| Summary: | 博士 === 國立臺灣大學 === 醫療機構管理研究所 === 98 === Background: The volume-outcome relationship has been widely discussed over past decades. Although previous studies examined the volume-outcome relationship show that the majority of these works support the reverse relationship of volume and outcome on varied procedures, but other studiess reported inconsistent results and raised arguments if volume is robust enough to predict outcome. Comparing to volume, efficiency not only emphasizes on the quantity of service provided by organizations, but also focus on the resources consumed to generate services. The Value-Based Purchasing Plan carried out by CMS recently also emphasizing on improving efficiency as well as clinical quality. Therefore, extending volume-outcome association to measuring efficiency as well as process quality of care, and linking the performance with outcome have been important issues to not only health purchasers, but also providers and consumers when pursuing cost containment and quality improvement in health care. Material and method: This study is going to explore the relationship between process quality, efficiency and survival as well as recurrence in breast cancer care by Cox’s regression and multilevel modeling, with using Taiwan Cancer Database combined with Taiwan National Health Insurance Database (NHID) and death registry. Breast cancer patients diagnosed in 2003 to 2004 and received surgical treatment will be included in this study. Process quality will be measured by a set of core measure indicators, and constant returns to scale (CRS) input oriented data envelope analysis (DEA) method will be used for measuring efficiency of individual hospital. Comorbidity and severity of illness will also be controlled in analysis. Result: 6,396 female breast cancer patients, reported by 26 hospitals, were included in this study. After controlled for patient and provider characteristics, hospital and physician’s surgical volume for breast cancer as well as hospital efficiency are not associated with the patient survival or recurrence. Patients received care with high process quality is associated with better survival and lower recurrence. The multilevel analyses found random effect for the hospital-patients clustered sample, but the effect for physician-patient clusters is not as significant. This study also found the provider’s process quality also has the moderating effect for patient-level process quality. Conclusion: Volume is not associated with breast cancer recurrence or survival, nor it has moderating effect on process quality. The clustered feature of data should be considered for volume-outcome related studies. Future researches should apply a longitudinal design to explore how quality related health outcomes can be affected by a change in provider efficiency.
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