探討癌症病人就醫經驗、信任醫師與更換醫師意向之關係

張琬婷

doi:10.6342/NTU201601606

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探讨癌症病人就医经验、信任医师与更换医师意向之关系

Exploring the relationship among cancer patient experience, trust in physician and intention of changing physician

张琬婷 , 硕士　　导师：锺国彪　　

繁体中文 DOI： 10.6342/NTU201601606

病人报告为结果的测量；医病关系；癌症病人就医经验；病人信任；更换医师； patient-report outcome measure ； physician-patient relationship ； cancer patient experience ； patient trust ； change physician

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摘要 │ 参考文献 (143) │ 国际计量

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背景与目的：自1982年起，癌症已连续33年高居国人死因首位，且发生和死亡的速率皆有增加的趋势，对国人的健康一直存在威胁。WHO(2000)、IOM(2001)和OECD(2006)提出回应民众需求及病人为中心为健康照护体系的要素，此两要素逐渐成为全球医疗品质发展的趋势，且近年来医疗品质的测量也转向发展病人观点或就医经验的调查，成为品质改善的重要依据。而信任是建立良好医病关系的重要元素，会受到病人就医经验的优劣所影响，且病人信任度在医疗过程中也会造成许多正负面的影响(如健康结果、更换医师等)。因此本研究欲了解就医经验、病人信任和更换医师意向三者间的关系，找出影响因素以提升病人对医师的信任度，进而降低病人更换医师的可能性。
研究方法：本研究为横断性研究，采自填式结构问卷进行调查，收案对象为在医院接受照护的六大癌症(乳癌、结肠直肠癌、子宫颈癌、肺癌、口腔癌和肝癌)病人，研究工具采用癌症病人就医经验问卷(CPES)和信任肿瘤科医师量表(TiOS)作为调查问卷，收案期间为2015年11月16日至2016年6月8日，共得有效问卷为277份。在就医经验的部分将癌症病人在医疗过程中实际接受到的经验换算成构面的正向经验比率，代表该构面医疗品质的优劣；信任医师的部分采Likert五点尺度作为程度高低的分数计算，再以加总分数代表病人信任度；而更换医师意向则以二分法区分为不想或想。本研究使用SPSS20.0和IBM SPSS Amos 21.0，将收集到的资料以因素分析、描述性分析、独立样本T检定、单因子变异数分析、卡方检定、皮尔森积差相关、复回归和罗吉斯回归分析等方法进行资料分析。
研究结果：年龄和种族为影响癌症病人信任度的因素；其中、年龄亦会影响癌症病人更换医师意向。在控制其他变项後，癌症病人就医经验七构面(以病人为中心的照护、医病间沟通情形、癌症资讯的给予及支持、情绪支持、参与治疗决策及照护计画、照护的连续性、财务及工作支持)皆会显着影响其对医师的信任程度。而癌症病人信任度会显着影响其更换医师意向。除财务及工作支持外，其余的癌症病人就医经验六构面皆会显着影响病人更换医师的意向，且此癌症病人就医经验六构面与更换医师意向间的关系，皆会受到病人信任度的完全中介影响。
结论：癌症病人在以病人为中心的照护、医病间沟通情形、癌症资讯的给予及支持、情绪支持、参与治疗决策及照护计画、照护的连续性、财务及工作支持构面中的就医经验愈好，病人信任度就会愈高；提升癌症病人的信任度，可降低其更换医师的可能性；此外，除了财务及工作支持构面，其余六构面的癌症病人就医经验愈好，而其更换医师的可能性会愈低，且此六构面会透过病人信任度来影响其更换医师的意向。进一步分析发现医病沟通对於癌症病人是否会更换医师而言是相当重要的影响因素，建议医疗院所可将沟通技巧纳入教育训练课程中，提升医师的沟通能力，让医病沟通能更有效率及效益，也建议医师在看诊时可与个管师做搭配，让病人得以获得更详细的说明。

并列摘要〈TOP〉

Background and aims: Since 1982, cancer has been ranked top of death cause for 33 years, also the rate of occurrence and mortality have been increased. It had become a threat to the health of population. WHO, IOM and OECD indicated that responsiveness and patient-centered were the key elements of health care system. These two elements have gradually become the trend of medical quality development. Recently, the measure of medical quality has turned to develop the survey of patient perspective or experience which become the critical basis for quality improvement. Trust is the crucial element of building good physician-patient relationship, and is affected by patient experience. Patient trust will cause many positive and negative results, such as health outcomes, changing physician etc. This study attempts to explore the relationship among patient reported experience, patient trust and the intention of changing physician, and find out the influential factors to increase the degree of patient trust and reduce the possibility of changing physician.
Method: This is a cross-sectional study and adopt self-report questionnaire to collect the data. The subjects of study include six kinds of cancer patients that receive care in hospital. The questionnaire adopt Cancer Patient Experience Survey (CPES) and Trust in Oncologist Scale (TiOS) as investigative tools. There were 277 valid samples with collection period from November 16th 2015 to June 8th 2016. In CPES, the cancer patient during a medical procedure practical experience, is converted into a percentage calculated under dimensions. In TiOS, using the sum of Likert five-point scale as the scores of high and low degree. The part of change physician is to divide into two sections. The data is analyzed by methods of factor analysis, descriptive analysis, independent-sample T test, one-way ANOVA, chi-square test, Pearson Product-Moment Correlation, multiple linear regression and logistic regression.
Results: Age and race are the factors of influencing cancer patient trust, and age also affects the intention of changing physician. In the part of medical treatment experience, controlling for other variables, the patient receives patient-centered care experience in the process, communication experience with physicians, providing cancer information, providing emotional support, patient involvement in treatment-related decision-making and care planning, continuity of care, financial and work support are significant with patient trust. Patient trust will significantly affect the intention of changing physician. Except for financial and work support, the rest six dimensions will also significantly affect the intention of changing physician, and the relation between these dimensions and the intention of changing physician will totally intermediate by patient trust.
Conclusion: The better the cancer patient experience in the dimensions of receiving patient-centered care experience in the process, communication experience with physicians, providing cancer information, providing emotional support, patient involvement in treatment-related decision-making and care planning, continuity of care, and financial and work support, the higher degree of patient trust. Increasing the degree of patient trust will reduce the possibility of changing physician. Except for financial and work support, the better the rest six dimensions of cancer patient experience, the lower the possibility of changing physician. Furthermore, these dimensions will affect the intention of changing physician through patient trust. After further analysis, communication experience with physicians is the most important dimension. It is recommended that hospitals could include communication skill in education training to improve the ability of physicians and let communication more efficient and beneficial. In addition, it is recommended that physicians could cooperate with case managers during the outpatient service to help cancer patients to obtain more elaborate explanations.

参考文献 ( 143 ) 〈TOP〉

Abel, G. A., Saunders, C. L., & Lyratzopoulos, G. (2013). Cancer patient experience, hospital performance and case mix: evidence from England. Future Oncology, 10(9), 1589-1598. doi: 10.2217/fon.13.266
连结：
Anderson, L. A., & Dedrick, R. F. (1990). Development of the Trust in Physician scale: a measure to assess interpersonal trust in patient-physician relationships. Psychol Rep, 67(3 Pt 2), 1091-1100. doi: 10.2466/pr0.1990.67.3f.1091
连结：
Anderson, L. A., & Dedrick, R. F. (1990). Development of the trust in physician scale: A measure to assess interpersonal trust inpatient-physician relationships. Psychological reports, 67(3f), 1091-1100.
连结：
Arah, O. A., ten Asbroek, A. H., Delnoij, D. M., de Koning, J. S., Stam, P. J., Poll, A. H., . . . Klazinga, N. S. (2006). Psychometric properties of the Dutch version of the Hospital-level Consumer Assessment of Health Plans Survey instrument. Health Serv Res, 41(1), 284-301. doi: 10.1111/j.1475-6773.2005.00462.x
连结：
Arora, N. K., & Gustafson, D. H. (2009). Perceived Helpfulness of Physicians' Communication Behavior and Breast Cancer Patients' Level of Trust Over Time. Journal of General Internal Medicine, 24(2), 252-255. doi: 10.1007/s11606-008-0880-x
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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（）。