臺灣博碩士論文加值系統

臨床經驗中，部分良性攝護腺肥大症合併下泌尿道症狀(BPH/LUTS)病人對於目
前通用之國際攝護腺症狀 (IPSS) 量表項目過於冗長或模糊，導致填寫時遭遇一
些困難。我們研究的目的是發展合適病人填寫之修正之攝護腺肥大症合併下泌尿
道症狀量表，並驗證量表之可行性。
自2009年5月至2012年3月，共有4865名40 歲以上男性參加研究並完成自
填式之國際攝護腺症狀量表，量表包含IPSS-1排尿不清、IPSS-2尿頻、IPSS-3
排尿斷續、IPSS-4尿急、IPSS-5尿流無力、IPSS-6排尿費力、IPSS-7夜尿次數
等7項下泌尿道症狀(各項評分為無至最嚴重，0-5六個尺度)與1項症狀影響生
活品質的評分(非常好至很痛苦，0-6七個尺度)，前7項症狀量表的評分總合稱
為IPSS總分(0-35)。所有資料以Spearmen相關係數(Spearmen’s rank correlation
coefficient)與相關法則(association rule)分析，以最少的k項且與PSS總分比較相
關係數≥ 0.95，被定義為修正之攝護腺肥大症合併下泌尿道症狀量表。分析中顯
示相關係數最高(0.89)之兩項組合為IPSS-2,5 (尿頻與尿流無力);相關係數最高
(0.94)之三項組合為IPSS-1,2,5 (排尿不清、尿頻與尿流無力);相關係數最高(0.97)
之四項組合為IPSS-1,2,5,7 (排尿不清、尿頻、尿流無力與夜尿次數)，相關法則
分析顯示相關係數也達0.96，支持IPSS-1,2,5,7量表模型的穩健性。因此我們定
義尿流無力(weak stream)、排尿不清(incomplete emptying)、夜尿次數(nocturia)、
尿頻(frequency)為修正之攝護腺肥大症合併下泌尿道症狀“WINF”量表，同時進
行年齡層分析，也得到一致性的結果。
自2012年4月至11月，共有1111名40 歲以上男性參加驗證研究並完成自填式
之國際攝護腺症狀量表(第一次來診)與“WINF”量表(第二次來診)。結果顯示
receiver operating characteristic (ROC)曲線以下之面積為0.919，病人填寫“WINF”
滿意度達99%。應用支持向量機(Support vector machine)與隨機森林(Random
forests)進行由“WINF” 回推IPSS量表，各個年齡層之準確度為73.7-84.8 %。結
果顯示攝護腺肥大症合併下泌尿道症狀之篩檢，可以“WINF”量表替代國際攝護
腺症狀(IPSS)量表。
本研究的貢獻在於量表的修正可以減輕醫病雙方填表的負擔，增進醫病關係與病
人滿意度，並可應用在醫療機構中之流程改善與再造，以利提升在醫療市場之競
爭優勢。

In clinical experience, some patients with lower urinary tract symptoms following benign prostatic hyperplasia (BPH/LUTS) were not well satisfied with given self-administered International Prostate Symptom Score (IPSS) questionnaire for the questions’ ambiguity. Our study aimed to develop and validate the modified BPH/LUTS questionnaire.
Between May 2009 and March 2012, 4865 men aged 40 years or over were enrolled
and completed self-administered IPSS questionnaire, the sum of seven separated IPSS scores for each patient was categorized as IPSS-total. The Spearmen’s rank correlation coefficient and association rule mining were used to analyze and the least k items of IPSS with correlation coefficient ≥ 0.95 was defined as modified model. At the analysis, the highest correlation coefficient of any two IPSS items with IPSS-total was 0.89 (IPSS-2,5 i.e. frequency and weak stream); the highest correlation coefficient of any three IPSS items was 0.94 (IPSS-1,2,5 i.e. incomplete voiding, frequency and weak stream); and the highest correlation coefficient of any four IPSS items with IPSS-total was 0.97 (IPSS-1,2,5,7 i.e. incomplete emptying, frequency, weak stream and nocturia), respectively. The modified four items “WINF”, including
weak stream, incomplete emptying, nocturia and frequency, also fitted the patients with different age groups.
From April to November 2012, 1111 patients were recruited in the study to validate the robustness and measure the satisfaction of the “WINF” questionnaire.
The results disclosed high satisfaction rate (99%) with “WINF” comparing to IPSS questionnaire. The area under receiver operating characteristic (ROC) curve was 0.919. The support vector machine and random forests were used to measure the inference of the “WINF” to IPSS with accuracy of 73.7-84.8 % in different age groups.
The “WINF” model provides its feasibility in clinical utility and the reduction of burden on the patient. It might be an alternative screening tool for patients with LUTS following BPH. The study contributes to improve the healthcare services quality, the patients’ satisfaction and the rapport between patients and healthcare providers. The healthcare organization needs to implement the innovative process reengineering in order to take the competitive advantages in emerging healthcare market.

Contents page
Chapter One：Introduction………………………………..............................01
(1) Background………………………………………………………..……..........................01
(2) Purpose……………………………………………………….……..……........................03
Chapter Two：Literature Review…………………………………...…...................05
(1) Prostate gland…………………………………………………..……..…....................05
(2) Benign prostatic hyperplasia………………………………………....…..............08
(3) International Prostate Symptom Score (IPSS) questionnaire……....22
(4) Quality of life…………………………………………….….………...….................25
(5) Nocturia………………………………………………….….……….…...27
Chapter Three：Research Materials and Methods...……….….….…29
(1) Problem description……………………….……………………..….…....29
(2) Patients and methods…………………….……………………..………...30
(3) Statistical analyses……………………….…………………..…………...31
Chapter Four：Results………………………...………………………..…..…37
(1) Modification of the IPSS questionnaire….………………………...….…37
(2) Validation of “WINF” questionnaire ….………………………..... 48
Chapter Five：Discussion…………………………………………………………….…..……..51
(1) Modification stage…………………………………...................................51
(2) Validation stage……………………………………………………………56
(3) Managerial implications…………….……………………………………..57
Chapter Six：Conclusions and future studies…………………………59
(1)Research conclusions………………………………………………………59
(2)Future studies……………………………….………………………...........60
References………………………………………………………………..........…61
Appendix…………………………………………………………………….........73
I
Figure contents
Page
Figure 2-1-1 Anatomy of the prostate………………………………………………..7
Figure 2-2-1 Age-specific prevalence of BPH/LUTS…………………….………….9
Figure 2-2-2 Age-specific incidence of BPH/LUTS……………………….………...9
Figure 2-2-3 Normal uroflowmetry……………………………………….………...18
Figure 2-2-4 Mild obstructive type uroflowmetry…………………………………..18
Figure 2-2-5 Moderate obstructive type uroflowmetry……………………………...18
Figure 2-2-6 Severe obstructive type uroflowmetry………………………………...18
Figure 4-1-1 Age distributions of study sample……………………………………..37
Figure 4-1-2 The IPSS-total distribution in study sample…………………...............38
Figure 4-1-3 The IPSS-total distribution in men aged 40-49 years………………….38
Figure 4-1-4 The IPSS-total distribution in men aged 50-59 years………………….39
Figure 4-1-5 The IPSS-total distribution in men aged 60-69 years………………….39
Figure 4-1-6 The IPSS-total distribution in men aged over 70 years………...............40
Figure 4-2-1 The ROC AUC of “WINF” comparing to IPSS-total………...………..49
I
Table contents
Page
Table 4-1-1 The associations between IPSS-total and QoL in different age
groups………………………………………………...…… ..………....40
Table 4-1-2. The relative weights of each IPSS item among IPSS-total in different
age groups……………………………………………………… …...…41
Table 4-1-3 The relative correlations among IPSS-total, prostate size and maximum
uroflow………………………………………………………………….41
Table 4-1-4 The correlations between age and IPSS-total, prostate size, maximum
uroflow………………………………………………………………….42
Table 4-1-5 Classification of IPSS items into two categories by PCA………………42
Table 4-1-6 The most associated item compared with IPSS-total items……… …….43
Table 4-1-7 The most 2 associated items compared with IPSS-total items….............43
Table 4-1-8 The most 3 associated items compared with IPSS-total items……….....44
Table 4-1-9 The most 4 associated items compared with IPSS-total items………….45
Table 4-1-10 The higher eleven 4-item combinations were analyzed by
association rule………………………………………………………...46
Table 4-1-11 The correlation coefficients between selected four IPSS items and
IPSS-total in different age groups……………………………………..47
II
Table 4-2-1 The correlation coefficients among IPSS, IPSS related QoL, “WINF”
and “WINF” related QoL by Spearman’s rank correlation
coefficient……………………………………………………………….48
Table 4-2-2 Comparison of inference accuracy from “WINF” score to each
non-select item score between Support vector machine (SVM)
and Random forest (RF) in different age groups……………………….48
Table 4-2-3 Inference accuracy of “WINF” score vs. IPSS-3, 4, 6 sum score
and “WINF” score vs. IPSS-total score in different age groups………..49

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