醫師的遵循行為可促進病患的存活嗎？以台灣非小細胞肺癌病患為例

Can Physician Adherence to Treatment Guidelines Improve Patient Survival? A population-based Analysis of non-small Cell Lung Cancer (NSCLC) in Taiwan

10.6288/TJPH2010-29-02-04

陳錫杰(His-Chieh Chen)；蘇慧芳(Hui-Fang Su)；李中一(Chung-Yi Li)；賴美淑(Mei-Shu Lai)；謝碧晴(Pi-Ching Hsieh)

非小細胞肺癌 ； 一年存活 ； 遵循治療指引 ； 台灣癌症診療資料庫 ； non-small cell lung cancer NSCLC ； one year survival ； guideline adherence ； Taiwan Cancer Data Base

台灣公共衛生雜誌

29卷2期（2010 / 04 / 01）

118 - 130

繁體中文

目標：探討在控制病患特性、醫院及醫師特性後，非小細胞肺癌病患接受遵循指引治療，對一年存活情形之影響。方法：此回溯性世代追蹤研究，資料源自2004年台灣癌症診療資料庫、2002到2004年健保資料庫，及2004到2005年死因登記檔。Kaplan-Meier繪製存活曲線，Cox涉險模型進行風險校正，分析病患接受遵循指引治療對存活情形的影響。結果：57%的病患為第四期，66.6%接受遵循指引治療。不同期別，遵循指引者皆比未遵循者有較好的一年存活率(51.1% vs. 22.1%)。校正後，遵循指引治療者在診斷後一年內死亡的風險比未遵循者低(HR=0.44; 95% CI=0.41-0.48)。期別與遵循指引與否有顯著的交互作用。期別早期且遵循指引者，診斷後一年內死亡的風險，比期別晚期者為低。結論：醫師能遵循治療指引提供照護，能顯著提升病患一年的存活情形，特別是期別較為早期者，其診斷後一年內死亡的風險較低。故早期診斷非小細胞肺癌並促進治療指引共識之建立及落實執行是控制疾病的有效策略。

To explore the relationship between adherence to treatment guidelines and one-year survival of all stages of non-small cell lung cancer (NSCLC) patients after adjustment for the characteristics of patients, hospitals and physicians. Methods: Population-based data were retrieved from the Taiwan Cancer Data Base (TCDB) in 2004, National Health Insurance Research Database (NHIRD) in 2002-2004 and Taiwan's Death Registries in 2004-2005. This was a retrospective cohort study and Kaplan-Meier analysis was used to construct survival curves. A multivariate Cox proportional hazard model was employed to estimate the hazard ratio (HR). Results: Fifty-seven percent of NSCLC patients were at cancer stage IV. Overall, 66.6% of NSCLC patients in the study cohort were compliant with treatment guidelines. The patients who received treatments in adherence to guidelines had a higher one-year survival rate than those who did not adhere (51.1% vs. 22.1%), even in various stages of cancer. Multivariate analysis showed that the patients who received treatments in adherence to guidelines had a lower risk of one-year mortality (HR=0.44; 95% CI=0.41-0.48). A significant interaction effect between cancer stage and guideline adherence was found. The early-stage cancer patients who adhered to guidelines had a lower risk of one-year mortality then those diagnosed with late-stage cancer. Conclusions: Physician adherence to treatment guidelines is associated with one-year survival of NSCLC patients regardless of the stage of the cancer. Such a favorable effect is particularly noteworthy for patients diagnosed at an early-stage. Early diagnosis and promotion of the adoption of guidelines for treatment are effective strategies for NSCLC control.

1. 行政院衛生署： 衛生統計系列(一)死因統計。http://www.doh.gov.tw/statistic/data/衛生統計叢書 2/95/上冊/index.htm。引用2007/12/08。
2. WHO. WHO Statistical Information System (WHOSIS).Available at: http://www.who.int/whosis/en/index. html. Accessed March 18, 2008
3. National Comprehensive Cancer Network. Clinical practice guideline in oncology. Available at: http:// www.nccn.org/professionals/physician_gls/PDF/nscl.pdf. Accessed March 13, 2008.
4. 行政院衛生署：癌症登記年度報告。http://crs.cph.ntu.edu.tw/crs_c/annual.htm。引用2007/11/20。行政院衛生署：癌症登記年度報告。http://crs.cph.ntu.edu.tw/crs_c/annual.htm。引用2007/11/20。,未出版
5. Bach,PB,Cramer, LD,Schrag, D,Downey, RJ,Gelfand, SE,Begg, CB(2001).The influence of hospital volume on survival after resection for lung cancer.N Engl J Med,345,181-188.
6. Birim, Ö,Kappetein, AP,van Klaveren, R,Bogers, AMC(2006).Prognostic factors in non-small cell lung cancer surgery.Eur J Surg Oncol,32,12-23.
7. Burdett, S,Stewart, LA,Rydzewska, L(2006).A systematic review and meta-analysis of the literature: chemotherapy and surgery versus surgery alone in non-small cell lung cancer.J Thorac Oncol,1,611-621.
8. Cabana, MD,Rand, CS,Powe, NR(1999).Why don't physicians follow clinical practice guidelines? A framewouk for improvement.JAMA,282,1458-1465.
9. Charlson, ME,Pompei, P,Ales, KL,MacKenzie, CR(1987).A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis,40,373-383.
10. Cheng, SH,Wang, J,Lin, JL(2009).Adherence to quality indicators and survival in patients with breast cancer.Med Care,47,217-225.
11. D''Addario1, G.,Felip, E..Non-small-cell lung cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up.Annual of Oncology,19(suppl 2),ii39-ii40.
12. 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.
13. Farray, D,Mirkovic, N,Albain, KS(2005).Multimodality therapy for stage III non-small-cell lung cancer.J Clin Oncol,23,3257-3269.
14. Hannan, EL,Radzyner, M,Rubin, D,Dougherty, J,Brennan, MF(2002).The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer.Surgery,131,6-15.
15. Hébert-Croteau, N,Brisson, J,Latreille, J,Rivard, M,Abdelaziz, N,Martin, G(2004).Compliance with consensus recommendations for systemic therapy is associated with improved survival of women with node-negative breast cancer.J Clin Oncol,22,3685-3693.
16. Jett, James R.,Schild, Steven E.,Keith, Robert L.,Kesler, Kenneth A..Treatment of Non-small Cell Lung Cancer, Stage IIIB ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition).Chest,132(suppl),266S-276S.
17. Klabunde, C,Warren, JL,Legler, J(2002).Assessing comorbidity using claims data: an overview.Med Care,40,IV-26-IV-35.
18. 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.
19. Minter, RM,Spengler, KK,Topping, DP,Flug, R,Copeland, EM,Lind, DS(2001).Institutional validation of breast cancer treatment guidelines.J Surg Res,100,106-109.
20. Parkin, DM,Bray, F,Ferlay, J,Pisan, P(2005).Global cancer statistics, 2002..CA Cancer J Clin,55,74-108.
21. Robinson, Lary A.,Ruckdeschel, John C.,Wagner, Henry Jr,,Stevens, Craig W..Treatment of Non-small Cell Lung Cancer-Stage IIIA ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition).Chest,132(suppl),243S-265S.
22. Scott, Walter J.,Howington, John,Feigenberg, Steven,Movsas, Benjamin,Pisters, Katherine.Treatment of Non-small Cell Lung Cancer Stage I and Stage II ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition).Chest,132(suppl),234S-242S.
23. Sinuff, T,Cook, D,Giacomini, M,Heyland, D,Dodek, P(2007).Facilitating clinician adherence to guidelines in the intensive care unit: a multicenter, qualitative study.Crit Care Med,35,2083-2089.
24. Sjetne, IS,Veenstra, M,Stavem, K(2007).The effect of hospital size and teaching status on patient: a multilevel analysis.Med Care,45,252-258.
25. Socinski, Mark A.,Crowell, Richard,Hensing, Thomas E.,Langer, Corey J.,Lilenbaum, Rogerio,Sandler, Alan B.,Morris, David.Treatment of Non-small Cell Lung Cancer, Stage IV ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition).Chest,132(suppl),277S-289S.
26. Strand, TE,Rostad, H,Moller, B,Norstein, J(2006).Survival after resection for primary lung cancer: a population based study of 3211 resected patients.Thorax,61,710-715.
27. Yun, YH,Park, SM,Noh, DY(2007).Trends in breast cancer treatment in Korea and impact of compliance with consensus recommendations on survival.Breast Cancer Res Treat,106,245-253.
28. 台灣癌症臨床研究合作組織肺癌研究委員會(2004)。肺癌臨床指引。台北:國家衛生研究院癌症研究組。
29. 賴美淑、邱秀渝、唐秀治、鍾國彪、謝碧晴(2006)。癌症中心品質提升評估整合型研究計畫（第三年）期末報告。台北:行政院衛生署國民健康局。

1. 蔡欣芸(2018)。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。國立臺灣大學健康政策與管理研究所學位論文。2018。1-128。