鼻咽癌治療結果與醫療資源利用之探討

中文摘要研究目的： 1. 瞭解鼻咽癌治療患者的病患特質、疾病嚴重程度不同、癌症治療模式、治療結果和醫療利用情形 2. 瞭解鼻咽癌患者治療後存活、復發情形及其影響因子 3. 瞭解鼻咽癌治療患者醫療利用情形及其影響因子研究方法：本研究採回溯性縱貫性研究設計，利用回溯性病歷審查自1998年9月至2004年12月間，初次診斷為鼻咽癌並在台東馬偕醫院接受治療並追蹤之患者，累計共42位，收集相關資料；研究工具為個案病歷及醫療費用申報資料，將病歷詳加回顧後收集得到病患個人資料、疾病嚴重度、治療模式、與治療結果，醫療利用資源利用，包括六個月、十二個月內、十八個月內門診次數，總住院天數，總門住診費用，比較其個案特性、醫療療效、存活分析、和醫療利用之相關連，並進行統計以簡單迴歸分析及複迴歸來分析自變項及依變項之相關性，進而產生在不同治療期間醫療費用產生之預測模式；以Kaplan-Miere存活分析和Ｃox等比例危害函數模式，探討存活、復發情形及其影響因子。研究結果：本研究顯示，病患之人口學質仍以男性居多，29位69%；年齡層以30-50歲最多，24位78%；病患族群以原住民26位較多；而病患之疾病初次診斷時大部分為晚期stage3、4，共26位62%，治療模式中接受同步化學放射治療19位45％；病患接受治療後平均 6、12、18個月內總住院天數分別為 25、35.5、43日；平均 6、12、18個月內門住診總費用分別為台幣 327,538、393,327、455,928元；存活分析顯示，所有患者5年存活率為62%，其中早期之鼻咽癌患者5年存活率達80%，Cox等比例危害函數分析顯示腫瘤的大的患者其危害風險是腫瘤的小的患者的5.8倍，在復發狀態之危害函數當中，顯示鼻咽癌分期晚期的患者其復發風險是早期患者的8.4倍，年齡愈大，復發風險愈低。逐步複迴歸分析顯示在12個月內門住診醫療總費用，族群因素及腫瘤的大小(T)為顯著之影響因子，在18個月內門住診醫療總費用方面，族群因素及腫瘤的大小(T)為顯著之影響因子。12和18個月內鼻咽癌醫療總費用預測模式當中，整體解釋力(Adjusted R square)分別為25.1%及19%。結論與建議：鼻咽癌之治療仍需要早期的發現、早期的診斷，提高存活及減少復發；原住民和漢族治療結果並沒有明顯差異；鼻咽癌患者醫療利用影響因子複雜，而預測模式中顯示和醫療利用之顯著相關連的預測因子為患者是否為原住民、疾病嚴重度。關鍵詞：鼻咽癌、成本分析、醫療利用

關鍵字

鼻咽癌；成本分析；醫療利用

並列摘要

Abstract Objectives: 1. To investigate the relationship of various pretreatment case-mix characteristics、treatment modalities and treatment outcome with medical utilization for patients with nasopharyngeal cancer(NPC). 2. To investigate prognostic features and treatment outcome in patients with nasopharyngeal cancer 3. To investigate predicting factors in the medical utilization of nasopharyngeal cancer management Design: Retrospective chart review and billing record analysis Methods: The charts and billing records of 42 patients diagnosed and treated with nasopharyngeal cancer at Taitung Mackay Memorial Hospital between September 1, 1998 and December 31, 2004 were reviewed. The independent variables included various pretreatment various pretreatment patient-mix and tumor characteristics (age, gender, marriage status, distance to hospital, smoking history, and co-morbidity as defined by Kaplan-Feinstein grade，AJCC TNM clinical stage) as well as type of treatment and treatment outcome. The dependent variables included outpatient utilization, length of stay, medical charges incurred during the 0to 6, 0 to 12, and 0 to 18month billing periods after the initiation of cancer-directed therapy. Simple and multiple regression analyses were used to investigate the relationships between dependent and independent variables and to develop medical utilization predictive models of nasopharyngeal cancer management. The Kaplan-Meier survival analyses and Cox proportional hazards regression were used to examine prognostic factors about the result of 5 year survival and locoregional control of NPC. Results: There are 29(69%) male patients. The average of 42 patients’ age is 51 y/o. There are 26 (62%) aboriginal patients. According to the AJCC 1997 staging system, 26 (62%) patients diagnosed with late stage. There are 19 (45%) patients received CCRT (concurrent chemoradiotherapy). The length of stay of total 6 months, 12 months and 18 months is 25, 35.5, 43 days. The medical charges of total 6 months, 12 months and 18 months is NT＄ 327538、393327、455928 dollars. Kaplan-Meier survival analyses reveals 5 year survival rate is 62%. The 5 year survival rate of patients diagnosed with early stage is 80%. The Cox proportional hazards regression model revealed that only tumor classification was statistically significant. The risk ratios is 5.8 . Late clinical stage classification, and younger age are poor prognostic factors for locoregional control. Multiple regression analyses indicated that race and tumor classification (T stage) were significant variables in one or more of the models predicting charges incurred during total 12 months and 18 months billing periods. The models yielded R2 values for the total 12 months and 18 months billing periods of 0.25 and 0.19, respectively. Conclusions: This work supports continued study of measures that may result in earlier detection of nasopharyngeal cancer as a potential means of reducing management charges. There is no different treatment outcome between Chinese and Aboriginals. The race and severity of cancer are significant variables predicting medical utilization in nasopharyngeal cancer management. Key word: Nasopharyngeal cancer，Cost analysis ，Medical utilization