| 摘要: | 目的：本研究旨在探討影響高額臨終癌症病患整體醫療利用適當性之因素與醫療不適當原因。方法：本研究為病歷回溯性研究，以2003年1月至2007年6月，雲嘉南地區住院三十天內醫療費用超過五十萬且出院後一個月內死亡之臨終個案120件為研究對象，每件病歷分別請兩位資深臨床專科醫師進行醫療利用適當性獨立性審查，並說明醫療不適當原因，若見解不一致，則再請第三位確認之，採用羅吉斯廻歸分析探討影響醫療利用適當性之相關因素，依內容分析法執行醫療不適當原因質性分析之分析。結果：研究個案醫療利用適當者有77件(64.2%)，醫療不適當較少有43件(35.8%)。分析結果顯示合併症指數、院內感染、主要手術或處置適當性、高價檢驗檢查適當性、高價特材適當性與後線抗生素適當性對整體醫療利用適當性的影響有顯著差異，主要手術或處置不適當個案中，整體醫療利用適當之個案沒有發生，在性別、年齡、癌症轉移與主要手術或處置等控制變項下，顯著影響醫療利用適當性為合併症指數，合併症指數每增加一分整體醫療利用不適者相對於適當者之勝算為1.237倍(95%信賴區間為1.006~1.522， p<0.05)。醫療不適當原因主要兩個範疇為過度醫療與醫療不足，過度醫療包括病患身體狀況不宜手術、無效益治療、宜選擇安寧療護、不宜化療、檢查過多、抗生素使用不當，醫療不足包括無支持治療與檢查不足。結論：本研究初步結果顯示合併症指數與主要手術或處置適當性為主要影響整體醫療利用適當性之因素，醫療不適當原因以病患身體狀況不宜手術居多，建議此病況應利用支持治療或安寧療護。
Objectives: To explore the determinants affecting case’s integrated medical appropriateness of high-expenses moribund cancer patients and provide insight into the reasons behind medical inappropriateness. Methods: This study conducted a retrospective patient record review in 120 patient records of discharged with cancer taking precedence over other major illness/injury and incurred medical expenses at more than NT $ 500,000 and deceased within 30 days after discharge in the Yunlin, Chiayi and Tainan Area hospitals between January 2003 and July 2007. The records were reviewed by two independent reviewers (one surgeon and one internist) regarding the each case’s medical appropriateness and medical inappropriate reasons statement. Any disagreements between the two reviewers were resolved by reference to a third research colleague. A multivariable predictive model for case’s medical appropriateness was established using logistic regression. Qualitative physicians’ statement as to medical inappropriateness were collected and extracted by content analysis. Results: The reviewer reporting 77 (64.2%) cases were medical appropriateness and 43 cases (35.8%) being medical inappropriateness. Charlson comorbidity indexes, nosocomial infection, the appropriateness of principal procedures, use of high cost examination or materials were associated with case’s medical appropriateness. The medical inappropriate group had statistically higher Charlson comorbidity index (5.12±5.16) than medical appropriate group (3.01±3.3, p<0.05). Cases with nosocomial infection, inappropriateness of using high cost medical examination and materials were more likely to be a case’s medical inappropriateness, odds ratio were 2.948 ([95% CI 1.207~7.201], P <0.05), 2.615 ([95% CI 1.077~6.346], P <0.05), 2.965 ([95% CI 1.088~8.08], P <0.05), and 3.234 ([95% CI 1.288~8.125], P <0.05), respectively. No cases with inappropriate principal procedures were judged to be case’s medical appropriateness. When gender, age, cancer metastasis and the appropriateness of principal procedures were added to logistic model, Charlson comorbidity index (OR, 1.237; [95% CI 1.006~1.522], p <0.05) was the only predictor for case’s medical appropriateness. Content analysis of qualitative data validated medical inappropriateness including over-treatment (surgery was not suitable for patients with serious condition, ineffective treatment, choosing hospice care, unnecessary chemotherapy, over-examination, inappropriate use of antibiotics) and under-treatment (no supportive therapy and under-examination). Conclusions: This was the first study to retrospectively examine case’s medical appropriateness of moribund cancer patients. These findings highlight the principal procedure appropriateness and Charlson comorbidity index were the more robust correlate of case’s medical appropriateness among moribund cancer patients with high expenses. The major reason of medical inappropriateness revealed that surgery was not medically suitable for patients with serious illness who would benefit from supportive care or hospice care. |
