試辦計畫品質指標乃是經實證醫學資料收集、專家討論並用健保資料實證後由健保局公布，包含結構面、過程面與結果面各項的品質指標，用以確保乳癌病人的醫療品質，並作為論質計酬的基本衡量工具。本研究主要在應用乳癌試辦計畫品質指標，針對某癌症中心乳癌第三期病人，作其臨床意義與醫療費用分析的實證研究。
本研究為一回溯性研究，採用次級資料，臨床資料來自醫院臨床研究室之乳癌病人癌症資料庫，財務資料來自醫院財務部收據檔資料庫。資料分析包括描述性與分析性統計，以獲得下列資訊：1. 流行病學與事件史，2.乳癌試辦計畫各品質指標於各年代執行情況，3. 品質指標執行情況與預後的關係，4. 不同品質指標執行率、預後與醫療費用的關係，與5. 根據上列資料作對於包括未來研究者、醫院行政管理、與健保局的建議。
研究發現，在收集的208位病人資料可以看出1. 乳癌第三期病人平均49歲，有67人經治療後復發，51人復發後死亡。2. 自1990至2000年，某癌症中心各品質指標執行率很高(81%-99%)，但診療指標完全執行情況則較低(66%-81%)，自1997年全面實施診療準則後，診療指標完全執行有明顯的改善(56-74%提昇至75-87%)。3. 治療完全執行，不論年代，對存活率與無病存活率均有極大的影響(p < 0.01)。4. 復發病人醫療費用是無復發病人的兩倍(856,818元比449,474元)，治療完全執行這一組病人加上復發風險平均費用為627,619元，而治療不完全執行這一組為439,441元，差別188,178元，但是兩組復發率相差24%而存活率相差33%。5. 由於過程面指標直接關係於預後，且指標完全執行更重要，基於癌症診療是一體而不可分割的特性，一個良好的醫療團隊與在診療過程面即用品質指標予以監控，方能改善病人的預後並保障醫療品質。乳癌病人發病年齡較年輕，其估計餘命平均約20年，指標完全執行即使有較高的醫療費用也是值得考慮的。

關鍵字

論質計酬 ； 醫療品質 ； 品質指標 ； 完全執行

並列摘要

The quality indicators of pay-for-performance for breast cancer are originated from the evidence-based literature review, formed through expert meeting and tested by the data of National Health Insurance Bureau and implemented by National Health Insurance Bureau to assure the quality of care of breast cancer patients and be the fundamental measurement of pay-for-performance. The content consisted of three parts: structure, process and outcome. The purpose of this study is to evaluate and analyze the clinical outcomes and medical expenses of stage III breast cancer patients in one cancer center by the quality indicators mentioned above.
In this study, we collect data retrospectively from clinical protocol office and financial department of one cancer center. The major issues to be analyzed are: 1. epidemiological data and time to event, 2. the adherence rates of each quality indicators in each year, 3. the relationship between adherence rate and outcome, 4. the relationship among the adherence rate, outcome and expense, 5. the suggestion proposed for future research, hospital administration and policy makers based on the findings of this study.
The major findings from this 208-patient study are:
1. The average age of disease acquisition is 49 years old and 67 patients had recurrence and 51 patients expired after recurrence.
2. The average adherence rates of each quality indicators are high (81% to 99%) but the rates of total adherence of diagnosis and treatment indicators are lower (66% to 81%). There is significant improvement in the rates of total adherence after the implementation of treatment guideline in 1997(from 56-74% to 75-87%).
3. The total adherence of treatment indicators has the most significant impact on survival rate and disease-free survival rate, no matter before or after 1997.
4. The average expanse of recurrence patients is almost two times as much as those non-recurrence patients (856,818 vs. 449,474 NTD). The total average expanse (including risk of recurrence) of those patients with total treatment adherence is 627,619 NTD and 188,178 NTD higher than those without total treatment adherence. But the differences of recurrence rates and mortality rates between these 2 groups are 24% and 33%.
5. Because of the significant relationship between the process and outcome quality indicators, the importance of total treatment adherence, and the integrity and continuity of cancer treatment, the author suggests that it is important to have a functional team and the system for monitoring the adherence of the quality indicators. In this way, the improvement of outcome and quality of care can be assured. The young age, and their expected long-term survival (estimated median survival year 20 years) of stage III breast cancer patients make total treatment adherence worthwhile, although the average expense is higher.

並列關鍵字

Pay-for-Performance ； Quality of Care ； Quality Indicator ； Total Adherence

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