安寧緩和療護品質的探討:比較安寧療護病房與非安寧療護病房之療護品質差異

Evaluation of Quality of Care in Hospice Palliative Care Units: A Comparison to Non-Hospice Palliative Cancer Patients Care Units

邱仲峰(Jenf-Fong Chiou)

指導教授 ： 盧美秀 ； 黃國哲

臺北醫學大學/醫學院/醫學科學研究所/碩士(2001年)

摘要

癌症自1982年起，就是國人第一大死因；而起源於英國之安寧緩和療護是一種對癌病末期病人更好的照顧方式。如何來界定安寧緩和療護的醫療品質，則需要有優良的品質評量工具，進而實際評量並藉以提昇安寧緩和療護的醫療品質。此篇論文研究的主旨是，應用Higginson等人於1999年發表之緩和療護結果量表(The Palliative Care Outcome Scale；The POS)，經翻譯修正發展成中文版量表，並實際進行安寧緩和病房與非安寧緩和病房的醫療品質評量；並考慮進一步修改中文量表成為更適合國人使用之本土化量表。 中文版「緩和療護結果量表」經過嚴謹的信、效度檢測；內容效度用專家效度法，問卷中10題均達CVI值≧0.86；效標關連效度中，斯皮爾曼等級相關良好(0.59-0.68)，再測信度之皮爾森相關係數，P值<0.05；問卷內在一效度病患與醫護人員之Cronbach’s α係數，分別為0.73、0.74；評分者信度之皮爾森相關係數分別為0.97、0.88、0.81，P值<0.05。正式研究為民國89年8月至12月，分別於安寧病房組(馬偕醫院、衛生署桃園醫院、耕莘醫院)收案75名，非安寧病房組(馬偕醫院、衛生署桃園醫院、台北醫學大學附設醫院)收案90名；收案時依研究規定，同時對病人與主要照顧之醫護人員進行量表之訪談。同時也進行病人屬性之分析(共18項)及醫院屬性之分析(共7項)，找出對療護品質評量有影響之因素。 結果病人屬性方面有轉移部位與收案來源，醫院屬性方面有醫院別、總床數、醫師人力與護理人力，對品質評量有影響；將上述6項因素進行複迴歸分析，則只有醫院別有統計意義(P值0.0117)。安寧緩和病房組無論從病人組及醫護組來看，品質評量均優於非安寧緩和病房組。安寧與非安寧緩和病房之病人與醫護人員對品質評量的差異均有統計意義，而且顯出醫護人員的評量均優於病人的評量。在非安寧緩和病房的醫院中，以具備安寧緩和療護之理念者，品質評量上最好。 中文版「緩和療護結果量表」為一可信及實用性高之品質評量工具，值得推廣於相關緩和療護的使用，並作為品質評量的監測工具。但為使本量表更適用於國人，針對研究中發現之問題，經改良為一新的「緩和療護結果量表」。

關鍵字

安寧緩和療護 ； 醫療品質 ； 纋和療護結果量表

並列摘要

Since 1982 year, cancer was the first cause of death in Taiwan. The Hospice Palliative Care, which was originated from England, is a better medical care for terminal cancer patients. To define the quality of Hospice Palliative Care it is necessary to have an excellent evaluation tool, and further to use these evaluations in practice to improve the quality of the Hospice Palliative Care. The purpose of this study was to use the Palliative Care Outcome Scale(The POS), which published by Higginson et al in 1999, as quality indicator for Hospice Palliative Care units and Non-Hospice Palliative Care units in Taiwan. The POS has been translated and developed as a Chinese version. An attempt to modify the Chinese version of POS to become a scale for more proper to clinical use in Taiwan. Hopefully, to create a new and proper scale for native people. The Chinese Palliative Care Outcome Scale through a serial of rigorous tests for its reliability and validity. Content validity presented by professional validity, there were ten questions in the questionnaire, and every question’s CVI (Content Validity Index) must be over 0.86. Criterion-related validity showed Spearman rank correlation very well (0.59-0.68). Pearson Correlation Coefficients showed the stability P value<0.0v5. The internal consistency of questionnaire, Coefficients of Cronbach’s a value for patient and medical care staff group were 0.73 and 0.74. Inter-rater reliability for evaluators were 0.97, 0.88, 0.81 and P value <0.05. The investigation period of this study was from August to December in 2000. There are two investigated groups, one is Hospice Palliative Care Group that Mackay Memorial Hospital, Cardinal Tien Hospital, and Taoyuan Hospital were included, total has 75 patients. The other group was Non-Hospice Palliative Care, total has 90 patients from Mackay Memorial Hospital, Tasyuan Hospital and Taipei Medical University Hospital. The visiting and scaling for study have been done for patient and primary medical care staff at the same time. The descriptive analysis for patients (18 property variables) and hospital (7 property variables) were analyzed as cofactor that affected the quality of Hospice Palliative Care. The result of study showed that the patient property variables for metastatic organ and case admitted source, and the hospital property variables for hospital differentiation, total hospice beds, physician and nurse man powers had effected on the quality of the Hospice Palliative Care. If we did the multiple regression of these six variables, the result presented that the hospital differentiation has significant difference for P value =0.0117. The Hospice Palliative Care units has better quality of care which compare to the Non-Hospice Palliative Care units, no matter it was patient or medical staff group. There all has significant difference on the quality outcome between patient and medical staff of Hospice Palliative Care units and Non- Hospice Palliative Care units. Furthermore, the medical staff group showed better quality outcome than patients group. In the Non-Hospice Palliative Care Hospital, which had the concept of Hospice Palliative Care, had the best quality evaluation outcome. The Chinese Palliative Care Outcome Scale is a reliable and useful tool for quality evaluation. It is worth to promote to the Hospice Palliative Care relative hospitals as a quality indicator. In order to create an excellent outcome scale and an questionnaire suitable for our own society, according to this study results to modify and change the contents to be a new and better Chinese Palliative Care Outcome Scale.

並列關鍵字

Hospice Palliative Care ； Quality of Care ； Palliative Care Outcome Scale

參考文獻

楊國樞、文崇一，吳聰賢、李亦園(1994)。社會及行為科學研究法。台北:東華。 賴允亮(1998)。安寧療護服務品質稽核及作業系統之建立。衛生署委託計劃。 英文部份 Aaronson, N.K., Ahmedzai, S., Bergman, B. Kind, P. (1993). The European Organisation for Research and Treatment of Cancer QLQ-C30:A quality of life instrument for use in international clinical trials in oncology. Journal of National Cancer Institute, 83:365-376.

Bruera, E., MacDonald, S. (1993). Audit methods:The Edmonton Symptom Assessment System. In:Higginson I, ed. Clinical Audit in Palliative Care. Oxford:Radcliffe Medical Press. Calman, K.C. (1984). Quality of life in cancer patients-an hypothesis. Journal of Medical Ethics, 10:124-127.

Carmines, E.G., Zeller, R.A.(1979). Reliability and validity assessment . Beverly Hills, carifornia:Sage Publication, Inc. Cohen, S.R., Mount, B.M., Strobel, M.G. (1995). The McGill quality of life questionnaire:a measure of quality of life appropriate for people with advanced disease. A preliminary study of validity and acceptability. Palliative Medicine, 9:207-219.

Copperman, H. (1992). Hospice home care services (letter). Palliative Medicine, 6:260. Cronbach, L.J. (1995). Coefficient alpha and the internal structure of test. Psychometrika, 16:297-334.

Eve, A. Smith, A.M.(1994). Palliative care service in Britain and Ireland-update 1991. Palliative Medicine, 8 (1):19-27.