影響口腔癌篩檢陽性個案接受後續確診之因素探討

Investigation for The Reasons of Positive Oral Cancer Screening Cases Accept Subsequent Diagnosis

黃金聲(Chin-Sheng Huang)

指導教授 ： 黃茂栓

共同指導教授 ： 陳立昇

臺北醫學大學/口腔醫學院/牙醫學系碩博士班/碩士(2015年)

https://doi.org/10.6831/TMU.2015.00082

摘要

背景與目的：最新2014年衛生福利部發布之台灣癌登報告顯示，每年有超過六千例口腔癌(包含口咽、下咽)新發生個案。過去針對抽菸或嚼檳榔之高危險群者的篩檢，陽性率為8.5%，但轉介率僅為 52.3%。為提高轉介率，本研究結合口腔癌陽性個案之資料，進行癌症診療照護型態對預後之影響，陽性個案及各醫療院所間之影響，陽性個案及治療資源分布對確診之影響等，以促使各層級醫療院所提升陽性個案轉介。
方法及步驟：針對有實行口腔癌篩檢的醫療院所，以群集抽樣抽取隨機診所樣本，發放北區615家、中區267家、南區370家、東區34家，合計1286間醫療院所做為問卷訪視對象，問卷於2012年8月初開始發放，自發放後回收期為兩個月。本研究以多階層模式(Hierarchical Model)之建構為主要分析方法。
結果：在北部，高轉介率比例以醫學中心及其他各級醫院比全國平均高。中南部地區則以其他各級醫院、衛生所轉介率較全國高。東部高轉介率比例以醫學中心及衛生所較全國平均高。篩檢人力與陽性個案發現結果除衛生所外，牙科醫師為口篩主要人力，且口篩陽性個案在各級醫院得到最多共12740件，其次為醫學中心9360件。在篩檢人力篩得陽性個案的效益中，各級醫院有最高的效益為1:24，醫學中心為1:18。單日每一門診病人在醫學中心可發現陽性個案之比例約為1:18，其他各級醫院約1:68，從門診病人發現陽性個案的效率以醫學中心為高。而在平均轉介陽性個案，在醫學中心每一轉介人力每年約轉介234個陽性個案為最高。醫療院所若配合執行成人預防及曾經辦理戒菸班，則有較高轉介率。轉介成功與轉介未成功在兩組最大的差異在家人的支持度，轉介成功者，有83.2％其家人知道口腔黏膜有異狀，支持儘速就醫即早治療，反之未轉介成功者僅有28.3%其家人支持儘速就醫即早治療，且有22.5%個案是刻意隱瞞不願家人知道。
結論：本研究發現，醫療院所層次影響轉介率因素包括口腔癌治療設備完備性、配合社區篩檢、執行成人保健及轉介前衛教諮詢。個人層次影響轉介率因素則與家人關懷與支持度、年齡較輕、無嚼食檳榔習慣及重覆參加篩檢等因素有關，另外也和個案所就醫單位有無辦理成人預防保健及戒菸班相關。轉介未成功個案自述其最常見原因包括無病識感與時間因素(個人太忙、等待時間過久)；但若醫院提供便利轉介程序或可至鄰近診所就診是兩大鼓勵其就診因素，此外建議若能訂定轉介奬勵指標，積極鼓勵醫療院所對高危險族群積極進行轉介，以及提供診所個案管理之資源，或能成立基層診所聯合轉介服務中心，由衛生所或該中心協助陽性個案轉介，應能改善目前低轉介的困境。

關鍵字

口腔癌 ； 群集抽樣 ； 多階層模式 ； 陽性個案轉介率

並列摘要

Background and Purpose : Latest AD 2014, the Ministry of Health and Welfare reported Taiwan's cancer registration showed that there are more than six thousand new cases of oral cancer (including oropharynx , hypopharynx ) occurred each year. The positive rate of oral cancer screening for high-risk group who smoke or chew betel nut was 8.5% , but the referral rate was 52.3% .To promote all level medical institutions to enhance the positive referrals rate, this study combined the data of positive cases in oral cancer screening, impact on the prognosis of cancer treatment and care patterns , impact on the diagnosis between the positive cases and various medical institutions , the positive cases and the treatment of resource distribution and so on..
Methods and procedures : In medical institutions of oral cancer screening have implemented, we extract the random cluster sampling clinic samples , issued questionnaire to North 615, Central 267 , Southern 370 , East 34 , a total of 1,286 medical institutions in Taiwan, began in August 2012. In this study, the main analysis.method was the multi -class model (Hierarchical Model).
Results: In the northern of Taiwan, referral rates was higher in Medical Center and other level hospitals than the national average. In central and southern of Taiwan, other level hospitals and local health bureau had higher referral rate than the national average. In eastern of Taiwan, the medical center and local health bureau had higher referral rate than the national average. Oral cancer screening worker except of local health bureau, the dentist is a majority. Positive cases in other hospitals are up to a total of 12,740, followed by the Medical Center 9360. In oral cancer screening, other hospitals have the highest benefits are 1:24, then medical center are lower 1:18. For every positive case in every-singleday outpatient number, medical centers had the proportion of 1:18, then other hospital is about 1:68. That efficiency of positive cases screening in the medical center outpatient is highest. The average referral positive cases in the medical center are highest 234 positive cases. If the medical institutions implemented of adult health prevention and smoking cessation classes, there has higher referral rate. Difference between referrals successful and failed is the factor of family support. In the group of successful referrals, 83.2% of screening case family noticed the oral lesion and suggested received medical treatment as soon as possible, on the contrary, group of failed referral was only 28.3% supported by their families and 22.5% of the cases are deliberately concealed reluctant family to know that condition.
Conclusion: This study found that levels of medical institutions influence on referral rates include oral cancer therapy equipment, community area screening, adult health care and consultation before referrals. Individual level factors that influence the rate of referral are family support, younger age, betel nut chewing habit and repeated screening. In addition, adult preventive care and smoking cessation classes related to the referral rate. Cases of unsuccessfully referred told that the most common reasons include disease-insight and the time factor (too busy, prolong waiting time) ; if the hospital to facilitate referral program or encourage to receive local clinics follow. Suggestion are setting referral reward, encourage medical institutions refer positive actively , providing practice management resources of cases, assisting other clinic referral resource, setting up referral service primary care centers to improve the current plight of low referral .

並列關鍵字

oral cancer ； cluster sampling ； multi-class model ； positive referrals rate

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