[[alternative]]The effects of urban-rural differences on palliative care use and home death among cancer patients

Abstract

[[abstract]]背景：癌症為臺灣十大死因之首，癌症病人安寧療護使用及在宅死亡被認為是生命末期的品質指標，了解城鄉差異有助於衛生主管機關作為醫療資源分配與提升癌症病人醫療照護品質之參考依據。目的：探討臺灣近十年來，城鄉差異對癌症病人安寧療護使用及在宅死亡的影響。方法：本研究使用衛生福利部衛生福利資料科學中心之全民健康保險資料庫，以17,091位2011年至2020年死亡之癌症病人為研究對象，首先將各變項分為城市和鄉村以次數、百分比等描述性統計方式呈現其分佈情形，再以卡方檢定探討各類別變項間的差異，並採用簡單邏輯斯迴歸、多元邏輯斯迴歸分別探討自變項和控制變項對使用安寧療護和在宅死亡之影響。本研究將顯著水準(α level)設定為0.05，使用SAS 9.4統計套裝軟體進行資料處理及統計分析。結果：本研究之研究對象共17,091位，城市有11,818位，其中使用安寧療護者4,804位(40.65%)，在宅死亡者3,672位(31.07%)，鄉村有5,273位，其中使用安寧療護者2,013位(38.18%)，在宅死亡者3,407位(64.61%)；在使用安寧療護方面，相較於城市的癌症病人，鄉村的癌症病人使用安寧療護的機率顯著較低(AOR=0.919，95% CI：0.859~0.983)，在宅死亡方面，相較於城市的癌症病人，鄉村的癌症病人在宅死亡的機率顯著較高(AOR=4.014，95% CI：3.741~4.306)。結論：本研究發現癌症病人使用安寧療護及在宅死亡皆存在城鄉差異，城市的癌症病人更可能使用安寧療護，鄉村的癌症病人更可能在宅死亡，因此，研擬偏鄉安寧療護相關措施及提升醫療照護品質為衛生主管機關必須重視之任務，此外，臺灣城市之癌症病人多於醫院死亡，和過去研究中醫院死亡的臨終品質較差之論點相異，此現象值得主管機關深究。[[abstract]]Background:Cancer is the number one cause of death in Taiwan. The use of palliative care and dying at home among cancer patients is considered a quality indicator for end-of-life care. Understanding the differences between urban and rural areas is helpful for health authorities as a reference for allocating medical resources and enhancing the quality of healthcare for cancer patients.Objectives:Examining the impact of urban-rural disparities on the utilization of palliative care and home deaths among cancer patients in Taiwan over the past decade.Methods:This study utilized the National Health Insurance Database from the Health and Welfare Data Science Center to investigate 17,091 cancer patients who passed away between 2011 and 2020. Firstly, descriptive statistics such as frequencies and percentages were employed to present the distribution of various variables, categorized as urban and rural. Subsequently, chi-square tests were conducted to explore the differences between categorical variables. Simple logistic regression and multiple logistic regression analyses were then employed to examine the influence of independent and control variables on the utilization of palliative care and death at home, respectively. The significance level (α level) was set at 0.05, and data processing and statistical analyses were performed using SAS 9.4 statistical software.Results:The study included a total of 17,091 participants, with 11,818 individuals from urban areas. Among them, 4,804 individuals (40.65%) used palliative care, and 3,672 individuals (31.07%) died at home. In the rural areas, there were 5,273 participants, with 2,013 individuals (38.18%) using palliative care, and 3,407 individuals (64.61%) dying at home. Regarding the utilization of palliative care, the likelihood of rural cancer patients using palliative care was significantly lower compared to their urban counterparts (AOR=0.919，95% CI：0.859~0.983). On the other hand, concerning the place of death, the probability of rural cancer patients dying at home was significantly higher compared to urban cancer patients (AOR=4.014，95% CI：3.741~4.306).Conclusions:This study found that there are urban-rural disparities in the use of palliative care and place of death among cancer patients. Urban cancer patients are more likely to utilize palliative care, whereas rural cancer patients are more likely to die at home. Therefore, it is imperative for health authorities to develop measures related to palliative care in remote areas and enhance the quality of medical care. Additionally, in Taiwan, a significant number of cancer patients in urban areas die outside the hospital, which differs from the argument in previous studies that hospital deaths are associated with poorer end-of-life quality. This phenomenon warrants further investigation by the relevant authorities