結直腸癌病患接受手術之療效、醫療資源利用及健康生活品質相關探討

Quality of Life,Outcome and Resoure Utilization For Diagnosed Colorectal Cancer Patients Received Surgical Intervention

李佳蒨(Chia-Chien Lee)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理學研究所/碩士(2013年)

摘要

研究背景與目的

結直腸癌(Colorectal Cancer，CRC)為國人多年主要癌症死因第三位。醫療服務提供必須兼具效率和療效，及病患有較佳術後健康生活品質。本研究目的為：探討接受結直腸癌手術病患人口學、疾病特質和治療特質；探討接受結直腸手術病患當次住院療效及其影響因子；探討接受結直腸手術病患當次醫療資源利用及其影響因子；探討結直腸癌病患手術前後健康相關生活品質的趨勢改變；探討影響結直腸癌病患術後健康相關生活品質改變之影響因素。

研究方法

本研究同時採用前瞻性縱貫面及回溯性的研究設計，前瞻性以健康相關生活品質的問卷，回溯性則是病歷審查。本研究資料來源有三個部分：1.疾病特質、癌症特質及治療特質為病歷審查，2.資源使用為醫院住院醫療費用申報檔，3.健康相關生活品質為訪談病人術前、術後一個月、術後三個月及術後六個月之情形。健康相關生活品質研究工具以一般性癌症病患健康相關生活品質問卷European Organization for Research and Treatment Quality of life Questionnaires (EORTC QLQ-C30)及結直腸癌特定癌症治療的功能評估問卷Functional Assessment of Cancer Therapy-colorectal (FACT-C)進行訪問評估。收案對象為南部某醫學中心2009年11月至2012年7月31日止在個案醫院確診為結直腸癌並接受切除手術的病患。

統計分析利用SPSS 19.0 統計軟體，以卡方檢定、獨立樣本t檢定、變異數檢定、對數迴歸分析、複迴歸分析並使用STATA 8.0 版以廣義估計方程式控制研究時間點變項進行資料分析及驗證假說。

研究結果

結直腸癌手術病患平均年齡67.31歲、當次平均住院天數16.2天、當次醫療費用154,520元。當次住院療效部分，控制其他因素後，年齡、ASA(American Society of Anesthesiologists)分級、淋巴結侵犯為住ICU的重要影響因子。年齡大於75歲者住ICU的機率是小於65歲者的6.18倍(OR=6.18，95%CI=1.49~25.69)、麻醉ASA3~4級者住ICU的機率是1~2級者的2.79倍(OR=2.79，95%CI=0.62~12.62)。當次醫療資源利用部分，控制其他因素後，腸造口與術後併發症為當次醫療資源耗用的影響因子，有腸造口者比無腸造口者住院天數多5天，醫療費用多17,276元；術後有併發症的病患比沒有併發症的病患住院天數多10天，醫療費用多85,147元。

一般性癌症病患健康相關生活品質 (EORTC QLQ-C30)在術前、術後一個月、術後三個月、術後六個月之整體生活品質分數分別為53.98、64.21、66.3、69.54，隨著時間皆有逐漸改善；結直腸癌特定癌症治療的功能評估問卷(FACT-C)生理健康構面分數則分別為22.62、23.98、24.01、24.63。控制疾病特質、癌症特質及治療特質後，性別、年齡、教育程度、BMI值、家戶月收入和術後住ICU等因素皆會顯著影響術後的生活品質分數。

結論與建議

術後併發症是醫療資源耗用的重要影響因子，醫療照護團隊使病患在術後獲得最佳照護不僅具有醫療品質，也藉此減少手術病患的住院天數及有效地利用醫療資源。本研究指出手術後6個月健康相關生活品質改善趨勢，術後出院時間越久，生活品質各構面皆越佳，研究進一步表示當外科手術對結直腸癌病患是必要的，生活品質是手術過程成功的結果。

關鍵字

結直腸癌 ； 療效 ； 醫療資源使用 ； 生活品質

並列摘要

Objectives

Colorectal Cancer (CRC) is ranked top 3 in cancer mortality for years in Taiwan. Medical delivery has to take efficiency and effectiveness simutanously. In addition, treatment measure has to include health-related quality of life (HRQOL) after treatment. The aims of the study are: To examine characteristics of demographic, disease, and treatment for CRC patients underwent resection; to explore the medical utilization and outcome of hospital index of CRC patients and factors associated with, To explore the trends of HRQOL and factor associated with for patient underwent surgical treatment.

Methods

The study adopted both prospective and retrospectively study design. Prospective study was surveying HRQOL questionnaire, whereas, retrospective design to obtain medical chart and utilization. Data sources are: patients clinical derived from medical chart, medical utilization obtained from hospital claim data, and HRQOL were surveying patients at pre-operation, 1-month, 3-month and 6-month post operation. HRQOL instruments were used both European Organization for Research and Treatment Quality of life Questionnaires (EORTC QLQ-C30) and Functional Assessment of Cancer Therapy-colorectal (FACT-C). Sample was those CRC patients underwent surgery during November 2009 to July 2012 at one southern medical center.

Chi-square Test, independent t-test, ANOVA test, logistic regression analysis, multiple liner regression analysis were applied to test hypotheses by using SPSS 19.0 version. In addition, Generalized Estimating Equations (GEE) was used to examine longitudinal changes and factors associated HRQOL by using STATA 8.0 version.

Results

The average age was 67.31 for all CRC patients, average length of stay was 16.2 days, hospital-index expenditure was 154,520 NTD. After adjusting covariates, age, ASA (American Society of Anesthesiologists) and Lymph node involvement were predictors of ICU admission. Patients age 75 and older had 6.18 time (OR=6.18，95%CI=1.49~25.69) risk of being admitted to ICU greater than age group young than 65, and patients with ASA level 3-4 had 2.79 risk (OR=2.79，95%CI=0.62~12.62) of ICU admission than those of 1-2 level. After controlling for covariates, stoma and complication were significant variables to predict medical utilization. Patient had stoma stayed at hospital 5 more days as compared with those without stoma. Patients with complication stayed 10 more days and spend 85,147 NTD more than those patient without complication.

Patients overall generic quality of life ((EORTC QLQ-C30) were 53.98、64.21、66.3、69.54 at pre-Op, 1-month, 3-month and 6-month after operation. The QLQ score have been increasing over time. Cancer specific measure (FACT-C) were 22.62、23.98、24.01、24.63 at the same periods, which also demonstrated improving trend. After adjusting covariates, sex, age, education level, BMI, household income, and admitted to ICU were predictors of both generic and cancer specific quality of life.

Conclusions

The study found that complication is major predictor of medical utilization, a better post surgical care is not only results in a better quality of care, but also to lead to cost saving for patients underwent surgery. The study further indicated that patients experiencing improving trend in health-related quality of life 6-month after surgery. The findings implied that quality life is results of a good surgical procedure when surgery is necessary and possible to CRC patients.

並列關鍵字

Colorectal cancer ； Outcome ； Medical resourse utilization ； Quality of Life

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一、 英文部分

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