輔助治療模式對可切除之直腸癌病人的療效與醫療資源使用之影響

Medical Resource Utilization and Outcome of Adjuvant Treatment Modalities in Resectable Rectal Cancer Patients

崔樂平(Le-Ping Tsuei)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2013年)

摘要

目的
探討手術切除之直腸癌病人，不同的輔助治療模式與醫療資源耗用以及療效的關係。
方法
本文是一回溯性研究，從2006年1月至2010年12月，收集南部一家醫學中心，225位接受手術切除之直腸癌病人。資料分析包括病人疾病基本資料，以及2006年1月到2012年12月，病人在該醫院發生之包括門急診及住院，所有癌症相關醫療資源耗用。本研究將樣本分為同步和非同步化學放射治療(化放療)兩組；再將同步化放療分為術前同步化放療(治療模式A)、術前同步化放療加術後化療(治療模式B)以及術後同步化放療(治療模式C)三組，分別分析其當次住院及短、中、長期及整體之醫療資源耗用以及療效。時間定義如下：短期為診斷後6個月內，中期為診斷後6至18個月，長期為診斷後18個月以上。
統計分析利用SPSS 19.0統計套裝軟體，以描述性、獨立樣本t檢定、變異數檢定、卡方檢定、複迴歸分析、對數迴歸分析、Kaplan-Miere存活分析以及Cox迴歸進行資料分析與驗證。
結果
排除36個同時有兩種癌症以及資料不全之樣本後，共189個病例進入分析。研究樣本的平均年齡為64.7歲，追蹤時間為41.2個月，當次手術平均住院日數為17日，當次手術平均住院費用為151,255元；總醫療費用部分，短期平均為312,564元，中期平均為166,387元，長期平均為206,312元，整體平均為651,178元。
整體醫療費用以短期最高，長期次之，中期最少；結構部分以住院費用最多，約占70%。整體而言，同步化放療總費用高於非同步化放療，短期分別為401,585元及248,632元(p<0.001)；中期分別為259,693元及96,847元(p<0.001)；長期分別為240,193元及182,163元(p=0.30)；整體分別為864,986元及497,623元(p<0.001)。在同步化放療的治療模式A、B、C中，除了中期之外，各期總費用並無顯著差異，中期總費用在治療模式A、B、C中分別為149,705元、341,234元及196,170元(p=0.002)。當次手術住院費用和短期醫療總費用主要預測因子為併發症，有併發症的總費用分別多76,168元及90,954元；中期、長期和整體總費用主要預測因子為病理分期和復發狀態，各時期有復發者之總費用比無復發者分別多268,292元、509,972元及719,507元。
同步和非同步化放療在整體存活率上並無顯著差異。同步化放療的三種治療中，無病存活率及整體存活率也無顯著差異；但術前化放療的肛門括約肌保留手術的比例較高，治療模式A、B、C分別為85%、73.2%及44.4%(p=0.01)。
結論和建議
本研究發現併發症是影響當次手術住院及短期醫療支出的顯著因子，病理分期和復發有無是影響直腸癌中、長期及整體醫療支出的顯著因子。建議相關衛生機關和各醫院加強大腸直腸癌的篩檢、減少併發症的發生以及落實病人的追蹤，以期能早期診斷，進而降低醫療支出。

關鍵字

直腸癌 ； 輔助治療模式 ； 同步化學放射治療 ； 醫療資源耗用

並列摘要

Purpose
To investigate medical resource utilization and outcome of adjuvant treatment modalities in resectable rectal cancer patients
Methods
From January 2006 to December 2010, we reviewed 225 resectable rectal cancer patients, retrospectively. We analyzed the data including the characteristics of the patient, cancer, and cancer related outpatient/inpatient medical resource utilization at the hospital from January 2006 to December 2012. All patients were divided into concurrent and non-concurrent chemoradiotherapy (CCRT and non-CCRT) groups. We also divided the CCRT group into preoperative CCRT (Model A), pre-operative CCRT and post-operative chemotherapy (Model B), and postoperative CCRT (Model C) groups. We analyzed the operation hospitalization, short-term, mid-term, long-term and overall medical resource utilization and outcome. Timing definition was as follows: short-term: within 6 months after diagnosis; mid-term: 6-18 months after diagnosis; long-term: over 18 months after diagnosis.
Result
36 patients with second malignancy and incomplete data were excluded. 189 patients were enrolled in this study. The mean age of the patients was 64.7 years. In average, the follow-up time is 41.2 months; the operation hospitalization hospital stay was 17 days; the operation hospitalization cost was 151,255 NTD; the short-term total dose was 312,564 NTD, mid-term total cost was 166,387 NTD; the long-term total cost was 206,312 NTD and overall total cost was 651,178 NTD.
The amount of overall cost was: short-term > long-term > mid-term. The inpatient cost was about 70% of total cost. The cost of CCRT was higher than non-CCRT and the short-term, mid-term, long-term and overall cost were 401,585 vs. 248,632, p<0.001; 259,693 vs. 96,847, p<0.001; 240,193 vs. 182,163, p=0.30; 864,986 vs. 497,623, p<0.001, respectively. In CCRT group, no total cost difference was observed in model A, B, C, except mid-term. The mid-term total cost is 149,705 vs. 341,234 vs. 196,170, p=0.02, respectively. The significant predictive factor of total cost in operation hospitalization and short-term was complication; mid-term, long-term and overall was pathologic stage and recurrence. Tumor recurrence increased the total cost of mid-term, long-term, overall by 268,292 NTD、509,972 NTD and 719,507 NTD respectively.
No overall survival difference is observed in CCRT and non-CCRT groups. There was no disease-free survival or overall survival difference among model A, B, C in CCRT. However, the sphincter preservation surgery rate is higher in pre-operative CCRT setting. The sphincter preservation surgery rate in model A, B, C were 85%、73.2% and 44.4% (p=0.01).
Conclusion
Our result showed the significant impact of the pathologic stage and recurrence to the medical cost of rectal cancer treatment. The authorities and hospitals should pay more attention to rectal cancer screening. Early diagnosis may decrease the rectal cancer medical treatment cost.

並列關鍵字

rectal cancer ； adjuvant treatment ； concurrent chemoradiotherapy ； medical resource utilization

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