提供者服務量與膀胱癌病患進行膀胱根除術之結果分析

Role of Surgeon Volume and Hospital Volume in Radical Cystectomy Outcomes of Bladder Cancer Patients

10.6288/TJPH2009-28-03-03

劉嘉年(Chia-Nien Liu)

結果 ； 醫師服務量 ； 醫院服務量 ； 膀胱根除術 ； 多層級模式 ； Outcomes ； Surgeon volume ； Hospital volume ； Radical cystectomy ； Multilevel model Analysis

台灣公共衛生雜誌

28卷3期（2009 / 06 / 01）

184 - 193

繁體中文

目標：針對罹患膀胱癌且進行膀胱根除術的病患，以多層級模式分析其醫師、醫院手術量與手術結果的關係。方法：採次級資料分析法，資料來源為全民健保學術研究資料庫。研究對象為2002~2005年間因膀胱癌(ICD-9-CM code188，236.7)住院，同時接受膀胱根除術(ICD-9-CM，code 57.7)者為對象。在提供者服務量變項方面，醫師分成高、中、低手術量三組，醫院分成高、低手術量兩組。結果變項以手術短期結果為主，包含住院死亡率、併發症、與超長住院。本研究以多層級模式處理階層性資料，以減少群集效應。結果：2002~2005年間罹患膀胱癌且接受膀胱切除術病患有1,045人，院內死亡者有21人(2.01%)，住院期間發生手術併發症者有129人(12.34%)，住院超過30日者235人(22.49%)。在控制影響因素之後，發現醫師手術量越高的分組，其住院死亡率、併發症比率與超長住院比率越低；而醫院手術量則與住院死亡率、併發症、以及超長住院無關。結論：醫師手術量越高者其手術結果較佳，醫師手術量比醫院手術量對結果更具影響力。

Objectives: This study used a multilevel model to analyze the relationship between procedure volume and radical cystectomy outcomes of bladder cancer patients. Methods: We conducted a secondary data analysis study of the association between annual cystectomy volumes and outcome indicators. A total of 1,045 patients from 2002 to 2005, diagnosed with bladder cancer (ICD-9-CM codes 188, 236.7) and treated with radical cystectomy (ICD-9-CM code 57.7) were selected from the database of ”Inpatient Expenditures by Admissions” provided by the Bureau of National Health Insurance (BNHI). To obtain physician and hospital information, we linked the inpatient records of the research samples with the databases of ”registry for medical personnel” and ”registry for contracted medical institutions.” Outcome indicators were in-hospital mortality, complication rate, and prolonged length-of-stay (over 30 days). Multilevel logistic regression was used to adjust factors for different nested levels of patients and physicians. Results: The in-hospital mortality rate, overall complication rate, and prolonged length-of-stay in our study were 2.01%, 12.34%, 22.49%, respectively. After controlling for other factors, physicians with higher cystectomy volumes had significantly better outcomes, including lower in-hospital mortality, lower complication rate, and shorter lengths-of-stay, than physicians with lower procedure volumes. Hospital volumes had no significant relationship with outcomes indicators. Conclusions: Better outcomes in bladder cancer patients with cystectomy occurred when surgeons had high procedure volumes. Surgeon volumes had a greater effect on outcomes than hospital volumes.

1. 王庭荃、楊長興(2008)。醫師年資、醫療服務量與消化性潰瘍治療效果之相關研究。台灣衛誌，27，57-66。
   連結：
2. 簡麗年、朱慧凡、劉見祥(2003)。醫院、醫師手術量與醫療品質之關聯性探討－以全股（髖）關節置換為例。台灣衛誌，22，118-126。
   連結：
3. Barbieri CE,Lee B,Cookson MS(2007).Association of procedure volume with radical cystectomy outcomes in a nationwide database.J Urol,178,1418-1421.
4. Birkmeyer JD,Stukel TA,Siewers AE,Goodney PP,Wennberg DE,Lucas FL.(2003).Surgeon volume and operative mortality in the United States.N Engl J Med,349,2117-2127.
5. Bjerre BD,Johansen C,Steven K.(1995).Health-related quality of life after cystectomy: bladder substitution compared with ileal conduit diversion. A questionnaire survey.Br J Urol,75,200-205.
6. Charlson M,Pompei P,Ales KL,Mackenzie CR.(1987).A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chron Dis,40,373-383.
7. Clark PE,Stein JP,Groshen SG(2005).Radical cystectomy in the elderly: comparison of clincal outcomes between younger and older patients.Cancer,104,36-43.
8. Deyo RA,Cherkin DC,Ciol MA.(1992).Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.J Clin Epidemiol,45,613-619.
9. Elting LS,Pettaway C,Bekele BN(2005).Correlation between annual volume of cystectomy, professional staffing, and outcomes: a statewide, population-based study.Cancer,104,975-984.
10. Finlayson EV,Goodney PP,Birkmeyer JD.(2003).Hospital volume and operative mortality in cancer surgery: a national study.Arch Surg,138,721-725.
11. Goodney PP,Stukel TA,Lucas FL,Finlayson EV,Birkmeyer JD.(2003).Hospital volume, length of stay, and readmission rates in high-risk surgery.Ann Surg,238,161-167.
12. Gore JL,Saigal CS,Hanley JM,Schonlau M,Litwin MS.(2006).Variations in reconstruction after radical cystecomy.Cancer,107,729-737.
13. Harmon JW,Tang DG,Gordon TA(1999).Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection.Ann Surg,230,404-411.
14. Hollenbeck BK,Daignault S,Dunn RL,Gilbert S,Weizer AZ,Miller DC.(2007).Getting under the hood of the volume-outcome relationship for radical cystectomy.J Urol,177,2095-2099.
15. Hollenbeck BK,Miller DC,Taub DA(2006).The effects of adjusting for case mix on mortality and length of stay following radical cystectomy.J Urol,176,1363-1368.
16. Hollenbeck BK,Wei Y,Birkmeyer JD.(2007).Volume, process of care, and operative mortality for cystectomy for bladder cancer.Urology,69,871-875.
17. Hu JC,Gold KF,Pashos CL,Mehta SS,Litwin MS.(2003).Role of surgeon volume in radical prostatectomy outcomes.J Clin Oncol,21,401-405.
18. Konety BR,Allareddy V.(2007).Influence of post-cystectomy complications on cost and subsequent outcome.J Urol,177,280-287.
19. Konety BR,Allareddy V,Herr H.(2006).Complications after radical cystectomy: analysis of population-based data.Urology,68,58-64.
20. Konety BR,Dhawan V,Allareddy V,Joslyn SA.(2005).Impact of hospital and surgeon volume on inhospital mortality from radical cystectomy: data from the health care utilization project.J Urol,173,1695-1700.
21. Lien YC,Huang MT,Lin HC.(2007).Association between surgeon and hospital volume and in-hospital fatalities after lung cancer resections: the experience of an Asian country.Ann Thorac Surg,83,1837-1843.
22. Lin HC,Xirasagar S,Chen CH,Lin CC,Lee HC.(2007).Association between physician volume and hospitalization costs for patients with stroke in Taiwan.Stroke,38,1565-1569.
23. Lin HC,Xirasagar S,Tsao NW,Hwang YT,Kuo NW,Lee HC.(2008).Volume-outcome relationships in coronary artery bypass graft surgery patients: 5-year major cardiovascular event outcomes.J Thorac Cardiovasc Surg,135,923-930.
24. Luft HS,Bunker JP,Enthoven AC.(1979).Should operations be regionalized? The empirical relation between surgical volume and mortality.N Engl Med,301,1364-1369.
25. National Institute of Clinical Excellence(2001).Guidance on Cancer Services-Improving Outcomes in Urological Cancers.London:National Institute of Clinical Excellence.
26. Porter MP,Wei JT,Penson DF.(2005).Quality of life issues in bladder cancer patients following cystectomy and urinary diversion.Urol Clin North Am,32,207-216.
27. Rasbash J,Browne W,Goldstein H(2001).A User's Guide to MLwiN.London:Center for Multilevel Modelling.
28. Snijders TAB,Bosker RJ.(1999).Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling.London:Sage.
29. Thrasher JB,Crawford ED.(1993).Current management of invasive and metastatic transitional cell carcinoma of the bladder.J Urol,149,957-972.
30. Wen HC,Tang CH,Lin HC,Tsai CS,Chen CS,Li CY.(2006).Association between surgeon and hospital volume in coronary artery bypass graft surgery outcomes: a population-based study.Ann Thorac Surg,81,835-842.
31. Wu SC,Chen CC,Ng YY,Chu HF.(2006).The relationship between surgical site infection and volume of coronary artery bypass graft surgeries: Taiwan experience.Infect Control Hosp Epidemiol,27,308-311.
32. Xirasagar S,Lien YC,Lin HC,Lee HC,Liu TC,Tsai J.(2008).Procedure volume of gastric cancer resections versus 5-year survival.Eur J Surg Oncol,34,23-29.
33. 仇光宇(2005)。碩士論文(碩士論文)。台北，台北醫學大學醫務管理學系。
34. 衛生統計資訊網：民國96年主要癌症死亡原因
35. 衛生統計資訊網：柒、健康及社會保險類
36. 呂庭輝、楊長興、黃昱瞳、林明慧(2007)。醫院、醫師手術量與肝癌病人術後死亡率之關係。澄清醫護管理雜誌，3，46-51。
37. 翁新惠、黃昱瞳、楊長興、呂庭輝(2005)。醫師服務量與極低出生體重新生兒照護品質關係的實證研究。台灣醫學，9，448-454。

1. 陳志成(2012)。應用邏輯斯迴歸建構中華職棒大聯盟優質先發之模型。輔仁大學體育學刊，11，18-34。