子宮頸癌病人併發精神疾患影響、醫療利用與存活率之探討

Medical Utilization and Survival Analysis Among Cervical Cancer Patients Initially Diagnosed with or without Anxiety and Depressive Disorders

吳建誼(Chien-Yi Wu)

指導教授 ： 許弘毅

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2015年)

摘要

研究背景與動機
過去台灣很少有研究針對女性特有子宮頸癌做全國性長期追蹤探討，故本研究目的為探討確診子宮頸癌病人的整體變化趨勢，後續併發精神疾病和其整體醫療利用及存活之情形。
研究方法
研究資料來源為1996~2010年全民健保資料庫，採回溯性次級資料縱貫研究，研究對象為ICD-9-CM診斷碼前三碼為180，來篩選出子宮頸癌患者。而焦慮症組是以 ICD-9-CM診斷碼為300.0X-300.9X，但排除3004；憂鬱症組是ICD-9-CM診斷碼為296.2X，296.3X，300.4，311.X；焦慮合併憂鬱症組則是診斷碼含以上兩組診斷碼者，其他則為「無精神疾病組」。以SAS 9.3版進行研究樣本傾向分數配對，使用SPSS 20.0版進行統計分析。
研究結果
一、 研究樣本共3,664人，平均年齡為53.5 ± 15.0歲，其中僅有焦慮症有862人(23.5%)，僅有憂鬱症有149人(4.1%)，罹患有焦慮合併憂鬱症有349人(9.5%)。新診斷子宮頸癌盛行率由1996年的94.8/每十萬人口，顯著下降到2010年的22.2/每十萬人口，改變率為-76.58%。
二、 經多變量分析，對併發精神疾患之情形，年齡有負相關傾向(OR：0.99, p = 0.07)，化療及醫院服務量為顯著負相關(OR：0.67, p = 0.001；OR：0.99, p = 0.001)，區域醫院或地區醫院與醫學中心就醫相比為負相關(OR：0.76, p < 0.05)。經傾向分數配對後，與無精神疾病的病人相比，精神疾病組病人確診後一、三、五年的後續門診次數顯著多16.5次、17.8次、18.5次(p < 0.001)，門診費用僅有第三年顯著多11,722.8元(p = 0.03)，住院天數無顯著差異，住院費用在第一、五年反倒分別顯著少14,799.4元、42,355.8元(p < 0.05)，最後在總醫療費用部分，第三、五年分別顯著多20531.6元及15,232.5元(p < 0.05)。與無精神疾病組相比較，精神疾病組一、三、五年與整體存活月數顯著較高(67.9% vs. 89.3%, 41.1% vs. 67.8%, 26.0% vs. 50.3%, p < 0.001)。

結論與建議
本研究發現子宮頸癌個案數隨時間逐漸下降，可見子宮頸抹片篩檢推廣有其成效，但整體來看有近四成病人有精神疾患，年紀越輕是罹患精神疾患之傾向，而化療與醫院特性對精神疾患有不同的影響程度，併發精神疾病者雖然門診就醫次數較多，但存活狀況較好，因此臨床照護人員推廣子抹篩檢與適度關心罹癌病人對整體預後有其幫助與價值。

關鍵字

子宮頸癌 ； 焦慮症 ； 憂鬱症 ； 醫療資源利用 ； 存活分析

並列摘要

Background and Purpose
Previously, few studies had focused on nationwide long-term trend analysis among cervical cancer patients in Taiwan. The study purposed to evaluate the changing trend, medical utilization and survival analysis among cervical cancer patients initially diagnosed with or without anxiety and depressive disorders.
Methods
This is a retrospective longitudinal study using National Health Insurance Research Database (NHIRD) from 1996 to 2010. The study objects were extracted by using ICD-9-CM 180 to identify cervical cancer patients. Anxiety and depressive disorders were defined by compatible ICD-9-CM codes (anxiety disorder: 300.0X-300.9X (minus 300.4X); depressive disorder: 296.2X-296.3X, 300.4, 311.X). The statistical analysis and propensity score method were employed by using the SPSS 19.0 and SAS 9.3 respectively.
Results
一、 The study objects were 3,664 patients totally and the average age was 53.5 ± 15.0 years old. In the study, 862(23.5%) patients were anxiety group, 149(4.1%) were depression group, and 349(9.5%) were both anxiety and depression group. The initially diagnosed cervical cancer prevalence was declined from 94.8/100000 in 1996 to 22.2/100000 in 2010. The change rate was -76.58%.
二、 After multivariate logistic analysis, about cervical cancer patients combined with psychiatric disorder, age had negative tendency(OR：0.99, p = 0.07). Chemotherapy(OR：0.67, p = 0.001), the amount of hospital service(OR：0.99, p = 0.001), seeking medical service in regional or local hospitals(OR：0.76, p < 0.05) were significantly associated with anxiety or depression disorders. After using propensity score method, compared to non-psychiatric disorder group, the clinical visits at the 1-, 3-, and 5-year were significantly higher in psychiatric group (16.5, 17.8, and 18.5, respectively)( p < 0.001). The outpatient costs were only significantly higher $ 11,722.8 in the 3-year (p = 0.03). The total length of stay (LOS) at the 1-, 3-, and 5-year were not significantly difference. The inpatient costs were reversely significantly lower $14,799.4 and $ 42,355.8 in the 1-year and 5-year (p < 0.05). Total medical costs were significantly higher $ 20531.6 and $15,232.5 in the 3- and 5-year (p < 0.05). Finally, the cumulative survival at the 1-, 3-, 5- year in psychiatric group were better than non-psychiatric disease group (67.9% vs. 89.3%, 41.1% vs. 67.8%, 26.0% vs. 50.3%, p < 0.001).

Conclusions and Suggestions
Our study found that the newly diagnosed cervical cancer patients were declined gradually. It can clearly be seen that pap smear has its effectiveness. There were nearly 40% cervical patients with psychiatric disorders. Among them, the younger patients had the tendency to suffer from psychiatric disorders, and the chemotherapy and the level of hospital had different influence. The clinical visits were higher in the cervical patients combined with psychiatric disorders, but their cumulative survival condition was better than non-psychiatric disorders groups. Therefore, the clinical medical staff should promote pap smear screening and afford appropriate concern to the cervical cancer patients. It would have clinical benefit and value to overall prognosis of cervical cancer.

並列關鍵字

cervical cancer ； anxiety disorder ； depressive disorder ； medical resources utilization ； survival analysis

參考文獻

李宣緯, 葉玲玲, 王金龍, 徐聖輝, & 黃達夫. (2002). 癌症住院病人精神醫療照護服務之醫療利用研究. 臺灣公共衛生雜誌, 21(4), 278-288.

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Fu, T. S., Lee, C. S., Gunnell, D., Lee, W. C., & Cheng, A. T. (2013). Changing trends in the prevalence of common mental disorders in Taiwan: a 20-year repeated cross-sectional survey. Lancet, 381(9862), 235-241. doi: 10.1016/s0140-6736(12)61264-1

中文部分

林玲華, 陳景彥, 劉嘉逸, & 陳美伶. (2002). 癌症住院病患憂鬱狀態的盛行率及預測因素. 臺灣醫學, 6(4), 535-545.