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  • 學位論文

前列腺腺癌的早期篩檢對醫療資源耗用影響之探討

The Effect of Early Screening in Prostate Cancer on Medical Resources Utilization

指導教授 : 張永源
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摘要


目 的: 基於國內之共識,針對血中前列腺特異抗原(PSA)值高於4.0 ng/ml的患者,都應接受前列腺切片檢查,結果為良性且追蹤之PSA值仍高於正常值,考慮再次切片前,當尋求以PSA及其相關變項來輔助診斷,做為新的切片檢查依據,其最主要的目的為有效地降低診斷的偽陰性,同時減少偽陽性的非必要切片檢查,管控不必要之醫療費用支出,節省成本,符合經濟效益。 方 法﹕ 584例經前列腺切片檢查的患者,前列腺腺癌185例,良性399例。記錄患者的年齡,血中PSA值,以及PSA之相關變項;一、訂定“年齡別”PSA臨界值,二、血中PSA每年上升的速度,三、PSA的密度,四、血中游離型(free)的PSA值與血中PSA(total)的比例。利用ROC曲線圖,分析各個因子的最適臨界值,具有最高敏感性與特異性,何者最能夠節省醫療支出,最少發生延誤診斷。利用對數回歸分析,進一步比較何者最具有診斷的影響力。 結 果﹕ 血中游離型PSA值與血中PSA總量值的比值;簡稱PSA的比值,經ROC曲線圖,分析的結果,在最適臨界值0.14時,敏感性為72%,特異性為70%,曲線下的面積最大,雖然陽性預測值為42%,但陰性預測值達85%,是能夠減少非必要的切片檢查,醫療費用支出最少,此外發生延誤診斷的機率最低。 結論與建議﹕ PSA的比值可以使70%的患者免除非必要的切片檢查,同時有72%的正確診斷率,醫療資源耗用最少。前列腺腺癌的早期篩檢,對保險人來說,醫界要避免非必要的切片檢查,管控醫療成本,杜絕浪費; 對被保險人來說,不能因為節省支出而延誤診斷。現今沒有一項前列腺腺癌的臆測因子是萬無一失的,可能有其他更為準確的臆測因子,端賴醫界共同努力,進一步提高正確的診斷能力。期盼國內保險人,被保險人,醫界,學界,共同擬定出一套前列腺腺癌的診斷標準,既節省成本又能提高診斷率,流程中能有各個臆測因子的標準臨界值,有了統一的標準,訂定標準的臨床路徑,才能提高醫療品質。

並列摘要


Objectives According to common agreement in this country, patients with prostate specific antigen(PSA) values higher than 4.0 ng/ml should undergo transrectal ultrasound-guide prostatic needle biopsy. If the result is benign but the tracked PSA value is still higher than normal, we should use the PSA and its relative variables to aid diagnosis and as the basis for a new biopsy examination before considering doing further biopsies. The main objective for this is to effectively lessen false negative diagnosis, and to lessen unnecessary biopsies in the case of false positive diagnosis. Doing so will control unnecessary medical expenditure, conserve cost, and be more economically effective. Methods Out of 584 cases of prostate biopsy patients, 185 cases were adenocarcinoma of prostate, and 399 cases were benign. Records were taken of the patient’s age, PSA value, and the following PSA relative variables: (1)age-specific PSA cut-off values, (2)annual increase in PSA velocity, (3)PSA density, (4)the ratio of free PSA value to total PSA value. The data were then using Receiver Operatiing Characteristic(ROC)curve graphs to analyze the optimal cut-off value for each other, the highest sensitivity and specificity, as well as the most possible to save medical expenditures and lessen delayed diagnosis.Further using logistic regression analysis to determined the factors that has impact on diagnosis. Results Under the ROC curve analysis, the ratio of free PSA value to total PSA value, otherwise known as PSA ratio, showed sensitivity at 72%, specificity at 70%, and the largest area under the curve at the optimal cut-off value of 0.14. Although the positive predictive value was 42%, the negative predictive value reached 85%. This can lessen the number of unnecessary biopsies, minimize medical expanses, and also produce the lowest chance of delayed diagnosis. Conclusions and Suggestions Diagnosis based on the PSA ratio can save 70% of patients from unnecessary biopsy examinations, and at the same time yield a 72% correct diagnosis rate as well as the lowest amount of medical expenditure. To the insurer, unnecessary biopsies should be reduced to control cost and terminate misuse of resources. To the insured, however, it is not right to delay diagnosis just to save expenses. Until now, there is still no exact factors of adenocarcinoma of prostate that guarantees diagnosis. We can only rely on the combined efforts of the medical field to raise the ability of correct diagnosis. I hope that the insurer, insured, the medical field, and academia can work together to set a standard for the diagnosis of adenocarcinoma of prostate that will both minimize expenses and raise diagnosis rates. The procedure should include the standard cut-off values of various factors. Only when there is a common standard and a set clinical pathway can there be a higher medical quality.

參考文獻


1.行政院衛生署: 中華民國84年國民健康局癌症登記報告。
2.行政院衛生署: 中華民國87年國民健康局癌症登記報告。
3.中華民國公共衛生學會:癌症登記年報。
4.行政院衛生署: 中華民國92年國民健康局癌症登記報告;
(中華民國95年12月13日公告)。

被引用紀錄


蔡銘順(2011)。從血清攝護腺特定抗原介於4-10 ng/ml病人中探討有效的攝護腺癌預測因子〔碩士論文,亞洲大學〕。華藝線上圖書館。https://www.airitilibrary.com/Article/Detail?DocID=U0118-1511201215470978

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