新診斷食道癌與胃癌趨勢及食道癌外科手術治療療效 與醫療資源利用

Trend for Newly Diagnosed Esophageal and Gastric Cancers and the Outcomes and Resource Utilization of Surgical Esophageal Cancer Patients.

李善茹(Shan-Ru Li)

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(2012年)

摘要

研究目的
食道癌與胃癌分別為全球癌症發生率排名第八及第四名之常見癌症，而我國十大癌症死因中則排名第八及第六名，在消化器官中死亡率僅次於肝癌及結直腸癌，在治療方式中以外科手術切除為主，希望透過本研究能了解外科手術治療療效(包含當次住院併發症、當次住院死亡及出院30天內死亡)與醫療資源耗用(包含當次住院天數與費用)情形。

研究方法
本研究採用次級資料分析法，以回溯性與兼顧縱貫、橫斷面方式進行研究。合併「全民健康保險資料庫」中住院費用清單明細檔(DD)、重大傷病證明明細檔(HV)、醫事機構基本資料檔(HOSB)以及承保資料檔(ID)等資料庫，分析1998年1月至2009年12月期間新診斷食道癌與胃癌病患，以及其中有接受外科手術之4,782名食道癌病患。採用SPSS 19.0統計軟體進行分析，包含卡方檢定、獨立樣本t檢定、變異數檢定、多項式對數迴歸分析(Multiple Multinomial logistic regression)、複迴歸分析、Kaplan-Meier存活分析、Cox 迴歸模型。

研究結果
新診斷食道癌病患平均年齡為60.8歲，診斷位置以重複或不明確占多數，上或中1/3食道癌有逐年增加趨勢；新診斷病患中有4,782名病患接受外科手術(占新診斷病患26.3%)，且有逐年增加的趨勢。新診斷胃癌病患方面，平均年齡為67.0歲，診斷位置以重複或不明確占多數，中或下胃部病患有逐年增加趨勢；新診斷病患中有25,311名病患接受外科手術(占新診斷病患55.8%)，有逐年增加的趨勢。

食道癌外科手術病患中，在當次治療療效方面，當次住院術後併發症的發生率為34.9%，平均當次住院費用為432,144元，平均當次住院天數為33.5天。校正其他因子後，有主要併發症比無併發症者在出院30天的死亡風險有顯著差異(OR=5.28，95% C.I=3.43-8.14)，在整體存活情形方面，發生主要併發症者比無併發症者有較少的平均存活時間(34.8 vs. 43.2個月，p<0.001)，在醫療資源耗用方面，發生主要併發症比無併發症者在住院天數及住院費用有顯著差異(多12.1天與196,671元，p<0.001) 。

結論與建議
有合併症的病患比例有逐年增加的趨勢，可能導致術後發生併發症的機率增加，對術後存活時間也有影響。因此，期望透過本研究了解治療療效與醫療資源耗用後，作為照護團隊與病患家屬在選擇治療方式時之參考依據，除了讓病患獲得最佳的照護服務，也讓醫療院所有效地利用醫療資源。

關鍵字

食道癌 ； 胃癌 ； 外科手術 ； 療效 ； 醫療資源耗用

並列摘要

Objective: Esophageal and gastric cancer, respectively, is the eighth and fourth most common cancer in the world. The top ten leading causes of cancer death is the eighth and sixth, and the mortality rank behind liver and colorectal cancer of the digestive system in Taiwan. The major treatment of esophageal cancer is surgical intervention. The aim of the present study is to know the surgical outcome (including postoperative complications, inhospital death and death within 30 days after discharged) and medical resource utilization (including the length of stay and the medical costs) during hospitalization.

Methods: This is a retrospective, longitudinal and cross-sectional study, with secondary data analysis. Enrolled newly diagnosed esophageal and gastric cancers patient during 1 January 1998 to December 2009, and surgical patient with esophageal cancer (N=4,782) by combining inpatient expenditures by admissions (DD), registry for catastrophic illness patients (HV), registry for contracted medical facilities (HOSB) and registry for beneficiaries (ID) from National Health Insurance Research Database. We used chi-square test, independent sample t-test, ANOVA test, multivariate logistic regression analysis, multiple regression analysis, Kaplan-Meier survival analysis, and Cox regression analysis, by using the SPSS 19.0 statistical software.

Results: Newly diagnosed esophageal cancer patients’ mean age is 60.8 years old, overlapping sites and unspecific tumor location are majority, 1/3 upper and mid of esophagus have a rising trend. Patients undergoing surgery (N=4,782) is to account for newly diagnosed of 26.3%, and there is a rising trend. Newly diagnosed gastric cancer patients’ mean age is 67.0 years old, overlapping sites and unspecific tumor location are majority, mid or lower of stomach patients are rising. There are 55.8 percent of newly diagnosed gastric patients undergoing surgery (N=25,311), and increasing year by year.

The incidence of postoperative complications within esophageal cancer surgery patients was 34.9%, the average length of days during hospitalization were 33.5 days, and the average hospitalization medical cost were $ 432,144 NTD. After adjusting for covariates, patient with major complications significantly have more risk to die during hospitalization or discharged within 30 days than patient without complications(OR = 14.36, 95% CI = 3.43-8.14). And patient with major complications significantly have more 12.1 hospital stay and $ 196,671 NTD costs than those who without complications (p <0.001). In the overall risk of postoperative death, patient with major complications has 1.32 times of risk to die than those without complications (p <0.001).

Conclusions and recommendations: The proportion of patients who have comorbidity is rising, and it may lead to increasing the risk of occurring postoperative complications, and also have an impact on postoperative survival. Therefore, to expect to understand the outcome and medical resource utilization through this study, as an option of the care team and family members of patients in the choice of treatment, to let the patients get the best care services and medical institutions the use of medical resources.

並列關鍵字

esophageal cancer ； gastric cancer ； surgical intervention ； outcome ； medical resources utilization

參考文獻

中文文獻

林淳榮. (2011). 早期胃癌的內視鏡治療 from

www1.cgmh.org.tw/lhcc/02.info/02.1.2.TxInfo/Tx_10.Ga06.pdf

林明瀅(2004)。胃癌病患院內感染之醫療資源耗用探討--以某醫學中心五年資料

為例。國立陽明大學醫務管理研究所碩士論文，台北市。