探討住院安寧療護病人醫療資源耗用與死亡及其相關影響因素之研究

研究目的目的一：探討住院安寧療護病人盛行率及其相關影響因素。目的二：探討住院安寧療護病人醫療資源耗用及其相關影響目的三：探討住院安寧療護病人死亡率及其相關影響因素。研究方法本研究為回溯性研究，追蹤時間從2009年9月至2010年12月，研究樣本為接受全民健保住院安寧療護病人爲研究對象，由全民健康保險研究資料庫之DD住院醫療費用清單明細檔、ID承保資料檔、HOSB醫事機構基本資料檔取樣。總樣本數480人，採用SPSS 19.0統計套裝軟體進行資料統整分析，包括卡方檢定(χ2-test)、獨立樣本t檢定(T- test)、單因子變異數分析(One-way ANOVA)、複迴歸分析(Multiple regression analysis)、Cox存活分析進行推論性統計分析。研究結果本研究發現全國百萬人口每一千個住院癌症病人住安寧病房盛行率呈現下降之趨勢(10.51%→2.86%)。趨勢分析部分，有肺癌的病患，隨著時間改變，T4的住院安寧療護病人是T1的1.92倍，達統計上顯著意義（95%CI：[1.01, 3.63]）。住院天數複迴歸分析中，年齡、治療模式(放射線治療、管灌膳食、血液透析、復健治療)、肝癌有無對住院天數達統計上顯著意義(P<0.05)。醫療總費用複迴歸分析部分，治療模式(放射線治療、管灌膳食、血液透析、復健治療)有統計上的意義(P<0.001)。接受安寧療護住院至死亡≦30天之死亡分析結果，有肝癌死亡風險是沒有肝癌的1.56倍(P＝0.002)，住院天數每增加一天死亡率下降0.2倍(P＜0.001)。接受安寧療護住院至死亡≦180天之死亡分析結果，有肝癌為沒有肝癌的1. 41倍(P＝0.006)，有乳癌是沒有乳癌的1. 59倍(P＝0.038)，住院天數每增加一天死亡率下降0.38倍(P＜0.001)。住院安寧療護病人的人口學特性、臨床特性、醫院特性變化與臨終場所之分析結果，有放射線治療臨終場所的勝算值(醫院死亡/病危自動出院)是沒有放射線治療的1.9倍(P＝0.023)，有復健治療臨終場所的勝算值(醫院死亡/病危自動出院)是沒有復健治療的0.15倍(P＝0.009)，區域醫院臨終場所的勝算值(醫院死亡/病危自動出院)是地區醫院的0.36倍 (P＜0.001)，醫師服務量每增加一人，臨終場所的勝算比(醫院死亡/病危自動出院)是未增加前的0.87倍(P＝0.002)。結論與建議全國百萬人口每一千個住院癌症病人住安寧病房盛行率呈現下降之趨勢，可能與行政院衛生署國民健康局自2007年推動安寧共同照護試辦計畫有關，一開始有5家醫院加入，2008年增加為38家，2009年又增加為42家，其中只有26%安寧共同照護病人轉至安寧病房住院，且逐年增加安寧共同照護病人數，使得住院安寧療護利用率減少，而使住安寧病房盛行率呈現下降之趨勢。整體來說，安寧療護利用率（安寧共同照護加住院及居家安寧療護）逐年上升，2009年癌症死亡個案使用安寧療護利用率19.6%，2000年7月至2001年12月安寧療護利用率22.4%，但對於末期病人健保支付來說，無效醫療仍是佔了絕大多數，如何有效地推動末期病人安寧療護利用乃是當務之急。隨著時間增加住院安寧療護病人有肺癌比沒有肺癌增加1.92倍，行政院衛生署統計2010年較2009年肺癌死亡人數增加3.06%，標準化死亡率增加2.79%。肺癌死亡人數增加、表示其末期住院人數也增加，相對造成肺癌住院安寧療護病人的增加。

關鍵字

安寧療護；醫療資源耗用；死亡

並列摘要

Purposes Objective one: To investigate the prevalence of hospitalized hospice patients and related factors. Objective two: To investigate the hospitalized hospice patient medical resource utilization and related factors. Objective three: To investigate the hospitalized hospice patient mortality and related factors. Methods All hospitalized hospice patients were included into this retrospective population-based study from September 2009 to December 2010. Total sample size was 480 people. The SPSS 19.0 statistical software package was used for data integration analysis. The chi-square test (χ2-test), independent sample t-test (T-test), single-factor analysis of variance (One-way ANOVA), multiple regression analysis, and Cox survival analysis for were employed for inferential statistical analysis. Results The prevalence of hospitalized hospice cancer patients decreased significantly from 10.51/105 in 2009 to 2.86/105 in 2010. According to the trend analysis, patients with lung cancer, hospitalized hospice patients in T4 was significantly 1.92 times than in T1 (95% CI: [1.01, 3.63]). The significant impact factors of hospitalization were age, mode of treatment (radiation therapy, tube feeding diet, hemodialysis, rehabilitation), and liver cancer (P <0.05). Treatment modalities (radiation therapy, tube feeding diet, hemodialysis, rehabilitation) are statistically significant associated with total hospital treatment cost (P <0.001). According to the duration from receiving hospitalized hospice to death ≦ 30 days, there is no risk of liver cancer liver cancer death 1.56 times (P = 0.002), the number of hospital days per additional day mortality rate decreased by 0.2-fold (P <0.001). According to the duration from receiving hospitalized hospice to death ≦ 180 days, results have liver cancer with no liver cancer 1.41-fold (P = 0.006), with breast cancer is no breast cancer 1.59-fold (P = 0.038), length of hospital stay for each additional one day mortality decreased 0.38-fold (P <0.001). After adjusting for hospitalized hospice patient demographic characteristics, clinical characteristics, hospital characteristics and dying place, the results showed that patients with radiation therapy dying place (hospital death / dying automatically discharged) was 1.9 times than those without radiation therapy there is no radiation therapy (P = 0.023), patients with rehabilitation dying place was 0.15 times than those without rehabilitation (P = 0.009), patients treated at regional hospitals dying place was 0.36 than those treated at district hospitals (P <0.001), and patients treated by high-volume physician was 0.87 than those treated by low-volume physician (P = 0.002). Conclusions and recommendations The decreased trend of this nationwide hospitalized hospice cancer patients may be due to the policy of the Department of Health Bureau of Health. Since 2007 the Government promoted hospitalized hospice shared care Pilot Project. At the beginning (2007), there are five hospitals to join, 2008 increased to 38, but in 2009, it has increased to 42, of which only 26% of hospice shared care patients go to the hospitalized hospice and gradually increased the number of hospitalized hospice shared care patients, making the utilization of inpatient hospice reduced, and leaving live hospice prevalence downward trend. Overall, medical utilization of hospitalized hospice (plus hospice shared care and inpatient hospice and home care) increased annually, 19.6% in 2009, from July 2000 to December 2001 increased to 22.4%. However, payment for health care for terminally illness patients, health care is still valid in the majority, but how to effectively promote the terminally illness hospice use is a priority. Additionally, increased in lung cancer deaths may also increase the number of hospitalizations and its final relative hospitalized hospice patients.