長期使用呼吸器癌症患者之發生率、平均餘命與存活相關因子研究

Abstract

一、研究背景 長期使用呼吸器患者之醫療照顧，為近年來台灣長期照顧體系努力整合的方向之一，也是現今急性醫療照護與慢性照護銜接所面臨的重大挑戰。我國在2007年正式邁入高齡化社會，而隨著人口結構急速老化，癌症人數日漸增加，部分病人亦同時為長期使用呼吸器個案。為探討相關病人之長期預後，本研究分析其發生率、平均餘命、調整生活品質後之存活壽命與存活影響因子。 二、研究方法 研究對象為我國健保資料庫西元1998-2007年住院之長期使用呼吸器癌症患者，選取年齡大於17歲，且連續使用呼吸器天數大於21天之個案為研究對象。並將資料連結重大傷病檔選出罹患癌症病人。對應我國死亡檔資料，以判斷至2007年底為止病人之存活狀態。另採用癌症登記檔資料，計算長期使用呼吸器於各類癌症病人之發生率。使用ISQoL軟體推算平均餘命，並乘以平均生活品質以估算調整生活品質後之存活壽命。多變項分析則採用Cox proportional-hazards regression model探討影響長期存活之因子，納入迴歸模型之變數如下: 年齡、性別、癌症類別、癌症轉移與否、共病症、治療醫院層級。 三、研究結果 本研究納入自1998至2007年共5138位新發生之長期使用呼吸器癌症患者。存活中位數為1.37個月，一年存活率為14.3%，平均餘命為1.21年。估算調整生活品質後之存活壽命於無意識與具有部分意識病人分別為，0.17和0.37健康人年。肝癌、肺癌與癌症轉移者死亡風險較高，其hazard ratio分別為1.54、1.44與1.52。 四、結論 長期使用呼吸器癌症患者之長期預後不佳。本研究提供醫護人員，長期使用呼吸器癌症病人之長期預後實證醫學上的依據，將有利於醫療決策討論。針對癌症轉移患者且長期使用呼吸器，建議考慮盡早合併安寧緩和醫療照護。由於照護長期使用呼吸器患者需花費大量的醫療資源，本研究亦希望提供給衛生主管機關進行政策制定與健保資源分配之參考，期能協助我國全民健康保險之永續經營。

Purpose This study aims to determine incidence, survival rate, life expectancy, quality-adjusted life expectancy (QALE), and prognostic factors of cancer patients of different organ-systems undergoing prolonged mechanical ventilation (PMV). Patients and Methods We used data from the National Health Insurance Research Database (NHIRD) of Taiwan, year of 1998 to 2007, and linked with the National Mortality Registry to ascertain the mortality. Subjects who had continuously undergone mechanical ventilation for longer than 21 days were enrolled. The incidences of cancer patients requiring PMV were calculated except multiple cancers. The life expectancies and QALE of different types of cancer were estimated. Quality of life data were taken from a sample of 142 patients under PMV. Multivariable proportional hazard model was constructed to assess the effect of different prognostic factors, including age, sex, types of cancer, metastasis, comorbidities, and hospital levels. Results The analysis of 5138 cancer patients undergoing PMV revealed a median survival of 1.37 months with one-year survival rate of 14.3%. The incidence of PMV was 2.5 per 100 new cancer cases. Head and neck cancer patients seemed to survive the longest. The overall life expectancy was 1.21 years with estimated QALE ranged from 0.17 to 0.37 quality-adjusted life years for patients with poor and partial cognitions, respectively. Cancer of liver, lung, and metastasis independently predict a shorter survival with hazard ratios of 1.54, 1.44, and 1.52, accordingly. Conclusion Cancer patients requiring PMV had a poor long-term outcome. Palliative care should be considered early in these patients, especially when metastasis occurred.