乳癌病人疾病管理與治療結果之分析-以論質計酬試辦計畫參與醫院為例

Disease Management and Outcome Evaluation of Breast Cancer Patients

蔡翠珍(Tsui-Chen Tsai)

指導教授 ： 湯澡薰

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2007年)

摘要

研究目的：比較「全民健康保險乳癌醫療給付改善方案試辦計劃」試辦醫院的收案病人，在醫療資源的利用、治療方式和醫療品質等情形是否有顯著差異。

研究方法：擷取試辦醫院於2003年4月至2004年12月開始治療、無復發狀況且完治的個案共2033人，觀察上述個案自治療日起1年內全國西醫醫院及基層診所的門、住診醫療費用申報資料，並經由勾稽全民健康保險之保險對象承保資料檔、全民健康保險重大傷病檔、治療完成個案醫療明細檔（B表），以分別取得投保、死亡、重大傷病及復發等資料。以百分比及平均數（標準差）來描述病人與醫院的特質；以卡方檢定、平均值t檢定及F檢定來了解病人及醫院的特質，在醫療利用、治療方式和醫療品質等情形是否有顯著差異；以線性複迴歸分析及羅吉斯複迴歸分析來評值醫療利用、治療方式和醫療品質等方面，在醫院間是否有顯著差異。

研究結果：B、C、E、F醫院病人的平均總就醫次數顯著偏高。B醫院之病人急診情形顯著偏高。各醫院間收案病人之跨院就醫次數沒有顯著差異。除第0期病人外，醫院間對相同期別的病人存在著不同的治療方式。B及C醫院之第0及1期手術病人執行乳房保留手術情形顯著偏低。C醫院病人治療開始一年內之復發情形顯著偏高。E醫院病人治療開始一年內之死亡情形顯著較低。

結論：試辦醫院在疾病管理與治療結果上有顯著的差異，中央健康保險局應繼續監測各醫院的治療及品質狀況。

關鍵字

乳癌 ； 論質計酬 ； 疾病管理 ； 醫療利用 ； 治療方式 ； 醫療品質

並列摘要

Objectives: To compare the health care utilization, treatment modality and clinical outcome among patients enrolled in the “National Health Insurance Breast Cancer Disease Management Program”.

Methods: A total 2,033 newly diagnosis breast cancer patients participated in this program during April 2003 and December 2004 were identified from Enrollment list（Table A）and Closed case list（Table B）. The National Health Insurance（NHI）claims data related medical uses were traced for one year from the date of principal treatment. Information on patients’ treatment modality and clinical outcome was retrieved from Table B and Death file.
Percentage and mean（standard deviation）were used to describe patient’s characteristics and institution’s factors. χ2 test, t test and F test were used to test whether health care use, treatment modality and clinical outcome were significantly different among patient’s characteristics and institution’s factors. Multiple Logistic regression was employed to assess whether health care use, treatment modality and clinical outcome were significantly different among hospitals.

Results: Compared with patients treated in Hospital A, patients treated in Hospital B、C、E and F have higher number of visits. Compared with patients treated in Hospital A, patients treated in Hospital B have higher number of emergency visits. There was no significant difference in number of irregular visits. Except for non- invasive patients treatment modalities were significantly different among hospitals. Compared with patients treated in Hospital A, patients treated in Hospital B and C were significantly less likely to undergo breast conserving surgery. Compared with patients treated in Hospital A, patients treated in Hospital C was significantly more likely to recurrent within one year. Compared with patients treated in Hospital A, patients treated in Hospital E was significantly less likely to die within one year.

Conclusions: There were significant differences exist in disease management and outcome between hospitals participated in this program. The NHI should keep monitoring on treatment and quality of the hospitals.

並列關鍵字

Breast Cancer ； Disease Management ； Health Care Utilization ； Treatment Modality ； Clinical Outcome

參考文獻

王貴霞、劉哲銘、呂志得（2005）。乳癌病患的困擾及擔憂問題。北市醫學雜誌，2（9），844-850。

朱娟秀 （2001）。乳癌病理診斷。台灣醫學雜誌，5（5），552-556。

朱娟秀、黃俊升、張金堅（1998）。乳癌的病理特徵在預後的重要性。慈濟醫學雜誌，10（4），265-271。

林慧淳、葉玲玲、吳仁佑、黃達夫 （2002）。以醫療品質的觀點探討台灣乳癌之診療型態。台灣公共衛生雜誌，21（5），349-362。

陳海雯、張財旺、蘇五洲、郭浩然、曹朝榮、梁永昌（2000）。醫學中心可手術之侵襲性乳癌的放射治療成果。放射治療與腫瘤學，7（4），221-231。