新診斷結直腸癌切除病患治療療效和醫療資源利用

研究背景與目的：結直腸癌(Colorectal Cancer，CRC)為全球常見癌症第三名。連續為近年來國人癌症發生率第二名和國人癌症死因第三位。過去少有利用臨床資料連結醫療費用為材料進行結直腸癌接受手術後之療效和醫療資源利用。因此，本研究目的主要探討接受結直腸癌手術病患術後當次住院併發症、術後住ICU、30日再入院的療效、醫療資源利用和其影響因子；探討腹腔鏡手術對結直腸癌病患之療效和經濟效益；探討接受結直腸癌手術病患術後中長期療效、醫療資源利用和其影響因子。研究方法：本研究為一縱貫性研究，以回溯性方式進行研究。收案對象為南部某醫學中心，收案期間從2005年1月至2010年12月確診為原發性結直腸癌(ICD_9_CODE：153-154)，並接受初次切除手術的病患(N=902)。研究終止日期為病歷審查的最後一次就診日期或死亡。研究資料來源主要為病歷審查和住院醫療費用。採用SPSS14.0統計軟體，利用卡方檢定、獨立樣本t檢定、變異數檢定、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。研究結果：病人平均發病年齡69.2歲，腫瘤位置以結腸比例最高68.3%，平均醫療費用126,490元，平均住院天數18.5天。校正其他因子後，當次住院期間有輸血的病患發生次要和主要併發症的機會分別為OR=3.13、OR=2.53。當次住院發生主要併發症的病患比沒有併發症的病患術後住ICU的機會高5.66(2.39-13.42)倍。腹腔鏡手術和傳統開腹式手術在治療療效和醫療資源利用方面，皆未有顯著差異。術前腸穿孔或腹膜炎病患住院天數顯著比沒有的病患多44.43天，當次住院發生次要、主要併發症的病患住院醫療費用顯著比沒有併發症的多30,903元和36,504元。中長期療效方面，合併症、AJCC和併發症為存活影響因子。AJCC分期Ⅲ、Ⅳ的病患出院後6個月內住院次數顯著比AJCC分期Ⅱ的病患多4.16次、5.39次。結論與建議：本研究發現術前有腸阻塞、腸穿孔或腹膜炎住院等不但容易併發症的產生，也影響當次住院療效和資源利用。臨床管理需重視以避免併發症的產生。腹腔鏡和傳統開腹式手術在治療療效和醫療資源利用未有差異，值得後續之研究。中長期存活和醫療資源利用方面，合併症和AJCC分期為死亡風險因子，早期檢查為重要的預防政策。

關鍵字

結直腸癌；外科手術；療效；醫療資源利用；中長期

並列摘要

Background：Colorectal cancer (Colorectal Cancer, CRC) is the third common cancer in the world. In recent years, the incidence of CRC is second for all cancer, and the third leading causes of death. In the past, there are few studies about CRC treatment after surgery outcome and medical resource utilization that using clinical data linking the medical cost. Therefore, an attempt was made to research CRC patients receiving postoperative complications when the hospitalization, postoperative in ICU, 30 days and then admitted the efficacy of medical resource use and impact factor. To examine the outcome and resources utilization of the CRC patients who received Laparoscopic surgery. To identify the impacting factors of long-term survival and medical resources utilization of CRC patients who received a surgery inpatient treatment. Methods：This is a retrospective and longitudinal observation design study. We enrolled in the period from January 2005 to December 2010 diagnosed with primary colorectal cancer (ICD_9_CODE:153-154), and accept the initial surgery patients (N = 902).All patients were follow-up to the patient last treatment in our study hospital or death. Data source were derived from medical records and hospital medical expenses. All statistical analyses were performed using the SPSS14.0 statistical software. We used chi-square test, independent samples t-test, variance test, multivariate logistic regression analysis, multiple regression analysis, Kaplan-Meier survival analysis, Cox regression analysis. Results：Study results showed the patients average age is 69.2 years old, colon has the highest proportion of 68.3% in tumor location, and average inpatient medical costs were 126,490NTD and the average length of stay were 18.5 days. After adjusting for covariates, patient have transfuse blood at inpatient had OR=3.13 and OR=2.53 times of having minor and major complications Patient with major complication had 5.66 (2.39-13.42) times high risk post-operation in ICU, as compared to patient without complication. There were no difference between Laparoscopic surgery and traditional open-type surgery in the post-operation outcome and medical resources utilization. The patient with perforation or peritonitis before operation inpatient days significantly more than without perforation or peritonitis before operation 44.43 days, Patient with minor or major complications the hospitalized medical costs significantly more than those without complications 36,504 NTD and 30,903 NTD. With respect to Long-term outcome, the impacting factors of survival are complications, AJCC and complications The patient with AJCC stage Ⅲ, Ⅳ who 4.16 and 5.39 inpatient days than patients with AJCC staging Ⅱ within 6 months discharged from hospital. Conclusion and recommendations：The study found that, preoperative obstruction, perforation or peritonitis, is not only predict to complications, also affect the post-operation outcome and medical resource utilization. Complications need to avoid in clinical management. Laparoscopic and traditional open-type surgery in the post-operation outcome and medical resources utilization were no difference; it is worth follow-up of the study. With long-term survival and medical resources utilization, the death risk is comorbidities and AJCC stag; early detection is an important preventive policy.