臺灣博碩士論文加值系統

研究背景與目的：雖然在許多疾病治療上皆有證據支持「服務量-結果」關係，但在國內外研究中，大腸直腸癌手術服務量與照護成效仍然無一致的結論。且過去文獻少以同時探討醫院服務量、照護過程面指標、照護結果三者之間的關係，因此本研究擴大「服務量-結果」的假設，除了再次驗證台灣醫院大腸直腸癌手術服務量與病人照護結果的關係，也探討大腸直腸癌核心測量指標達成度對於病人照護結果的影響，及大腸直腸癌核心測量指標對於「服務量-結果」關係的影響情形。
研究方法：本研究以2004年台灣癌症診療資料庫(TCDB)中大腸直腸癌新發診斷個案為研究對象，共4254位病人，分別於29家醫院進行手術治療。醫院服務量係以該院年平均進行的大腸直腸癌手術量計算，而照護過程指標則是以國內大腸直腸癌核心測量指標為依據。本研究以階層邏輯斯迴歸(Multilevel logistic regression)進行分析醫院服務量、核心測量指標對於病人死亡、復發風險的影響。
研究結果：在病人層次的核心測量指標達成率有效影響病人之死亡情形與復發情形。而醫院層次部分，在控制病人特性後，醫院核心測量指標達成率對於病人之死亡及復發情形不具有顯著影響效果，而醫院服務量則為病人的死亡情形的顯著預測變項，但並不影響復發情形。進一步分析得知，在指標達成率高的醫院，其醫院服務量對於病人死亡情形的影響效果較大，而在指標達成率低的醫院，其醫院服務量對於病人死亡情形的影響效果較小。
結論：根據研究結果，醫院服務量對於病人死亡情形仍具有顯著影響力，因此，本研究支持手術集中化策略，另外，本研究建議醫院可投入更多資源在增加病人的照護品質上：在照護品質好的醫院，透過增加服務量對於病人照護結果可產生綜效。

Background：Many studies have been conducted the relationship between hospital volume and outcome, however the relationship has not to be determined for resection of colorectal cancer in Taiwan. This study examines the association of hospital volume with mortality and recurrence in colorectal cancer patients.It also examines the associations of core measure with outcome and the impact of core measure on the relationship between volume and outcome.
Method：All newly diagnosed with colorectal cancer registered at Taiwan Cancer Databased in the year 2004 were entered into the study. The population consisted of 4254 patients from 29 hospitals. Data was analyzed using multilevel logistic regression to adjust factors for different nested levels of patients and hospitals.
Results：In patient level, the adherence of core measure has influence on the 5 year mortality and recurrence. In hospital level, the adherence of core measure does not have impact on outcome. And after controlling other fators, hospital volume significantly impacts on the 5 year mortality, but not on 5 year recurrence. Besides, the relationship between hospital volume and 5 year mortality is stronger in hospitals with high adherence of core measure than in hospitals with low adherence of core measure.
Conclusion：According to the results, the hospital volume has impact on the 5 year mortality. This study supports the strategy of surgery centralization. This study also suggests that hospitals could invest more resources to improve the quality of care. In high quality hospital, by increasing hospital volume can have the synergy results.

致謝 i
中文摘要 ii
Abstract iii
目錄 iv
表目錄 vi
圖目錄 viii
第一章 緒論 1
第一節、研究背景與動機 1
第二節、研究目的 3
第二章 文獻探討 4
第一節、大腸直腸癌簡介、照護品質測量指標、預後因素 4
第二節、「服務量-結果」相關研究結果現況 9
第三節、「照護過程品質指標」對於「服務量-結果」的影響 32
第三章 研究方法 34
第一節、研究架構 34
第二節、研究假說 35
第三節、研究材料與研究對象 38
第四節、研究變項及其操作型定義 40
第五節、統計分析方法 44
第四章 研究結果 51
第一節、描述性統計 51
第三節、階層迴歸模型 65
第四節、分層分析後之階層迴歸模型 83
第五節、研究結果小結與假說驗證 110
第五章 討論 114
第一節、結果討論 114
第二節、資料及分析方法 120
第三節、研究限制 122
第六章 結論與建議 123
第一節、結論 123
第二節、建議 124
參考文獻 126
附錄 133
附錄1：各醫院在大腸直腸癌核心測量指標的平均值表現 133
附錄2：醫院服務量、指標達成率對病人五年內死亡情形的影響(八指標) 134
附錄3：醫院服務量、指標達成率對病人五年內復發情形的影響(八指標) 136
附錄4：醫院服務量(連續變項)對於病人死亡情形之階層模型分析 138
附錄5：醫院服務量(連續變項)對於病人復發情形之階層模型分析 139

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