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研究生:陳廷語
研究生(外文):Ting-Yu Chen
論文名稱:醫療機構特性對子宮頸癌病人治療後遵從追蹤指引之探討
論文名稱(外文):Characteristics of Hospitals for Adherent to Surveillance Guideline Among Cervical Cancer Patients After Treatment
指導教授:郭年真郭年真引用關係
指導教授(外文):Kuo, Raymond N
口試委員:湯澡薰鄭文芳
口試日期:2015-07-29
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:健康政策與管理研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2015
畢業學年度:103
語文別:中文
論文頁數:150
中文關鍵詞:子宮頸癌存活者追蹤癌症登記資料庫
外文關鍵詞:Cervical cancerSurvivorsSurveillanceTaiwan Cancer Registry Database
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背景與研究動機:在全球,子宮頸癌為僅次於乳癌,最常見的女性癌症,而癌症已為臺灣國人十大死因之首多年。整體而言,治療後的子宮頸癌病人,約有10-15%可能經歷復發,且有3/4的復發於治療結束後的2-3年內發生,因此追蹤監測是必要的。(Barnhill et al., 1992; Brooks et al., 2009; Elit et al., 2009; Greer et al., 2010; Grigsby, Siegel, Dehdashti, & Mutch, 2003; Mabuchi et al., 2010; Samlal et al., 1998; Tjalma, Van Dam, Makar, & Cruickshank, 2004; Vannagell et al., 1979),而透過定期追蹤監測,病人能夠早期監測復發,早期治療,進而獲得較佳的存活。過去國外有許多研究提到不同的病人特性會影響癌症存活者的追蹤情形,醫療機構特性的研究較少,且多屬大直腸癌與乳癌的探討,在醫療機構特性方面,多數癌症只提及醫療機構的所在地區不同病人的追蹤遵從情形有差異,而國內關於癌症病人治療後的追蹤監測研究更屬缺乏。
研究目的:透過本研究了解目前臺灣子宮頸癌存活者的追蹤情形,並探討不同醫療機構的特性對子宮頸癌病人治療後的門診追蹤遵從率與子宮頸抹片檢查遵從率。
研究方法:透過衛生福利部協作中心之民國93年至98年的癌症登記資料庫以及民國93年至101年全民健康保險研究資料庫的門診與住院的全人口就醫紀錄進行分析。研究民國93年至98年子宮頸癌初診斷的病人,於治療後之後是否遵從美國National Comprehensive Cancer Network(NCCN)臨床指引的門診追蹤頻率與子宮頸抹片檢查頻率,將觀察時間依指引的追蹤頻率分割成數個觀察區間,並將病人於觀察區內的符合指引門診追蹤頻率的次數除以指引建議應追蹤次數為門診追蹤遵從率、將觀察區間內的子宮頸抹片檢查符合指引頻率的次數除以指引建議應追蹤次數為子宮頸抹片檢查遵從率,利用統計軟體SAS進行多階層模型分析(Mutilevel analysis),探討醫療機構特性對門診追蹤遵從率與子宮頸抹片檢查遵從率的影響。
研究結果:4,829位子宮頸癌病人於首次療程結束後,觀察中位數為6年中,於治療醫院接受後續追蹤監測的整體門診追蹤遵從率為71.32%、子宮頸抹片檢查遵從率為59.20%,有91.18%的病人於治療後半年內有接受門診追蹤、71.8%的病人有接受子宮頸抹片檢查,而存活至第9年且沒有復發的病人,只有34.4%的病人有接受門診追蹤、23.99%的病人有接受子宮頸抹片檢查,兩者皆逐年下降。
多階層模型的結果顯示,沒有共病症、有接受輔助性化學治療、年齡較小、診斷年較晚、居住於都市化程度第一級的病人,其門診追蹤遵從率與子宮頸癌抹片檢查遵從率較高;而醫療機構特性中,醫院層級較高,其病人門診追蹤遵從率較佳。
結論:本研究結果顯示醫療機構層級較高的醫院其病人的門診追蹤遵從率較高,建議病人追蹤監測情形較差的醫療機構,應採取提高病人追蹤遵從率的相關方案,例如:透過癌症個案管理師管理癌症病人。而與國外的研究相比臺灣的子宮頸癌病人追蹤監測遵從率較低,建議衛生主管機關能夠重視癌症病人治療結束後的追蹤監測並納入癌症品質提升計畫當中。
關鍵字:子宮頸癌、存活者、追蹤、癌症登記資料庫


Background. Cervical cancer is the second most common cancer in women worldwide. In Taiwan, cancer is the top 1 cause of death for several years. Generally, 10-15% cervical cancer patients after treatment likely develop recurrence, and 3/4 recurrence develop in 2-3 years after treatment. So surveillance is important. By routinely surveillance, patients could diagnose early, treat early, and result in a better survival. Past researches in surveillance of cancer survivors more focused on patients characteristics, and most research objects are colorectal cancer and breast cancer survivors. Studies of correlates of cancer survivors surveillance focused on hospitals characteristics are much less. In Taiwan, researches in surveillance of cancer survivors are lack.
Objectives. To understand surveillance of cervical cancer survivors in Taiwan, and to determine characteristics of hospitals how to effect adherent to surveillance guideline among cervical cancer patients after treatment.
Methods. Using Taiwan Cancer Registry Database, cervical patients newly diagnosis between 2004 and 2009, underwent treatment, and survived at least 6 months after treatment were identified. Physician claims from National Health Insurance Research Database after treatment through 2012 were examined for surveillance visits in outpatient department and Papanicolaou test . Visits in outpatient department and Papanicolaou test adherent to NCCN surveillance guideline during follow-up period was compared across hospital groups using multilevel analyses.
Results. We identified 4,829 patients, with a median follow-up duration of 6 years. Adherence to NCCN surveillance guideline was 71.32% for visits in outpatient department, 59.20% for Papanicolaou test. 91.18% patients had least 1visit in outpatient department, and 71.18% had 1 papanicolaou test in first 6 months after treatment. The percentage of patients having visits in outpatient department and papanicolaou test during each observation period decreased over time. In multilevel analyses, patients had treatment in medical center and metropolitan hospitals were more likely to visit in outpatient department .
Conclusion. Cervical cancer patients in Taiwan whose adherence to cervical cancer post-treatment surveillance was low. Surveillance of cancer patients after treatment needs to take into quality of cancer care plan.
Keywords:Cervical cancer, Survivors, Surveillance, Taiwan Cancer Registry Database

致謝 I
中文摘要 II
ABSTRACT IV
目錄 VI
表目錄 VIII
圖目錄 IX
第一章 緒論 1
第一節 研究背景 1
第二節 研究動機 2
第三節 研究目的 3
第二章 文獻探討 4
第一節 子宮頸癌流行病學 4
第二節 子宮頸癌的治療與存活 7
第三節 臺灣癌症照護現況 13
第四節 醫療機構特性對癌症照護品質的影響 15
第五節 子宮頸癌的追蹤 28
第六節 病人特性對追蹤監測情形之影響 34
第七節 醫療機構特性對追蹤監測情形之影響 48
第三章 研究方法與設計 52
第一節 研究架構 52
第二節 研究假說 53
第三節 研究對象 54
第四節 資料來源與研究區間 54
第五節 資料處理流程 65
第六節 統計分析方法 66
第四章 結果 70
第一節 描述性分析結果 70
第二節 雙變量分析結果 83
第三節 多變量分析結果 99
第五章 討論 110
第一節 資料品質與來源的討論 110
第二節 研究方法的討論 112
第三節 研究結果討論 113
第四節 研究限制 121
第六章 結論與建議 122
第一節 結論 122
第二節 建議 123
參考文獻 125
附錄........ 135
附錄一  化學治療相關代碼 135
附錄二 化學治療藥物相關代碼 136
附錄三 放射治療相關代碼 137
附錄四  子宮頸癌手術相關代碼 138
附錄五  共病症代碼 139
附錄六  全民健康保險重大傷病項目(104年01月16日更新版本) 141
附錄七 勞工保險局都市化分級表 147
附錄八  子宮頸抹片檢查相關代碼 150


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