膽管癌之治療成效與醫療資源耗用之探討 -----人口學基礎之研究

A Cohort Longitudinal Study of Long-term Survival and Resource Utilization for Patients with Cholangiocarcinoma Underwent Multimodality therapy–- A Population Base Study

陳孟春(Men-Chun Chen)

指導教授 ： 李金德

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2012年)

摘要

膽管癌由膽管細胞形成之惡性腫瘤，其發生率約為肝臟惡性腫瘤的10-15%。最近幾年膽管癌的發生率有逐年增加的趨勢；而且的豫後不良，其存活中位數(median OS)為6-12個月。到目前為止，只有外科手術切除才能得到較好的療效。本研究極想探討本國膽管癌之發生率及各種處理方式的長期療效及醫療資源耗用情形。
本研究採用1996年至2009年之健保資料庫，膽管癌ICD-9 155.1、156.1、156.8及156.9的病人，並曾經接受治療的共8458人進入本研究。
本研究發現接受手術治療的病人，僅佔全部的37.3%，以男性居多佔55.1%，65歲以上的病人佔53.9%，發生率有增加的趨勢，由1996年每10萬人的4.33人增加至2009年的9.44人(X2MH=531.7,p<0.001)。
治療效果以外科手術切除為最佳，存活中位數為16.72個月，明顯優於其他治療方式(p<0.001)。至於保守治療的方式，改道手術vs支架置放術的median OS為6.67月vs 3.38月，改道手術的病患有較佳的長期存活(p<0.001);於支持性療法中，以化學治療的median OS 5.06月優於支架置放的3.32月及放射治療的2.53月(p<0.001)。合併治療可以提昇長期療效，支架置放+化療可提升median OS至7.56月，支架置放+放療可提升median OS至4.83月(p<0.001)。
醫療資源的耗用，以手術治療者的費用最高達NT$ 339850±285939元，住院日為45.13 ± 38.2日，而以化學治療者花費最少為NT$ 138244±125608元，住院日為28.32±27.05日。
存活因子的預測分析，以放射線治療的效果最差HR=3.27；腫瘤位於肝內+肝外的存活最佳HR=0.72；年齡愈大存活率越差HR逐年增加，>75歲HR=1.55；合併症多者存活率不良(cci>2之HR=1.13)，年代推進，近年來的病患其存活率較佳HR=0.80。(P<0.001)
醫療資源耗用的預測分析，單純接受化療者花費最少金錢，住院日也最少，腫瘤位於肝內+肝外者，花費最多，住院最久；高齡者大於75歲，花費及住院日最少;合併症多者cci>2的病人，花費多住院也較長;最近的年代(2005-2009)的住院日數減少，但費用却增加。(P<0.001)
結論，健保資料庫分析提供大量的資料及強力的證據，顯示外科手術對於膽管癌最具治療效果，長期療效最好；改道手術較支架置放術的長期療效較佳；合併不同的保守療法可以提昇治療效果。

關鍵字

膽管癌 ； 資源耗用 ； 肝臟手術

並列摘要

Introduction
Cholangiocarcinoma is a malignant tumor ,the annual incidence has been rising worldwide over the past decades.
Cholangiocarcinoma is highly lethal,the therapeutic intentions are predicted on the location of tumor as well as the resectability of disease .
The purpose of this study is to evaluate survival difference and utilization of medical resource between cholangiocarcinoma patients treated with multimodality therapy .
Method
The study analyzed administrative claims date obtained from the Taiwan Bureau of National Health Insurance (BNHI).The date were collected from 1996 to 2009 with the diagnosis of cholangiocarcinoma (ICD-9-CM code 155.1,156.1,156.8 and 156.9).
The statistic analysis was performed by X2-test、Kaplan-Meier analysis with log-rank test and cox-regression multivariate analysis and multiple linear regression test.
Results
Only 3153(37.3%) of 8458 patients with cholangiocarcinoma
underwent cancer direct surgery . Men were accounted for 55.1% in this study group, most of them were older than 65 years,
53.9%.
The annual incidence has been increased from 4.33 per 100000 in 1996 to 9.44 per 100000 in 2009(X2 -MH=531.7,P<0.001). The over-all mortality rate is 81.8% in the study period of 14 years.
Parametric estimated median survival for patients receiving surgical resection was 16.72 months; bypass operaion 6.67 months; chemotherapy(C) 5.06 months;stent replacement(S)3.38 months;radiotherapy(R) 2.53 months,the difference is statistitally significant (P<0.001).Combination therapy, however, improved the treatment effect,data showed median survival for S+C,7.56 months;for S+R,4.83 months(P<0.001).
Using multivariate analysis,surgery alone showed evidence of improved survival compared to non surgical treatment, radiotherapy alone was associated with survival decrement.
Intrahepatic tumor ,age older then 65,cci>2,all with poor risk for survival (P<0.001).
Regarding resource utilization ,the multiple linear rgression analysis showed surgery,intrahepatic + hilar tumor,cci>2,recent decade were associated with higher resource utilization ,while the elderly and regional hospital consumed lessly (P<0.001).
Conclussion
The annual incidence of cholangiocarcinoma has been increased,surgical resection carried the most feasible curative outcome by medion OS and cox regression analysis; combination therapy could improved the longterm survival. Medical resource ulilization could afford the data for policy making in BNHI.

並列關鍵字

Cholangiocarcinoma ； resource utilization ； liver surgery

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