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標題: | 臺灣安寧緩和療護品質管理計畫(TPCOC)介入, 對末期病人臨終照護品質及無效醫療之影響探討。 The Impact of Taiwan Palliative Care Outcomes Collaboration (TPCOC) on End-of-Life Care Quality and Non-Beneficial Treatment |
作者: | 吳家鈞 Jia-Jyun Wu |
指導教授: | 董鈺琪 Yu-Chi Tung |
關鍵字: | 安寧緩和,品質管理,臨終照護,無效醫療, palliative care,collaboration,patient-reported outcome measures,end-of-life care,non-beneficial treatments, |
出版年 : | 2023 |
學位: | 碩士 |
摘要: | 研究背景與目的:
臺灣推展安寧緩和療護多年且數次世界死亡品質調查表現卓越。然而,臺灣目前安寧緩和療護尚無由政府推動之品質管理和稽核標準介入,對於「服務品質」也無共識。臺灣自2020年5月28日起執行一項全國性計畫-臺灣安寧緩和療護品質管理計畫(Taiwan Palliative Care Outcomes Collaboration, TPCOC),讓團隊與病人家屬共同擬定照護計畫,提供更舒適更貼切的照護。該計畫主要參考澳洲的安寧緩和療護成效合作計畫(Palliative Care Outcomes Collaboration, PCOC),修改成適合臺灣本土臨床實務運作的品質管理計畫。 生命末期之臨終照護品質是末期及瀕死病人接受安寧緩和療護最重要的核心精神,其中生命末期之臨終照護品質指標(quality indicators of end-of-life care)可用以測量照護品質,藉此提昇臨床照護品質。此外,臺灣無效醫療(non-beneficial treatment)嚴重。根據2014年《參玖參公民平台》的「臨終前無效醫療報告書」,臺灣每年加護病房的無效醫療人次約22,000人次,平均每個月臨終前無效醫療頻率約17~20%,即臺灣加護病房病人約有1/5接受臨終前無效醫療。此外,劉嘉年等學者(2001)研究亦發現臺灣成年死亡人口之臨終成本約321億元,約佔該年度健保支出之11%;死亡前三個月的醫療費用佔死亡前一年總費用達54.5%,可見臺灣臨終前照護之成本支出龐大。無效醫療不僅造成醫療資源浪費,更可能對末期病人產生傷害,增加痛苦及延長沒有尊嚴的瀕死過程。過去研究發現以病人自述結果測量結果(patient-reported outcome measures , PROM)為主之安寧緩和品質管理計畫可藉由有效溝通,以滿足病人及家屬之未滿足需求,減少衝突以改善無效醫療發生。 臺灣為亞洲第一個執行PROM相關安寧緩和品質管理計畫之國家,雖然PCOC已有諸多研究證實其品質改善成效,但國外品質管理計畫未必能全然移植至亞洲或臺灣本土。目前亦尚無針對PCOC介入後,末期病人之臨終照護品質和無效醫療改善之相關研究。期望藉由此研究,作為未來國健署推動與改進安寧緩和療護品質管理計畫之參考。 研究方法: 本研究為一回溯性研究,並以臺中某一醫學中心之安寧緩和病房住院病人為研究對象,其中2021年6月至2022年8月之住院病人設為TPCOC介入組,2020年1月至2021年5月之住院病人設為對照組。資料來源為該院病歷次級資料,並串聯衛生福利部死因統計檔。研究資料包含病人基本特徵、末期主診斷、共病症分數、臨終照護品質指標、無效醫療。研究統計採描述性與推論性統計,推論性統計採雙變項分析與多變項回歸模型分析TPCOC介入與各指標之關聯性。 研究結果: 研究對象共1,121人,其中TPCOC對照組(2020/1~2021/5)為555人、TPCOC介入組(2021/6~2022/8)為566人。所有研究對象中88.58%之末期主診斷為癌症,平均年齡為68.39±14.21歲,大多為男性病人(59.95%),平均共病症分數(CCI)為7.64±2.63分,平均住院天數為20.24±17.31天。兩組研究對象除了死亡地點有顯著差異外,其餘基本特性分布無顯著差異。針對臨終照護品質之影響,羅吉斯迴歸分析發現TPCOC介入可顯著減少死亡地點在醫院(即在家善終),校正後勝算比為0.26(95%信賴區間0.16-0.41、p值<0.001)。TPCOC介入在其他臨終照護品質(包含死亡前30天是否急診就診、死亡前30天是否住院、死亡前30天住院天數)與死亡前30天醫療費用,則無明顯差異。針對無效醫療之影響,羅吉斯迴歸分析發現在TPCOC介入雖有減少趨勢,但無統計上顯著差異,包含死亡前14天是否輸血、死亡前14天是否有使用人工靜脈營養、死亡前14天是否有使用鼻胃管或胃造口、死亡前14天是否有使用全靜脈營養。 結論: 臺中某一醫學中心安寧緩和病房於2021年6月試行TPCOC計畫,其介入顯著減少死亡地點在醫院,即讓末期病人可在家善終。以PROM設計之TPCOC介入可減少其他無效醫療使用,但缺乏統計上顯著意義。未來國健署制定相關安寧緩和療護品質管理計畫時應將PROM評估工具融入計畫和給付中。針對其他臨終照護品質和無效醫療之影響,但仍需進一步研究證實。 Introduction: Palliative Care Outcomes Collaboration (PCOC) is an internationally recognized program based on patient-reported outcome measures (PROMs) developed in Australia. It was proven to improve palliative care outcomes and benchmarks. Taiwan's government implemented the PCOC program in June 2021, which was the first country in East Asia to implement the program. There is little research on the impact of PCOC in Asia, especially on end-of-life (EOL) care quality and non-beneficial treatments (NBTs). We sought to examine the impacts of Taiwan PCOC program on palliative outcomes. Methods: We enrolled terminally ill patients from the inpatient palliative care units in the medical center in middle Taiwan. We developed a retrospective cohort study to analyze the impacts of PCOC. Patients enrolled in the PCOC program from June 2021 to August 2022 were in the intervention group, and patients under usual palliative care from January 2020 to May 2021 were in the comparison group. Poor EOL care quality included death in the hospital, more than one emergency department (ED) visit or hospitalization, long lengths of stay (LOS), and high medical costs within 30 days before death. NBTs included blood transfusion, nutrition, and fluid supplements within 14 days before death. The hypotheses were that the PCOC program could improve EOL care quality and reduce NBTs and medical costs. Results: We collected 1,121 patients, 555 in the PCOC comparison group and 566 in the PCOC intervention group. The average age was 68.39±14.21. Most patients were male (59.95%) and with terminal cancer (88.58%). Except for the death in the hospital, there was no significant difference between the two groups. Patients in the PCOC group had less mortality in the hospital. It remained statistical significance under the multivariate regression model (OR 0.26, 95% CI 0.16-0.41, p-value <0.001). The PCOC program might reduce the NBTs but without statistical significance. Conclusions: PCOC in Taiwan significantly lowered the number of terminally ill patients who died in the hospital and might reduce the NBTs. The results might be related to the effects of communications via PROMs. PCOC program needs more research to implement in Asia. Besides, the impact of collaboration programs on EOL care quality and NBTs needs further studies. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/89635 |
DOI: | 10.6342/NTU202301794 |
全文授權: | 同意授權(全球公開) |
顯示於系所單位: | 健康政策與管理研究所 |
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