不同期別結直腸癌病患術後醫療資源使用及成本效果分析

Medical Resource Utilization and Cost-effectiveness Analysis in Different Stages of Surgery Colorectal Cancer Patients

楊宜誠(Yi-Cheng Yang)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士班/碩士(2016年)

摘要

研究背景與目的
結直腸癌(Colorectal Cancer，CRC)為全球常見的癌症疾病之一，近年為國內的癌症發生率第一名，且為國內癌症死因第三名，另外根據2012年國民健康署的資料，台灣每十萬人口大腸癌發生率為45.1人，在世界衛生組織(WHO)於2012年的全球大腸癌統計中，台灣為全球大腸癌發生率最高之國家。而隨著癌症病患的增加，對於不同期別癌症病患的治療與醫療資源使用亦逐漸受到重視，因此本研究針對不同期別結直腸癌手術病患在不同治療階段的醫療資源使用、整體存活、治療成本效果進行評估與探討。

研究方法
本研究同時兼具前瞻性及回溯性研究設計，前瞻性研究以健康相關生活品質問卷訪問、回溯性則以病歷審查方式。研究對象以南部某醫學中心2005年1月1日至2015年12月31日期間，被新診斷為結直腸癌且接受手術治療病患，共計十年(N=1,595)。本研究資料來源分為三大部份，第一部份為健康相關生活品質問卷，於2010年1月1日開始收集至2015年12月31日為止，收案對象最長追蹤至手術後五年，最短為手術後一個月或止於收案期間內死亡。第二部份為病歷審查，以南部某醫學中心病患入院就診之病歷資料。第三部份為資料庫使用，包含病患住院、門診醫療費用與死因檔。

統計分析採用SPSS20.0統計軟體，以卡方檢定、獨立樣本t檢定、變異數檢定並使用STATA11.0版以廣義估計方程式(GEE)控制時間變項進行資料分析。

研究結果
研究結果顯示不同期別結直腸癌手術病患於治療三階段中皆以Terminal Stage花費為最高，其中又以IV期病患差異最大，其Terminal Stage的花費相較Initial Treatment Stage多花201,800元；另外在治療三階段的費用比較中，也以IV期病患的花費為最高，相較I期病患多花341,195元。於各治療階段費用裡又可發現，Initial Treatment Stage中以IV期病患花費為最高，相較I期病患多花161,714元，Continuous Care Stage中也以IV期病患花費為最高，相較I期病患多花431,768元。另外病患術後一至五年的費用，亦發現不論哪一期別的癌症病患，其花費皆逐年下降，且以IV期病患下降為最多，其術後第五年的費用相較術後一年的費用少花677,403元。

結直腸癌病患術後的死亡風險以IV期病患為最高，相較I期病患高3.73倍，而存活率以IV期病患為最低，僅為69.2%，相較I期病患低22.7%。治療成本效果則以早期(I-II期)病患較晚期(III-IV期)病患佳；QALYs以I期病患為最佳，相對IV期病患高0.179，而II期病患為次高，相對IV期病患高0.161；另外每增加一個QALYs所需的總醫療費用以早期病患花費較少，其I期病患相較IV期病患少花1,925,571元、II期病患相較IV期病患少花2,076,929元。

結論與建議
本研究結果發現，不同期別結直腸癌手術病患於不同治療階段中皆以IV期病患花費為最多，而治療成本效果分析中亦以IV期病患的成本較高、治療效果較差，因此結果顯示結直腸癌晚期病患其治療需要高成本但僅得到低效果，反觀早期病患則花較少的錢而得到較佳的效果。而根據本研究結果，建議醫師、醫療院所、衛生政策單位能夠加以注重癌症之篩檢，除了降低癌症的發生之外，早期診斷早期治療亦為一個重要之議題與政策方向。

關鍵字

結直腸癌 ； 不同期別 ； 醫療資源使用 ； 治療三階段 ； 存活 ； 治療成本效果

並列摘要

Background
Colorectal Cancer (CRC) is the most common cancer in the world; in recent years, it is also the first incidence rates of cancer and the third main cause of cancer death in Taiwan. According to the 2012 statistics database of Taiwan Health Promotion Administration (HPA) shows the incidence rates among CRC is 45.1 per 100,000 people and the global cancer statistics report shows that Taiwan’s incidence rate of CRC was highest than other countries by World Health Organization (WHO) in 2012. With the increase of cancer patients, the treatment method and medical resource utilization have gradually taken seriously. Therefore, the purposes of study are to assess and discuss in medical resource utilization, survival and cost-effectiveness analysis in different staging CRC patients.

Methods
The research contained prospective and retrospective design, the prospective study was conducted to investigate health-related quality of life (HRQoL) questionnaires during 2010 to 2015 and the retrospective study was conducted to collect the data from medical record. The patients of study were the newly diagnosed CRC and underwent surgery between January 2005 to December 2015 at one medical center in Southern Taiwan. Data sources included three parks: 1st was HRQoL questionnaires, 2nd was medical record and 3rd was database (including inpatient costs, outpatient costs and death file). We used General Estimating Equations (GEE) to control time by STATA 11.0 statistical software.

Results
For treatment stage costs, the result shows that Terminal Stage cost more dollars than other treatment stages in all staging CRC patients, and Terminal Stage cost was also significantly higher than Initial Treatment Stage among the staging IV CRC patients (NTD$201,800). Otherwise, the result shows that staging IV CRC patients cost more money than other patients in all treatment stage costs, Initial Treatment Stage costs and Continuous Care Stage costs were all higher than staging I CRC patients (NTD$161,714；NTD$431,768). The study found that postoperative 1-5 years costs decline by years in all staging CRC patients, especially in staging IV CRC patients, 5 year costs less than 1 year (NTD$667,103).

Survival analysis shows that staging IV CRC patients’ hazard ratio significantly higher than staging I CRC patients (HR 3.73) and mortality ratio higher than staging I CRC patients (69.2% versus 91.9%). And the result of the cost-effectiveness analysis (CEA) in different staging CRC patients shows that early staging CRC patients had better outcome but cost less than other staging CRC patients. Especially, staging I CRC patients significantly cost less than staging IV CRC patients (NTD$1,925,571).

Conclusions
The study shows that staging IV CRC patients cost more money in all treatment stage and also had worse cost-effectiveness. The result shows that late staging CRC patients cost more money but got lower treatment effect than early staging CRC patients, according to our results, suggesting clinic physician and ministry of health and welfare administration to continuing for popularizing cancer screening and stress on early diagnosis and therapy.

並列關鍵字

Colorectal Cancer ； Different Cancer Staging ； Medical Resource Utilization ； Treatment Stage Costs ； Survival ； Cost-effectiveness Analysis

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