臺灣博碩士論文加值系統

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」。

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.

目錄
誌謝Ⅰ
中文摘要Ⅱ
英文摘要Ⅳ
目錄Ⅵ
表目錄Ⅷ
圖目錄Ⅹ
附錄目錄XI
第一章 緒論1
第一節研究動機----------------------------------------------1
第二節研究目的----------------------------------------------4
第二章文獻探討----------------------------------------------------5
第一節醫療品質的定義與涵蓋層面------------------------------5
第二節安寧緩和療護服務品質稽核相關研究----------------------7
第三節應用品質評量於安寧緩和療護----------------------------9
第四節國內安寧緩和療護之研究-------------------------------10
第三章研究方法---------------------------------------------------12
第一節研究架構---------------------------------------------12
第二節研究假設---------------------------------------------13
第三節名詞界定---------------------------------------------13
第四節研究工具---------------------------------------------14
第五節研究工具之信度與效度---------------------------------18
第六節研究對象及收案過程-----------------------------------22
第七節資料處理及分析---------------------------------------23
第四章結果分析---------------------------------------------------25
第一節描述性分析-------------------------------------------25
第二節病人與醫院屬性對緩和療護品質評量結果之影響-----------35
第三節安寧與非安寧緩和病房之療護品質稽核差異---------------40
第五章討論-------------------------------------------------------44
第一節安寧緩和病房與非安寧緩和病房在療護品質結果之
差異-------------------------------------------------44
第二節影響緩和療護評量結果的因素探討-----------------------47
第三節病人與醫護人員品質評量差異的探討---------------------49
第四節緩和療護的意義與前景---------------------------------50
第五節「緩和療護結果量表」的發展與中文版適用性探討---------51
第六節研究限制---------------------------------------------53
第七節結論與建議-------------------------------------------54
參考文獻----------------------------------------------------------60
中文部分-------------------------------------------------------60
英文部分-------------------------------------------------------60
附錄一 問卷英文原稿-------------------------------------------66
附錄二 經專家效度檢測修改後之中文量表-------------------------73
附錄三 病患資料收集表-----------------------------------------80
附錄四 安寧緩和療護病房基本資料-------------------------------82
附錄五 量表回復翻譯並經原作者確立-----------------------------83
附錄六 The POS原作者Higginson教授之書信回函------------------90
附錄七 專家效度名單-------------------------------------------92
附錄八 致專家信函與效度評鑑表及建議內容-----------------------93
附錄九 「緩和療護結果量表」修改版-----------------------------99
表目錄
表一全國安寧緩和療護機構-------------------------------------2
表二緩和療護從構造面、過程面、結果面的評估例子---------------6
表三世界各國目前現有之安寧療護臨床稽核指引-------------------8
表四現階段國內安寧療護照護品質之研究文獻--------------------11
表五比較The POS 與EORTC QLQ-C30，The STAS 之關連
效度----------------------------------------------------19
表六專家效度CVI值-----------------------------------------20
表七「緩和療護結果量表」之再測信度，皮爾森相關係數----------21
表八病人屬性資料分析----------------------------------------27
表九安寧緩和療護醫院屬性資料--------------------------------30
表十「緩和療護結果量表」各選項回答分佈情形------------------32
表十一病人屬性對緩和照護結果量表之評分影響--------------------36
表十二安寧緩和療護醫院屬性對緩和療護結果量表之影響------------39
表十三不同醫院非安寧緩和病房病人對療護品質結果評量之差
異情形--------------------------------------------------39
表十四不同醫院非安寧緩和病房醫護人員對療護品質結果評量
之差異情形----------------------------------------------39
表十五緩和療護結果量表各題得分差異之無母數分析----------------40
表十六緩和療護結果量表病人組各題得分差異之無母數分析----------41
表十七緩和療護結果量表醫護組各題得分差異之無母數分析----------41
表十八病人組之安寧病房與非安寧病房緩和療護品質之比較----------42
表十九醫護組之安寧病房與非安寧病房緩和療護品質之比較----------42
表二十安寧與非安寧緩和病人組與醫護組照護品質差異之比較--------42
表二十一六組病人(三組安寧病房及三組非安寧病房)之品質評分
差異情形------------------------------------------------43
表二十二癌症疼痛與末期照顧的國家政策----------------------------47
表二十三「緩和療護結果量表」修改內容----------------------------56
圖目錄
圖一 1966-1994 相關品質稽核論文數目---------------------------4
圖二 研究架構------------------------------------------------12
圖三 緩和療護結果量表各題得分平均值--------------------------31
圖四 安寧病房組「緩和療護結果量表」之各題得分分佈圖----------33
圖五 非安寧病房組「緩和療護結果量表」之各題得分分佈圖--------34
圖六 安寧緩和療護的比重示意圖--------------------------------46
圖七 安寧緩和療護架構----------------------------------------51
目錄
誌謝Ⅰ
中文摘要Ⅱ
英文摘要Ⅳ
目錄Ⅵ
表目錄Ⅷ
圖目錄Ⅹ
附錄目錄XI
第一章 緒論1
第一節研究動機----------------------------------------------1
第二節研究目的----------------------------------------------4
第二章文獻探討----------------------------------------------------5
第一節醫療品質的定義與涵蓋層面------------------------------5
第二節安寧緩和療護服務品質稽核相關研究----------------------7
第三節應用品質評量於安寧緩和療護----------------------------9
第四節國內安寧緩和療護之研究-------------------------------10
第三章研究方法---------------------------------------------------12
第一節研究架構---------------------------------------------12
第二節研究假設---------------------------------------------13
第三節名詞界定---------------------------------------------13
第四節研究工具---------------------------------------------14
第五節研究工具之信度與效度---------------------------------18
第六節研究對象及收案過程-----------------------------------22
第七節資料處理及分析---------------------------------------23
第四章結果分析---------------------------------------------------25
第一節描述性分析-------------------------------------------25
第二節病人與醫院屬性對緩和療護品質評量結果之影響-----------35
第三節安寧與非安寧緩和病房之療護品質稽核差異---------------40
第五章討論-------------------------------------------------------44
第一節安寧緩和病房與非安寧緩和病房在療護品質結果之
差異-------------------------------------------------44
第二節影響緩和療護評量結果的因素探討-----------------------47
第三節病人與醫護人員品質評量差異的探討---------------------49
第四節緩和療護的意義與前景---------------------------------50
第五節「緩和療護結果量表」的發展與中文版適用性探討---------51
第六節研究限制---------------------------------------------53
第七節結論與建議-------------------------------------------54
參考文獻----------------------------------------------------------60
中文部分-------------------------------------------------------60
英文部分-------------------------------------------------------60
附錄一 問卷英文原稿-------------------------------------------66
附錄二 經專家效度檢測修改後之中文量表-------------------------73
附錄三 病患資料收集表-----------------------------------------80
附錄四 安寧緩和療護病房基本資料-------------------------------82
附錄五 量表回復翻譯並經原作者確立-----------------------------83
附錄六 The POS原作者Higginson教授之書信回函------------------90
附錄七 專家效度名單-------------------------------------------92
附錄八 致專家信函與效度評鑑表及建議內容-----------------------93
附錄九 「緩和療護結果量表」修改版-----------------------------99
表目錄
表一全國安寧緩和療護機構-------------------------------------2
表二緩和療護從構造面、過程面、結果面的評估例子---------------6
表三世界各國目前現有之安寧療護臨床稽核指引-------------------8
表四現階段國內安寧療護照護品質之研究文獻--------------------11
表五比較The POS 與EORTC QLQ-C30，The STAS 之關連
效度----------------------------------------------------19
表六專家效度CVI值-----------------------------------------20
表七「緩和療護結果量表」之再測信度，皮爾森相關係數----------21
表八病人屬性資料分析----------------------------------------27
表九安寧緩和療護醫院屬性資料--------------------------------30
表十「緩和療護結果量表」各選項回答分佈情形------------------32
表十一病人屬性對緩和照護結果量表之評分影響--------------------36
表十二安寧緩和療護醫院屬性對緩和療護結果量表之影響------------39
表十三不同醫院非安寧緩和病房病人對療護品質結果評量之差
異情形--------------------------------------------------39
表十四不同醫院非安寧緩和病房醫護人員對療護品質結果評量
之差異情形----------------------------------------------39
表十五緩和療護結果量表各題得分差異之無母數分析----------------40
表十六緩和療護結果量表病人組各題得分差異之無母數分析----------41
表十七緩和療護結果量表醫護組各題得分差異之無母數分析----------41
表十八病人組之安寧病房與非安寧病房緩和療護品質之比較----------42
表十九醫護組之安寧病房與非安寧病房緩和療護品質之比較----------42
表二十安寧與非安寧緩和病人組與醫護組照護品質差異之比較--------42
表二十一六組病人(三組安寧病房及三組非安寧病房)之品質評分
差異情形------------------------------------------------43
表二十二癌症疼痛與末期照顧的國家政策----------------------------47
表二十三「緩和療護結果量表」修改內容----------------------------56
圖目錄
圖一 1966-1994 相關品質稽核論文數目---------------------------4
圖二 研究架構------------------------------------------------12
圖三 緩和療護結果量表各題得分平均值--------------------------31
圖四 安寧病房組「緩和療護結果量表」之各題得分分佈圖----------33
圖五 非安寧病房組「緩和療護結果量表」之各題得分分佈圖--------34
圖六 安寧緩和療護的比重示意圖--------------------------------46
圖七 安寧緩和療護架構----------------------------------------51
附錄目錄
附錄一 問卷英文原稿-------------------------------------------66
附錄二 經專家效度檢測修改後之中文量表-------------------------73
附錄三 病患資料收集表-----------------------------------------80
附錄四 安寧緩和療護病房基本資料-------------------------------82
附錄五 量表回復翻譯並經原作者確立-----------------------------83
附錄六 The POS原作者Higginson教授之書信回函-------------------90
附錄七 專家效度名單-------------------------------------------92
附錄八 致專家信函與效度評鑑表及建議內容-----------------------93
附錄九 「緩和療護結果量表」修改版---------------------------
99

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