新診斷結直腸癌病患術後之長期療效與醫療資源使用探討

摘要研究背景與目的於已開發國家中，結直腸癌(Colorectal Cancer, CRC)是非常常見且重要疾病。在台灣結直腸癌發生率及死亡率有逐年增加的趨勢。目前國內外針對結直腸癌的研究較少以資料庫進行術後療效及其醫療資源使用，甚至追蹤中長期療效。因此，本研究目的為探討新診斷結直腸癌住院病患及接受外科手術病患其人口學、疾病特質、治療特質及就醫醫院特質之趨勢分布；探討新診斷結直腸癌外科手術病患當次術後併發症、住院或出院天內死亡的療效、醫療資源使用和其影響因子；探討影響病患接受不同手術方式之因子及療效差異；探討接受結直腸癌手術病患術後中長期療效、醫療資源使用及其影響因子。研究方法本研究為兼具橫斷性及縱貫性研究，利用次級資料庫進行分析，以回溯性方式進行研究。研究期間為1998年1月1日至2009年12月31日為止，共計12年。研究對象為1998年初至2009年底新診斷結直腸癌且接受切除手術個案，共80,413人。本研究利用重大傷病證明明細檔、住院醫療費用清單明細檔、承保資料檔、醫事機構基本資料檔，串聯檔案及資料處理後，對本研究新診斷結直腸切除手術個案進行分析研究。統計分析採用SPSS18.0統計軟體，以t-test、卡方檢定、獨立樣本t檢定、變異數檢定、對數迴歸分析、多變項對數迴歸分析、複迴歸分析、Kaplan-Meier存活分析、Cox 迴歸模型進行資料分析及驗證假說。研究結果研究期間1998年至2009年止，結直腸癌住院病患持續增加，接受切除手術病患比率也從1998年的71.4%增加至2009年79.6%。研究十二年間併發症有增加情形；而當次住院死亡率則有減少情形；平均住院天數呈現下降情形；平均醫療費用則逐年增加。病人平均手術年齡65.3歲，腹腔鏡手術佔3.9%，平均住院天數18.5天，平均醫療費用為148,058元。在男性、年齡≥75歲、CCI>0分、腸阻塞、腹膜炎及腸穿孔、低服務量醫院及醫師中，有次要及主要併發症風險較高。在年齡≥75歲、結腸、傳統開腹式、CCI＞0分、有併發症、腸阻塞、腹膜炎及腸穿孔、低服務量醫院及醫師中，有當次住院或出院30天內死亡風險較高。校正其他因子後，年齡、性別、合併症、社經地位、腸阻塞、腹膜炎及腸穿孔、手術方式、醫院層級、醫院、醫師服務量、併發症皆為結直腸癌外科手術病患醫療資源耗用之重要影響因子。有主要併發症的病患較無併發症的病患住院天數多12.4天，醫療費用多106,302元。高服務量醫師較低服務量醫師其病患住院天數少3.5天，醫療費用少21,771元。對於腹腔鏡術式的選擇，在診斷部位、合併症、社經地位、醫院屬性及層級、醫師服務量皆為影響當次手術方式之因子。其中高服務量醫師執行腹腔鏡手術的機會是低服務量醫師的2.15倍(OR=2.15，95%CI=1.91~2.42)。長期療效方面，年齡、診斷位置、醫院屬性、合併症、醫師服務量、併發症、腸阻塞、腹膜炎及腸穿孔皆為存活影響因子；合併症≥3分的死亡風險是合併症0分的3.30倍(HR=3.30，95%CI=3.21~3.39)。結論與建議合併症分數、腸阻塞、腹膜炎及腸穿孔、醫院醫師服務量皆為影響式術後療效及醫療資源耗用的重要因子。在長期療效方面年齡、診斷位置、醫院屬性、合併症、醫師服務量、併發症、腸阻塞、腹膜炎及腸穿孔皆為存活影響因子。因此病患於術前應了解自身狀況，做好健康管理以減少合併症的產生；醫療提供及照護者應於病患治療前即詳細了解其狀況，有合併症的病患應妥善做好治療及控制，而在術後透過完善的照護，藉此減少住院天數及節省醫療費用。本研究也發現腹腔鏡手術較傳統開腹式手術有較好的療效及較少的醫療資源耗用情形。且高服務量的醫師執行腹腔鏡手術機會較低服務量醫師高，但腹腔鏡手術需要一定的時間和手術例數來完成其學習曲線，建議高服務量的醫師可以給予低服務量醫師指導及經驗傳授，使更多人力投入於執行腹腔鏡手術。

關鍵字

結直腸癌；手術；服務量；腹腔鏡；療效；醫療資源使用；存活分析

並列摘要

Abstract Background and Purpose In developed countries, colorectal cancer (Colorectal Cancer, CRC) is a very common and important disease. There is a rising trend in incidence and mortality of colorectal cancer in Taiwan. In the past, there are few studies about CRC treatments after surgery and medical resources utilization, and even to track medium-and long-term efficacy that using national database.Therefore, this study aimed to explore the new diagnosis of colorectal cancer inpatient and surgical patient demographics, disease characteristics, treatment characteristics and the medical treatment to the hospital characteristics distribution.To explore the CRC surgical patients who has postoperative complication, inhospital and 30-days mortality, and the efficacy of medical resourse and it’s impact factors. Also examining the outcome and resourse utilization of the patients received Laparoscopic surgery. Furthermore, follow the CRC surgical patients long-term efficacy, medical resource use and it’s impact factors. Methods This is a both cross-sectional and longitudinal study, and retrospective to use secondary database to analysis. During the study period January 1, 1998 to December 31, 2009, a total of 12 years. The subjects were newly diagnosed colorectal cancer and underwent surgery cases in early 1998 to the end of 2009, a total of 80,413 people. Data soures were use Registry for catastrophic illness patients(HV), Inpatient expenditures by admissions (DD), Registry for beneficiaries (ID), and Registry for contracted medical facilities (HOSB) four registration files. And all statistical analysis were performed using SPSS18.0 statistical software, used t-test, chi-square test, independent sample t-test, ANOVA test, logistic regression analysis, multivariate logistic regression analysis, multiple liner regression analysis, Kaplan-Meier survival analysis, Cox regression model to analyze the data and verify the hypothesis. Results In the study period of 1998-2009, the hospitalized patients of colorectal cancer continues to increase,the percentage of patients undergoing excision surgery increased from 71.4% in 1998 to 79.6% in 2009. Patients who had complications were increased between 12 years, and hospitalization mortality and length of stay were to decrease, but average inpatient medical costs were to increase. The surgical patients average age was 65.3 years old, 3.9% patients used laparoscopic surgery, and average length of stay were 18.5 days and the average inpatient medical costs were 148,058NTD. Patients who are male, age ≥ 75 years, CCI> 0, intestinal obstruction, peritonitis and intestinal perforation, and operated by low-volume hospitals and physicians, had high risk in secondary and major complications. And patients in age ≥ 75 years, colon cancer, open surgery, CCI> 0, complications, intestinal obstruction, peritonitis and intestinal perforation, and operated by low-volume hospitals and physicians, were high risk in inhospital and 30-days mortality. After adjusting for coveriates, age, gender, comorbidities, socioeconomic status, intestinal obstruction, peritonitis and intestinal perforation, the surgical approach, the hospital level, volume and complications are impact factors of CRC surgical patients inpatient medical use. Patients with major complication the length of stay and medical costs significantly more than without complicatons 12.4 days and 106,302NTD. Patients’ surgery by high volume surgeon the length of stay less than low volume surgeon 3.5 days, and medical costs less 21,771NTD. In the use of laparoscopic surgery, comorbidities, socioeconomic status, the property and level of hospital, and the volume of surgeon are impact factors. Used laparoscopic surgery were 2.15 times of high volume surgeons than low volume surgeons. The long-term efficacy, the impact factors of survival are age, diagnosis location, intestinal obstruction, peritonitis and intestinal perforation, hospital property, comorbidities, surgeon volume and complications. Conclusion and recommendations The study found that, comorbidity score, intestinal obstruction, peritonitis and intestinal perforation, hospital and surgeon volume all affect the post-operation outcome and medical resourse utilization. In long-term efficacy, age, diagnosis location, intestinal obstruction, peritonitis and intestinal perforation, hospital property, comorbidities, surgeon volume and complications are survival impact factors. Before surgery, patients should do well self health management to reduce comorbidity, and health care providers should learn more about patients condition, give the patients with comorbidities appropriate treatment, and provid comprehensive care after surgery to reduce the length of days in hospital and save medical costs. The study also found that laparoscopic surgery compared with traditional open surgery have better outcome and fewer medical resources utilization. The opportunities of performe laparoscopic surgery are more in high volume surgeons than low volume surgeons, and laparoscopic surgery requires time and cases to train and to complete the learning curve. Recommend high volume surgeons to give low volume surgeons more guidances and experiences, after that more manpower can provid this technique.