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系統識別號 U0026-0812200915213134
論文名稱(中文) 大腸直腸癌照護品質測量指標遵循率與病人存活關係之研究及其管理意涵
論文名稱(英文) Adherence to Quality Indicators and Survival in Patients with Colorectal Cancer and It’s Management Implication
校院名稱 成功大學
系所名稱(中) 高階管理碩士在職專班(EMBA)
系所名稱(英) Executive Master of Business Administration (EMBA)
學年度 97
學期 2
出版年 98
研究生(中文) 溫義煇
研究生(英文) Yih-huei Wen
電子信箱 swinnie0213@yahoo.com.tw
學號 r0796108
學位類別 碩士
語文別 中文
論文頁數 88頁
口試委員 口試委員-蔡明田
口試委員-李勇輝
口試委員-莊立民
指導教授-蔡明田
口試委員-李國瑋
中文關鍵字 現代測驗理論  古典測驗理論  指標遵循率  直腸癌  大腸癌 
英文關鍵字 colon cancer  modern test theory  adherence rate to indicators  rectum cancer  classic test theory 
學科別分類
中文摘要 越來越多國際組織(initatives)倡議醫生要遵循已被證實能改善結果之臨床準則,然而在大腸直腸癌遵循癌症照護準則之流程—結果(process-outcome)關係仍未明。
本研究係應用經實證醫學資料收集、專家討論並用健保資料實證後由健保局公布之15 項大腸直腸癌品質指標,針對某醫學中心2003至2006年742位大腸直腸癌病人 (一)驗證其指標遵循率與病患之存活效果 ,(二)探討指標遵循率之主要影響因子 ,(三)建立監測、提昇指標遵循率之管理機制。
本研究為一回溯性研究,採用次級資料,臨床資料來自醫院臨床手術後的大腸直腸癌病人癌症資料庫。資料分析包括描述性與分析性統計,以獲得下列資訊:(一) 大腸直腸癌品質指標於各年度執行情況 ,(二)品質指標執行情況與預後的關係 ,(三)不同族群(如性別、年齡等)在各品質指標執行上的功能差異分析 ,(四)利用試題反應理論擷取其各個案的偏離配適指標,做為偵測品質指標執行的特異個案,品質持續改善的依據參考。
由所收集742位病人資料顯示:(一) 大腸直腸癌指標遵循率與第二及三期的大腸直腸癌患者之存活效果存在有因果關係,(二) 影響大腸直腸癌指標遵循之主要影響因子為病患的年齡、癌別、是否復發、手術邊界無腫瘤侵犯及癌瘤數目(三) 試題反應理論除了能克服古典測試理論 missing data 的許多限制,還能利用Outfit偏離均方誤及Z分數的指標建立監測指標遵循率之管理機制。
本研究應證大腸直腸癌病人的存活率與執行品質照護指標有明顯相關,不但說明醫療團隊合作與過程面品質指標之重要性,也間接證實大腸直腸癌適用於論質計酬的付模式。試題反應理論除了能克服傳統測試理論之缺點外,尚能提供偏離配適指標而成為監測指標遵循率之有效管理工具。
英文摘要 International initatives increasingly advocate physician adherence to clinical protocols that have been shown to improve outcomes, yet the process-outcome relationship for adhering to colorectal cancer care protocol is unknown.

The aim of this study was (1) to evaluate the relationship between adherence to quality indicators and survival in patients with colorectal cancer, (2) to explore the key factors and influences of adherence to quality indicators, (3) to develop a monitor mechanism to enforce adherence to quality indicators.
Method:We retrospectively collect the quality indicators for colorectal cancer are originated from the evidence-based literature review, formed through expert meeting and tested by the data of Taiwanese National Health Insurance Bureau (NHIB) from clinical protocol office and computer science department of one medical center. The major issues to be analyzed were: (1) to know the implementation effects of adherence to quality indicators across years, (2) to evaluate the relationship between adherence rate and outcome, (3) to explore the indicator differential functioning among groups to justify their invariance in implementation, (4) to develop a monitor system to enhance adherence to quality indicators using modern test theory.

The major findings from this 742-patient study were that : (1) a closer relationship was existed in adherence rate and outcome, especially for patients with stage II and III colorectal cancer, (2) the main factors were found and influenced by patient age, type of cancer, recurrence, tumor involvement of surgical margin and lesion number, (3) it is possible using Outfit statistical quality control index and Z score derived from item response theory to detect adherence to quality indicators.
This study confirmed that the implementation of core measures indicators of colorectal cancer can improve it/s care quality and patient/s survival , which not only demonstrated the importance of team work and the process indicators , but the suitability of quality pay model of colorectal cancer . In addition to overcome the weak point/s of classic test theory, item response theory can provide Outfit statistical index to work as a management tool to monitor indicator/s adherence.
論文目次 封面內頁 I
授權書 II
考試合格證書 III
致謝 IV
摘要 V
目錄 VI
圖目錄 VII
表目錄 VIII
第一章 緒論1
第一節 研究背景與動機1
第二節 研究目的3
第三節 研究範圍與限制3
第四節 研究內容與方法4
第五節 研究流程5
第二章 文獻探討6
第一節 大腸直腸癌概論6
第二節 大腸直腸癌照護內容執行情形7
第三節 癌症指標之建立與遵循8
第四節 古典測驗理論之癌症指標遵循度12
第五節 試題反應應理論之癌症指標遵循度13
第六節 試題反應理論的Rasch分析14
第三章 研究方法18
第一節 資料來源及分析18
第二節 資料之取得與查驗18
第三節 資料分析21
第四節 研究架構22
第五節 存活分析22
第六節 Rasch分析建立提昇指標遵循率之管理機制24
第七節 Rasch模式參數估計之原理26
第八節 各指標之差異功能分析27
第四章 研究結果28
第一節 大腸直腸癌照護品質核心測量指標遵循度28
第二節 大腸直腸癌指標末100%遵循度之排名29
第三節 大腸直腸癌指標之Rasch分析30
第四節 大腸直腸癌照護品質核心測量指標遵循率與存活關係33
第五節 各癌期之指標遵循與存活關係37
第六節 指標遵循之主要影響因子39
第七節 各年度間指標遵循度之比較40
第八節 各癌期之指標遵循率在同一量尺上比較44
第九節 各指標之差異功能分析46
第十節 建立監測提昇指標遵循率之管理機制46
第五章 討論 47
第一節 研究發現 47
第二節 管理學的意涵 48
第三節 研究貢獻 49
第四節 研究應用 50
第五節 研究限制 51
第六章 結論 52
參考文獻 53
附錄 63
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