安寧緩和醫療對生命末期照護品質及醫療費用之相關性探討─以肺癌病人為例

蔡欣芸

doi:10.6342/NTU201800651

山西大学，您好！

感谢采购，人社期刊库｜人社论文库，期间：2025/01/01~2025/12/31

感谢试用，科学期刊库｜科学论文库，期间：2024/10/20~2025/01/20

浏览高级检索

关闭
检索检索高级检索出版物检索
浏览期刊主题浏览核心期刊浏览期刊拼音浏览

关闭

查询符号(半角)	查询符号意义说明
空格	表示为「AND」两个查询词之交集
双引号 ( " " )	片语以双引号标示开始及结束，而且只寻找出现顺序相同的字词，例： " image process "
?	表示一个字母切截，输入两个?表两个字母，依此类推，例：输入「Appl?」，查得结果应为appl e , appl y … ( 常用于英文字查询 )
*	表示不限字母切截，由0~n. 例：输入「appl*」，查得结果应为appl e , appl es , appl y , appl ied , appl ication … ( 常用于英文字查询 )
AND、OR、NOT	布尔逻辑组合关键字，用来扩大或缩小查询范围的技巧。 (1) AND ：缩小查询范围 (2) OR ：扩大查询范围(3) NOT：排除不相关的范围

DOI 是数位物件识别码（ D igital O bject I dentifier ）的简称，
为物件在网路上的唯一识别码，可用于永久连结并引用目标物件。

使用DOI作为永久连结

每个DOI号前面加上「 http://dx.doi.org/ 」便成为永久网址。
如以DOI号为 10.5297/ser.1201.002 的文献为例，此文献的永久连结便是： http://dx.doi.org/ 10.5297/ser.1201.002 。
日后不论出版单位如何更动此文献位置，永久连结所指向的位置皆会即时更新，不再错失重要的研究。

引用含有DOI的文献

有DOI的文献在引用时皆应同时引用DOI。若使用APA、Chicago以外未规范DOI的引用格式，可引用DOI永久连结。

DOI可强化引用精确性、增强学术圈连结，并给予使用者跨平台的良好使用经验，目前在全世界已有超过五千万个对象申请DOI。如想对DOI的使用与概念有进一步了解，请参考（）。

书目管理工具

相关连结

问题回报

全文下载

安宁缓和医疗对生命末期照护品质及医疗费用之相关性探讨─以肺癌病人为例

Exploring the Impact of Hospice Palliative Medicine on Quality of End-of-Life Care and Expenditures - Example from Lung Cancer Patients

蔡欣芸 , 博士　　导师：锺国彪　　

繁体中文 DOI： 10.6342/NTU201800651

肺癌；生命末期照护；积极性治疗；安宁缓和医疗；医疗费用； lung cancer ； end-of-life care ； aggressive care ； hospice palliative medicine ； health expenditure

0 个人觉得这篇文章赞

摘要 │ 参考文献 (134) │ 国际计量

摘要〈TOP〉

背景：为提升癌末照护品质及有效利用急性病房资源，卫生福利部逐步推动居家、住院安宁疗护及安宁共同照护及社居安宁服务，然而鲜少研究透过纵贯资料分析安宁缓和医疗使用的轨迹类型及对生命末期照护品质及费用的影响。本研究以肺癌为例分析生命末期照护品质趋势、安宁缓和医疗使用轨迹类型及影响因素，进而探讨安宁缓和医疗对生命末期照护品质及医疗费用的影响。
研究方法：本研究为一回溯性世代研究，透过癌症登记资料库、健保资料库及死亡登记资料库进行分析。研究对象为2004年至2012年申报至癌症登记资料库之新诊断肺癌并於2012年底死亡个案(N=65,552)，根据每位个案在死前30周每周安宁疗护使用情形透过群体轨迹模式辨识出安宁疗护轨迹类型，以生命末期积极照护指标代表个案生命末期的照护品质，医疗费用包括死前一、三、六个月及纳入安宁疗护後的总医疗费用，共变项为病人人口学及疾病特性、照护医师及医院特性。以年龄年代世代模式、多元罗吉斯回归、倾向分数加权及配对方法、广义线性混和模式进行假说验证。
研究结果：肺癌生命末期安宁疗护使用率逐年增加，积极照护指标逐年下降包括最後14天化学治疗、最後一个月住院超过一次、住院超过14天、使用加护病房、气管插管或呼吸器、及心肺复苏术；逐年增加指标包括最後14天标靶治疗、最後一个月急诊超过一次、及在医院死亡。群体轨迹模式归纳出四种轨迹类型：延迟安宁疗护组(85.7%个案，未使用安宁疗护或在最後一周使用)，晚期安宁疗护组(6.9%个案，死前6周开始使用且频率快速升高)、中期安宁疗护组(4.8%个案，死前13周使用且频率缓慢升高)、及早期安宁疗护组(2.6%个案，死前30周已使用且频率缓慢升高)。女性、年长者、病龄长、疾病严重度高、居住地都市化程度高，於通过癌症诊疗品质认证、有安宁病房资源及高肺癌照护服务量医师医院就诊患者有较高机率使用安宁疗护。倾向分数加权後之广义线性混和模式分析结果发现安宁疗护组在最後14天化学治疗、标靶治疗、最後一个月急诊超过1次、使用加护病房、插管呼吸器及心肺复苏术的相对风险低於延迟安宁疗护组，但住院超过一次或超过14天及在医院死亡风险高於延迟安宁疗护组。安宁疗护组在最後一、三、六个月、及纳入安宁疗护後总医疗费用皆显着低於延迟安宁组，但并非越早纳入安宁疗护医疗费用降低越多。
结论：肺癌生命末期照护随着安宁疗护政策推动有逐渐增加的安宁疗护使用率，同时减少积极照护使用及降低医疗费用。然而标靶治疗、急诊及在医院死亡比例逐年增加，而安宁疗护组在最後一个月住院及医院死亡比例高於延迟安宁疗护组，显示生命末期标靶治疗或其他新药的使用规范，及居家或社区安宁疗护制度仍需更完善的规划，以提升肺癌患者安宁疗护接受度及达到就地善终的目标。未来相关研究可透过群体轨迹模式作为客观分类纵贯性资料次群体方法的参考。

并列摘要〈TOP〉

Background: Hospice palliative medicine in Taiwan has been growing continuously since the National Health Insurance reimbursement scheme of hospice care was introduced to promote the quality of end-of-life (EOL) cancer care and to use the acute care resources efficiently. However, studies using longitudinal data to identify hospice palliative medicine trajectories and the impact on EOL care and medical expenditures were scant. This study aimed to explore the trend of EOL care quality among patients with lung cancer, to identify the trajectory patterns of hospice palliative medicine utilization and the factors related to these trajectories, and to evaluate the impact of hospice palliative medicine trajectories on EOL care quality and medical expenditures.
Methods: A longitudinal retrospective cohort study was conducted by using nationwide database including Taiwan Cancer Registry, National Health Insurance Research Database and Taiwan Death Registry. Study population was 65,552 newly diagnosed lung cancer patients between 2004 and 2012 and died at the end of 2012. Hospice utilization of each patient at each week during 30 weeks before death was analyzed to identify the trajectory patterns by applying group-based trajectory modeling. Aggressive care indicators were assessed to represent the quality of EOL care. Medical expenditures were calculated at one, three, six months before death, and after enrollment in hospice programs. Information about patient demographics, disease characteristics, physician and hospital characteristics were also collected. Age-period-cohort models, multinomial logistic regression models, propensity score weighting and matching methods, and generalized linear mixed models were used to estimate associations.
Results: Downward trends of aggressiveness EOL lung cancer care were observed for chemotherapy use, multiple hospitalizations, hospitalization exceeding 14 days, ICU admissions, intubation or mechanical ventilation use, and CPR use; upwards trends were observed for targeted therapy use, multiple emergency department visits, died in hospitals, and hospice palliative care use. Four distinct trajectory groups of hospice utilization in terminal lung cancer patients were identified: a late-referred group, a group with medium-referral and rapid rise in hospice utilization, a group with medium-referral and slow rise in hospice utilization, and an early-referral group. With late-referral as the reference group, those who were female, older age, longer disease duration, higher disease severity, living in higher urbanization area were more likely to use hospice care. The odds increased in patients whose treatment by physicians with a higher annual lung cancer case volume, and those whose treatment in hospitals that achieved the accreditation of cancer care quality, having inpatient hospice facilities, and with a higher annual lung cancer case volume. Multivariate analysis showed that medium- and early-referral patients were significantly less likely to undergo aggressive EOL care than late-referral patients including chemotherapy and targeted therapy use, multiple emergency room visits, ICU admissions, intubation, mechanical ventilation and CPR use. However, they were more likely to undergo multiple hospitalizations, hospitalization exceeding 14 days, and died in hospitals. Besides, medical expenditures of one, three, six months before death and after enrollment in hospice programs were significantly lower in medium- and early-referral groups than late-referral groups. However, not the earlier patient enrolled in hospice programs the more savings in medical expenditures. 
Conclusions: As the implementation of hospice reimbursement scheme, use of hospice palliative medicine increased, aggressive EOL care and medical expenditures decreased for patients with lung cancer. However, there is still room for developing the regulations of targeted therapy and new medication use at EOL, as well as home-based and community-based hospice palliative care system to increase the use of hospice palliative care and to reach the goal of passing on at home. Moreover, future researches could apply group-based trajectory modelling for longitudinal data classification.

参考文献 ( 134 ) 〈TOP〉

Bach, P. B., Schrag, D., & Begg, C. B. (2004). Resurrecting treatment histories of dead patients - A study design that should be laid to rest. Jama-Journal of the American Medical Association, 292(22), 2765-2770. doi: 10.1001/jama.292.22.2765
连结：
Bade, B. C., & Silvestri, G. A. (2016). Palliative Care in Lung Cancer: A Review. Seminars in Respiratory and Critical Care Medicine, 37(5), 750-759. doi: 10.1055/s-0036-1592110
连结：
Barbera, L., Paszat, L., & Qiu, F. (2008). End-of-life care in lung cancer patients in Ontario: Aggressiveness of care in the population and a description of hospital admissions. Journal of Pain and Symptom Management, 35(3), 267-274. doi: 10.1016/j.jpainsymman.2007.04.019
连结：
Blecker, S., Anderson, G. F., Herbert, R., Wang, N. Y., & Brancati, F. L. (2011). Hospice Care and Resource Utilization in Medicare Beneficiaries With Heart Failure. Medical Care, 49(11), 985-991. doi: 10.1097/MLR.0b013e318235c221
连结：
Braga, S., Miranda, A., Fonseca, R., Passos-Coelho, J. L., Fernandes, A., Costa, J. D., & Moreira, A. (2007). The aggressiveness of cancer care in the last three months of life: A retrospective single centre analysis. Psycho-Oncology, 16(9), 863-868. doi: 10.1002/pon.1140
连结：

国际计量

〈TOP〉

E-mail ：

文章公开取用时，将寄通知信至您填写的信箱地址

E-mail ：

使用DOI作为永久连结

引用含有DOI的文献

DOI可强化引用精确性、增强学术圈连结，并给予使用者跨平台的良好使用经验，目前在全世界已有超过五千万个对象申请DOI。 如想对DOI的使用与概念有进一步了解，请参考 （ ） 。

DOI可强化引用精确性、增强学术圈连结，并给予使用者跨平台的良好使用经验，目前在全世界已有超过五千万个对象申请DOI。如想对DOI的使用与概念有进一步了解，请参考（）。