我國思覺失調症與情緒障礙症患者癌症篩檢服務利用情形之初探

Abstract

背景： 精神疾病病人除了需要心理健康的照護，也需要生理健康的預防保健。然而，這類病人的照護往往著重在其精神疾病的控制與管理，其生理健康狀況常常被忽略，事實上，精神障礙患者平均餘命較低，常是因自殺或其他慢性疾病所致，而臺灣過去長期追蹤研究指出，思覺失調症與雙相情感障礙症患者在性別、年齡標準化癌症發生率較普通人群高。癌症治療的關鍵乃是透過定期篩檢，早期診斷、早期治療，能使患者有較佳的預後並減少後續疾病負擔。雖癌症篩檢的成本效益已由實證研究證實，近年美國、加拿大、日本等相關研究卻發現精神疾病患者癌症篩檢率顯著低於其他民眾。我國過去研究對於精神障礙者的醫療服務利用，並未著重在癌症篩檢。據此，了解我國思覺失調症與情緒障礙症患者癌症篩檢服務利用情形及相關影響因素極為重要。 目的： 本研究主要分析近年國內思覺失調症與情緒障礙症患者在乳癌、子宮頸癌及大腸癌篩檢服務利用情形，是否與其他民眾存在差異，並進一步探討相關的影響因素。 方法： 本研究運用全民健保資料庫進行次級資料分析，依癌症篩檢對象及頻率，分別選取2017年全民健保承保檔中45-67歲女性(乳癌篩檢)、30歲以上女性(子宮頸癌篩檢)以及50-73歲成人(大腸癌篩檢)以完整觀察三年，串聯2017-2019年全民健保處方及治療明細檔、醫令明細檔(西醫門診)、死因統計檔、癌症登記年報檔進而分析。我們探討思覺失調症與情緒障礙症患者與其他民眾之人口學特質，以及乳癌、子宮頸癌及大腸癌三項癌症篩檢服務利用情形，運用卡方檢定及羅吉斯迴歸，分析思覺失調症與情緒障礙症患者與其他民眾接受三項癌症篩檢服務的比例是否存在差異，並探討影響接受篩檢服務的相關因素。 結果： 在本研究分析的年齡層對象中，2017年思覺失調症與情緒障礙症患者盛行率約為3%，二類患者相對於其他民眾有平均年齡較大(乳癌研究對象：55.88歲 vs 55.36歲、子宮頸癌研究對象：56.17歲 vs 52.64歲、大腸癌研究對象：59.81歲 vs 59.57歲)、投保金額等級較低(乳癌研究對象：低投保金額 30.29% vs 15.81%；子宮頸癌研究對象：低投保金額 33.12% vs 16.76%；大腸癌研究對象：低投保金額 33.27% vs 19.67%) 以及有較高比例罹患至少一個慢性病 (乳癌研究對象：62.75% vs 44.26%、子宮頸癌研究對象：63.15% vs 41.79%、大腸癌研究對象：70.27% vs 53.73%)；癌症篩檢率的雙變項分析結果顯示，我國思覺失調症與情緒障礙症病人在三種癌症的篩檢率均較其他民眾為高（乳房X光攝影檢查三年篩檢率為50.46% vs 48.15%、子宮頸抹片檢查為49.07% vs 47.90%，糞便潛血檢查為52.32% vs 45.83%），而性別、年齡、投保金額及投保單位地區等均個別與民眾是否接受癌症篩檢服務顯著相關；最後，透過二元羅吉斯迴歸分析調整其他控制變項後，我國思覺失調症與情緒障礙症患者在乳癌篩檢(OR=1.078, 95%CI [1.064 , 1.092])、子宮頸癌篩檢(OR=1.127, 95%CI [1.116 , 1.138])與大腸癌篩檢(OR=1.156, 95%CI [1.144 , 1.168])的勝算比均顯著高於其他民眾。然而由於病例組的異質性高，本研究進一步進行次群體分析發現，思覺失調症患者在乳癌(OR=0.835, 95%CI [0.813, 0.859])與子宮頸癌(OR=0.590, 95%CI [0.578, 0.603])的篩檢勝算比，顯著低於其他民眾；在糞便潛血檢查的勝算比(OR=1.081, 95%CI [1.058, 1.104])則仍高於其他民眾。此外，女性相對於男性接受糞便潛血檢查的勝算比較高(OR=1.471, 95%CI [1.466 , 1.476])；而隨著年齡增加，接受乳房X光攝影檢查及糞便潛血檢查勝算比越高；但是子宮頸抹片檢查分析結果則相反，投保金額等級為中、高的民眾相對於低者，接受各項癌症篩檢服務的勝算比越高；另外，不同縣市在推動癌症篩檢服務上亦存在勝算比的差異。 結論： 2017至2019年我國思覺失調症與情緒障礙症患者在乳癌、子宮頸癌及大腸癌篩檢服務利用比例上，均顯著高於其他民眾，然而，思覺失調症患者在乳癌與子宮頸癌篩檢率則顯著低於其他民眾。此外，性別、年齡、共病症情形、投保金額及投保單位地區等因素對於研究對象是否接受癌症篩檢服務，亦有不同程度的影響，建議有關單位應針對低癌症篩檢率之群體，發展合適的介入措施。

Background： In addition to mental health care, people with mental illness also need preventive health care for their physical health. However, healthcare programs for those individuals often focus on controlling and managing their mental illness, and their physical health has often been overlooked. In fact, life expectancy of people with mental illness was lower, however, often due to suicide or chronic physical diseases. Past longitudinal follow-up studies have found out that gender- and age- standardized cancer incidence among people with schizophrenia and bipolar disorder was higher than that among general population in Taiwan. Cancer screening is a critical component of cancer care. Through regular screening, early diagnosis, and early treatment, people with cancer can have a better prognosis and reduced burden of subsequent diseases. Although empirical studies have confirmed the cost-effectiveness of cancer screening, prior studies in the United States, Canada, and Japan have found that the cancer screening rates of people with mental illness were significantly lower than that of other people. Past research on the utilization of medical services for people with mental illness in Taiwan has not focused on cancer screening. Therefore, it is essential to understand the utilization of cancer screening services and associated influencing factors among people with schizophrenia and mood disorders. Objectives： This study analyzed whether there were differences between people with schizophrenia or mood disorders and others in Taiwan in receiving guideline-concordant screening for breast cancer, cervical cancer, and colorectal cancer during 2017-2019, and further identified factors associated with receiving such screenings. Methods： This study utilized the National Health Insurance database to conduct secondary data analysis. Study samples were constructed in accordance with the cancer screening guideline for each type of cancer, including women aged 45-67 years-old for breast Cancer Screening, women aged over 30 years-old for cervical cancer screening, and people aged 50-73 years-old for colorectal cancer screening. Individuals were identified from the Registry for beneficiaries of 2017 and linked to their health care utilization from the 2017-2019 Ambulatory Care Expenditures dataset. Demographic characteristics were compared between people with schizophrenia or mood disorders and others. Furthermore, utilization of cancer screening services for breast, cervical, and colorectal cancers were also compared with Chi-square test. In addition, logistic regression was conducted to analyze whether there were differences in the proportion of individuals receiving cancer screening services between people with schizophrenia or mood disorders and others. Factors associated with cancer screening rate were also explored. Results： Among our study sample, the prevalence rate of people with schizophrenia or mood disorders in 2017 was about 3%. Compared with others, the patient group was older (breast cancer: 55.88 vs 55.36 years, cervical cancer: 56.17 vs 52.64 years, colorectal cancer: 59.81 vs 59.57 years), was with lower premium-based monthly wage (breast cancer: low wage group 30.29% vs 15.81%; cervical cancer: low wage group 33.12% vs 16.76%; colorectal cancer: low wage group 33.27% vs 19.67%), and had a higher proportion with at least one chronic condition (breast cancer: 62.75% vs 44.26%, cervical cancer: 63.15% vs 41.79%, colorectal cancer: 70.27% vs 53.73%). The bivariable analysis showed that people with schizophrenia and mood disorders had higher screening rates for all three types of cancer than the rest of the population(the three-year screening rate was 50.46% vs 48.15% for the mammography, 49.07% vs 47.90% for the pap smear, and 52.32% vs 45.83% for the fecal occult blood test). Gender, age, premium-based monthly wage, and the residing county of beneficiaries were all significantly correlated with receiving cancer screening services. Finally, results from the binary logistic regression analysis showed that compared with others, people with schizophrenia or mood disorders were significantly associated with higher odds of breast cancer screening (OR=1.078, 95%CI [1.064, 1.092]), cervical cancer screening (OR=1.127, 95%CI [1.116, 1.138]) and colorectal cancer screening (OR=1.156, 95%CI [1.144, 1.168]). However, due to the high heterogeneity of the patient group, this study conducted a subgroup analysis and found that people with schizophrenia were significantly associated with lower odds of breast cancer(OR=0.835, 95%CI [0.813, 0.859]) and cervical cancer screening(OR=0.590, 95%CI [0.578, 0.603]) than others. The odds ratio in fecal occult blood examination(OR=1.081, 95%CI [1.058, 1.104]) was still higher than the rest of the population. Women had a higher odds of receiving fecal occult blood test than men (OR=1.471, 95%CI [1.466, 1.476]), and with increasing age, the odds were higher of receiving mammography and fecal occult blood test. Increasing age, however, is associated with lower odds of receiving pap smear. Additionally, people with medium and high levels of premium-based monthly wage had a higher odds of receiving cancer screening services than those with low levels. Variations in odds ratios were also observed among different counties and cities in utilizing cancer screening services. Conclusions： From 2017 to 2019, the utilization rate of breast cancer, cervical cancer, and colorectal cancer screening services for patients with schizophrenia or mood disorders in our country was significantly higher than that of other groups. However, people with schizophrenia have significantly lower breast and cervical cancer screening rates than others. In addition, gender, age, comorbidities, premium-based monthly wage, and the residing county of the beneficiaries were also associated with receiving cancer screening services. The implications of these findings deserve further attention from policymakers in Taiwan to develop appropriate interventions.