探討影響癌症病人就醫經驗與整體評價之因素

Abstract

目的：醫療方面較先進的西方各國都已經開始進行癌症病人就醫經驗的調查，以加入較為完整且客觀的病人觀點醫療品質的評估，根據研究結果顯示，癌症病人的就醫經驗以及總體評價會受到病人特質、疾病特性及醫療提供者特性等因素的影響，然而，臺灣符合相關議題的研究明顯不足，此外，由於各國國情不同，因此其他國家的研究結果，是否能符合我國的情況，有待商榷，因此，本研究想探討，病人特質、疾病特性及醫療提供者特性是否為影響我國癌症病人就醫經驗及總體評價之因素，希望能夠以病人最直接反映的觀點，了解目前的醫療照護品質是否能夠滿足病人之需求，並提供醫療服務提供者以及未來相關政策擬定之參考。 方法：本研究採橫斷性混合型研究設計，量性部分採由英國國民健保制度(NHS)的Cancer Patient Experience Survey 2014之中文版問卷為研究工具，與全台14家醫院合作進行收案，收案期間自2015年3月14日至2016年3月31日止，以郵寄問卷方式回收518份問卷。此外，本研究以半結構式訪談大綱之焦點團體訪談蒐集質性資料，根據癌症別特性，將六癌分別以「乳癌與子宮頸癌」、「肺癌與口腔癌」以及「大腸直腸癌與肝癌」，共舉辦三場焦點團體訪談，每場人數為6至8人。期可以透過量性研究大範圍的蒐集資訊，同時透過團體互動的方式取得那些較無法從非團體互動形式中所產生的資料，以針對本研究議題有更深入之理解。 結果：複迴歸分析結果顯示，病人特質部分，控制其他變項後，女性的就醫經驗整體評價會低於男性；疾病特性部分，控制其他變項後，口腔癌病人的就醫經驗整體評價會低於大腸直腸癌病人；醫療服務提供者特性的部分，控制其他變項後，在醫學中心接受醫療照護的癌症病人，其就醫經驗整體評價會高於在區域醫院接受照護服務之癌症病人；在癌症病人就醫經驗問卷各構面部分，「病程資訊提供與支持構面」、「連續性照護」、「心理支持構面」以及「分享決策與治療計畫構面」與癌症病人整體評價達統計上顯著相關。質性焦點團體訪談研究結果發現，與醫師有好的互動經驗以及溝通經驗的癌症病人，對於治療過程及結果較為有信心，對於整體的照護評價也多是正向的回饋，片段的照護模式，會導致連帶的病程資訊或是其他相關資訊提供的不完全，心理支持的部份，許多研究參與者都提出主治醫師給予的關懷比較制式化，此外，研究參與者也提出照護的整體性，可以由主治醫師的整體團隊，像是個管師或是病友協會這樣的角色來補足，顯然在以病人為中心的團隊照護上，我國仍有進步空間。 結論：將量性與質性的研究結果結合找出交集，可以發現「病程資訊提供」、「共同決策與治療計畫」、「連續性照護」以及「心理支持」，是影響癌症病人就醫經驗中與整體照護評價不可或缺的重要因素。癌症病人的照護模式越趨多元與複雜，影響癌症病人就醫經驗的因素，也會隨著時間與照護模式的進步而有改變，本研究僅針對乳癌、大腸直腸癌、肺癌、肝癌、口腔癌以及子宮頸癌等六大癌症病人進行問卷施測，而國外的癌症病人經驗研究涵蓋的癌別更廣泛，因此建議可以擴大研究參與者的癌別，以增加癌症病人就醫經驗之完整性，提供能符合不同疾病特性之癌症病人更完善的照護。

Objectives: In some developed countries, with more complete medical management system, researchers have already been analyzing the relationship between the patient with cancer and their medical treatments. It is in order to include more complete and objective view of the quality of patient's care assessment. According to the previous studies, showing that patients’ characteristics, disease characteristics, the features of medical providers, and so on will affect their medical treatment experiences and the overall evaluation. However, studies in this field are obviously insufficient in Taiwan. Furthermore, whether the studies from other countries are suitable for Taiwan is uncertain because of the differences between nations. Therefore, this study aims to explore the factors in relation to patients’ medical treatment experiences and the overall evaluation. In accordance with direct feedbacks from patients, whether the quality of medical care meets the need in them can be comprehended. In addition, this might be served as references for medical providers or related policy making. Methods: The study uses cross-sectional mixed method and adopts the Chinese version of the UK National Healthcare System (NHS) of the Cancer Patient Experience Survey in 2014 as the questionnaire as a quantitative research tool. The surveys are done by 14 cooperated hospitals from March 14, 2015 to March 31, 2016, and 518 questionnaires are received by mail back. Also, the study focus group discussions with semi-structured interviews to collect qualitative data. Six types of cancers are chosen and divided into three groups, which are 'breast and cervical cancer', 'lung and oral cancer', and 'colorectal and liver cancer' according to the characteristics. Researchers in the project respectively hold three focus group meetings. Each one contains 6 to 8 people. The extensive and massive qualitative data and group conference are combined to let the survey have deeper comprehension. Results: Through multiple regression analysis, the result shows that overall evaluation of women’s medical treatment is lower than men’s on patients’ gender part; the people with oral cancer’s is lower than colorectal cancer’s on cancer types’ part; the individuals who experience medical treatment in medical centers is higher than those who experience it in regional hospital on medical providers’ part. Along with the dimensions of questionnaire of patients’ medical treatment experiences, the “Information and support”, “Continuity of care”,” Emotional support”, and “Shared decision making and care planning” are significantly related to overall evaluation. The research of qualitative focus group interview finds out those cancer patients who have better experiences and interactions with physicians are more confident in treatment process. Therefore, the results in overall evaluation of care are mostly positive feedback. On the other hand, fragmented medical care leads to the course of joint or provides incomplete relevant information. On emotional support part, many participants of the study say that the care from attending physician is more standardized. Furthermore, they suggest that the completion of care can be compensated by the people like case manager from the team of attending physician or patients’ support groups. Conclusion：The quantitative and qualitative findings meet the same result that illustrates “Information and support”, “Continuity of care”,” Emotional support”, and “Shared decision making and care planning” in the cancer patients’ experience and overall evaluation are important influence factors. Cancer care models have become more complex and diverse. Factors effecting the cancer patients' experiences of treatment will also change as care models improve over time. In this study, we conducted a questionnaire survey for six categories of cancer patients including breast cancer, colorectal cancer, lung cancer, liver cancer, oral cancer, cervical cancer. In other countries, many studies of cancer patients' experiences of treatment often contain more cancer categories. To increase the cancer patients' experiences of treatment integrity and to provide different disease characteristics of cancer patients with better care, we recommend that future studies include more cancer categories.