利用台灣全民健保資料庫探討使用急診醫療之大腸直腸癌患者三年存活率及其相關危險因子

Use of the Taiwan's National Health Insurance Research Databases to Investigate the Outcome of Emergency Department Treatment on the 3 year Survival Rate of Colorectal Cancer Patients and Other Factors

洪偉君(Wei-Chun Hung)

指導教授 ： 林立偉

義守大學/醫學院/學士後中醫學系/碩士(2019年)

摘要

台灣在西元2000年到西元2012年，大腸直腸癌患者使用急診次數逐年上升。然而是否急診使用影響這類病人存活率，或是受到其他危險因子干擾，真相仍不得而知，於是一個回溯性全國世代研究因此而生。我們使用全民健保資料庫之百萬歸人檔(Longitudinal Health Insurance Database 2000 ，簡稱LHID2000)，將上述年間的大腸直腸癌新發生個案分為使用急診組及未使用急診組，之後再依照傾向評分匹配(propensity scores)以一比一方式配對出急診組(實驗組)及非急診組(對照組)各1289名個案。Cox比例風險模式(Cox proportional hazards model)探討兩組三年存活率及其相關危險因子，其中死亡風險以調整風險比值(adjusted hazard ratios，簡稱aHR)表示，再以存活分析探討並繪製出存活曲線圖(Kaplan-Meier survival curves)。
我們發現實驗組死亡率高於對照組，發生在女性個案(aHR =1.32 [1.05-1.66] )、年齡小於四十歲(aHR =7.21 [1.6-32.52] )、就診於醫學中心(aHR =1.42 [1.14-1.77] )、南臺灣居民(aHR =1.77 [1.38-2.26] )、使用手術者(aHR =2.66 [1.64-4.24] )、使用化學治療者(aHR =1.79 [1.42-2.26] )、癌期為3~4期個案(aHR =1.7 [1.32-2.18] )、未有共病者(aHR =1.5 [1.22-1.85] )等各變項。實驗組不論在單變量分析(HR =1.33 [1.14-1.54] )及多變量分析上(HR =1.26 [1.09-1.47] )，皆有較高死亡率。三年的存活分析，對照組具有較高累積存活率(0.7733)。
結論是相較於對照組，實驗組有較低的三年累積存活率(0.6887)，而影響其存活率相關因子為年齡(P=0.0003)、居住地(P=0.0009)、手術(P=0.0007)、化學治療(P<0.0001)、癌期(P=0.0031)及共病(P=0.0129)。急診部醫療人員及臨床工作者可評估上述相關因子，並據此為大腸直腸癌患者提供更專業醫療照護。

關鍵字

大腸直腸癌 ； 急診 ； 存活率 ； 死亡率 ； 共病 ； 台灣全民健保資料庫

並列摘要

Background: The number of emergency department (ED) visits by patients with colorectal cancer (CRC) increased annually between 2000 and 2012 in Taiwan. However, how ED visits impacted the survival of those patients and whether the impact was affected by other factors are not completely understood. Therefore we conducted a nationwide cohort study to identify the predictors.
Methods: We surveyed data for CRC patients from 2000 to 2012 using the Longitudinal Health Insurance Database 2000 (LHID2000) retrospectively, and then divided the subjects into an ED group and a non-ED group. Afterwards, we matched (1:1) the two groups on the basis of propensity scores (PS) and selected 1,289 patients for each group. Three-year survival was compared between the two groups by variable with the Cox proportional hazards model and the risk of mortality was represented by adjusted hazard ratio (aHR). The risk of all-cause mortalities was also calculated with the Cox model and illustrated by the Kaplan-Meier survival curves. The factors that interacted with ED visits in their impacts on the patients’ survival were identified based on the Cox model.
Results: Mortality rates were higher in the ED group than the non-ED group among females (aHR =1.32 [1.05-1.66] ), those aged below 40 (aHR =7.21 [1.6-32.52] ), those visiting ED in level 1 hospitals (aHR =1.42 [1.14-1.77] ), those residing in north Taiwan (aHR =1.77 [1.38-2.26] ), those with surgery (aHR =2.66 [1.64-4.24] ), those with chemotherapy (aHR =1.79 [1.42-2.26] ), those at 3 to 4 stage (aHR =1.7 [1.32-2.18] ), and those without comorbidity (aHR =1.5 [1.22-1.85] ). Overall, the ED group had a higher risk of death than the non-ED group with the hazard ratio (HR) at 1.33 (1.14-1.54) in univariate analysis and 1.26 (1.09-1.47) in multivariate analysis. Statistically significant interaction was detected between ED visits and the following factors in their impacts on the 3-year survival: age (P=0.0003), geographic region (P=0.0009), surgery (P=0.0007), chemotherapy (P<0.0001), staging (P=0.0031) and comorbidity (P=0.0129). The 3-year cumulative survival of the non-ED group (0.7733) was higher than that of the ED group (0.6887).
Conclusions: CRC patients with ED visits has poorer 3-year survival compared to those without ED visits, and the impact of ED visits on survival is closely associated with age, geographic region, surgery, chemotherapy, stage, and comorbidity. Emergency physicians should consider these factors to provide more intensive and specific medical services.

並列關鍵字

Colorectal cancer ； Emergency department ； Survival ； Mortality ； Comorbidity ； Taiwan’s National Health Insurance Research Databases

參考文獻

[1] Available:https://www.who.int/en/news-room/fact-sheets/detail/cancer [cited 2018 06 mar].

[2] KK, S., et al., "Recognition and Evaluation of Oncology-Related Symptoms in the Emergency Department.pdf," Ann Emerg Med, 1995. 26: 12-17.

[3] Available: http://globocan.iarc.fr [cited 2018 16 feb].

[4] Available:http://www.hpa.gov.tw/Pages/Detail.aspx?nodeid=269&pid=8084 [cited 2015 28 dec].

[5] Azeem, S., et al., "Diet and Colorectal Cancer Risk in Asia - a Systematic Review," Asian Pacific Journal of Cancer Prevention, 2015. 16(13): p. 5389-5396.