以體療品質的觀點探討台灣乳癌之診療型態

The Quality Issues in the Diagnosis and Treatment of Breast Cancer in Taiwan

10.6288/TJPH2002-21-05-05

林慧淳(Huey-Chwen Lin)；葉玲玲(Ling-Ling Yeh)；吳仁佑(Jen-You Wu)；黃達夫(Anderew T. Huang)

實證醫學 ； 診療準則 ； 乳癌 ； 診療型態 ； 台灣 ； evidence-based medicine ； practice guideline ； breast cancer ； diagnosis and treatment ； Taiwan

台灣公共衛生雜誌

21卷5期（2002 / 10 / 01）

349 - 362

繁體中文

目標：本研究旨在以乳癌實證醫學為基礎之診療準則為架構，分析台灣各層級別醫院之診療型態，並探討其對確保醫療品質的意涵。方法：本研究利用1997年1月至1999年11月之全民健保門診與住院申報檔，進行次級資料分析。針對曾為1997年女性乳癌新發個案進行手術治療之醫療院，分析其乳癌診斷、治療與追蹤之三階段診療型態，並比較不同層級別醫院診療型態，呈現出醫療品質現況。結果：(１)乳癌診斷之診療型態中，除荷爾蒙接受體與乳房超音波或造影檢查比率較低外，其他檢查比率達97%；(２)0期病人進行改良型乳癌根除術者高達6成，本研究也顯示乳房保留手術病人術後進行放射治療比率低，且各醫院間差異大；(３)醫學中心與區域醫院之化學治療藥物處方較具一致性，而地區醫院高達6成未符合診療準則之藥物處方型態；(４)追蹤期間乳房超音波或造影檢查比率尚不及5成；(５)荷爾蒙治療前、後所需檢查達成比率偏低，各醫院間差異大。結論：藉由本研究乳癌診療型態分析可知，健保申報資料的分析可作為有效監控醫療照護品質的方式。研究結果亦顯示，若遵照實證醫學診療準則診斷或治療癌症，則可降低醫療資源不當利用的情形。此外，建議健保申報資料應增加影響診療型態的重要變項，如診斷期別，以便對國內醫療品質有更深入的瞭解。

Objectives: The objectives of this study were two-fold. Using the guidelines based on evidence, we analyzed the patterns of diagnosis and treatment of breast cancer in Taiwan. The second objective was to determine whether the data generated from the analysis could be adopted for assuring quality of care in breast cancer. Methods: We used the claims data of the Bureau of National Health Insurance (BNHI) from hospitals throughout Taiwan between January 1997 and November 1999 for a secondary data analysis. The patterns of diagnosis and treatment were divided into three stages, namely diagnosis, treatment, and follow-up conducted in hospitals when ever mastectomy was performed for the new cases of breast cancer recorded in 1997. The analysis was then made on the differences in the pattern of diagnosis and treatment amongst hospitals in Taiwan. Ultimately, a comparison was made against various quality indicators developed for breast cancer. Results: (1) In the diagnostic area, the rate of cytologic and histologic diagnosis as well as blood tests reached 97%. However this figure was not reached for the ER/PR receptor examination and breast sonography or mammography. (2) More than 60% of the patients with noninvasive carcinomas were still treated with modified radical mastectomy. This study also showed an unexpected low rate of radiation therapy after breast conservation surgery in most hospitals. (3) Medical centers and regional hospitals were consistent in their use of the chemotherapy regimen according to accepted practice guidelines, whereas the inconsistency rates among district hospitals were greater than 60%. (4) In the follow-up period, the breast sonography or mammography was less often ordered (50%) than what the standard required. (5) The rate of examination for ER/PR receptor status before and after initiation of hormonal treatment was low, and the variation among hospitals was also large. Conclusions: Breast cancer claims data of BNHI can be used to determine the quality of care with reasonable accuracy. Our analysis of breast cancer indicated that while certain tests or treatments were consistent with good practice of oncology based on evidences accepted worldwide, some important tests and treatments were carried out at frequencies significantly lower than what was considered to be acceptable. The only significant deficiency in the claims data for analysis of quality standards is the lack of staging information for breast cancer or any other cancer. We urge that such information be added as a requirement for the filing of reimbursement claims by the hospital which treats cancer patients.

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