大腸直腸癌病患中糞便潛血檢查的成本效果分析

Cost-effectiveness Analysis of Fecal Occult Blood Test in Screening for Colorectal Cancer Patients

陳懿文(I-Wen Chen)

指導教授 ： 張永源

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2016年)

摘要

摘 要
研究目的
我國自民國93年起即開始推行50歲∼69歲民眾接受大腸直腸癌篩檢。本研究目的探討:
探討糞便潛血篩檢組和未篩檢組的大腸直腸癌患者的篩
檢成本(僅限直接成本)。
探討糞便潛血篩檢組和未篩檢組的大腸直腸癌患者的篩
檢效果、醫療資源利用、治療方式的比較。
探討糞便潛血篩檢組和未篩檢組的大腸直腸癌患者的成
本效果比 (Incremental cost effectiveness，ICER)的
比較。

研究方法
本研究採用回溯性次級資料分析法分為糞便潛血篩檢組及未篩檢組，資料來源採用2012年百萬全國抽樣歸人檔，研究對象為2009年6月1日至2012年12月底新診斷大腸直腸癌(CRC)患者及持有重大傷病證明個案共2399人，做二項對數迴歸(Binary logistic regression)進行傾向分數配對(Propensity score matching，PSM)；1:2配對，將參與此研究的大腸直腸癌患者分為二組：1.為住院前曾接受糞便潛血篩檢患者(417人)2.未接受糞便潛血篩檢患者(834人)；分析糞便潛血檢查在大腸直腸癌病患的成本與效果。本研究利用住院醫療費用清單明細檔(DD)、重大傷病證明明細檔(HV)，串聯檔案及資料處理後，研究探討篩檢組及未接受篩檢組的大腸直腸癌病患進行篩檢效果、醫療資源利用、治療方式及成本效果分析研究。
研究工具為SPSS 22.0統計套裝軟體執行統計分析，分為描述性統計(包括平均值、標準差、次級分配及百分比)與推論性統計(包括卡分檢定、t檢定、複迴歸分析、對數迴歸分析)之統計方法進行資料分析及驗證假說。最後針對篩檢組及未篩檢組兩組進行遞增成本效果比(Incremental cost effectiveness, ICER)的分析。

研究結果
研究期間為2009年6月至2012年止，糞便潛血篩檢組比未篩檢組成本多90〜130元；而二組當次住院併發症，未篩檢組有較多發生人數(未篩檢組：83人；篩檢組：17人，卡方：15.321，p=.002) ；而在當次住院死亡方面，未篩檢組死亡比例較高(未篩檢組：2.9%；篩檢組：0.72%，卡方：6.132，p=.013)；而二組在每人住院平均醫療費用上未有明顯差異(未篩檢組：86215.8點；篩檢組：86676.0點，F值：.01，p=.922)，但是在總住院醫療費二者比較上，未篩檢組花費較高(未篩檢組：333255.183點；篩檢組：271587.062點，F值：7.913，p=.005)；在手術方面，人工肛門手術的人次二組無明顯差異(未篩檢組：23人；篩檢組：14人，卡方：.348，p=.334)；接受化學治療或放射治療中，未篩檢組患者放射治療的人數多於篩檢組(未篩檢組：98人；篩檢組：18人，卡方:18.580， p=.0001)。而遞增成本效果比(ICER)共三種分別為：ICER1(併發症)＝24662點，ICER2(死亡人數)＝6852點，ICER3(人均住院日)＝-220243點，綜合以上三種ICER代表糞便潛血篩檢是具有成本效果的策略。

結論與建議
糞便篩檢策略的實施為影響併發症(腹膜炎、腸穿孔、腸阻塞)及當次住院死亡的重要因子，而在醫療資源利用及治療方式，糞便篩檢組可以降低總住院醫療費用。糞便潛血篩檢的成本效果比未篩檢組好，因此國家推行糞便潛血篩檢政策，應鼓勵一般風險民眾(50∼74歲)接受糞便潛血篩檢；陽性反應後接受大腸直腸鏡檢查，早期發現，早期接受治療。將糞便潛血檢查大力推廣至台灣各個醫療院所，也提供醫護人員以及大腸直腸癌病患與家屬，於治療前了解其狀況，對於臨床預後照護的參考。
關鍵詞:大腸直腸癌、糞便潛血篩檢、遞增成本效果比(ICER)

關鍵字

大腸直腸癌 ； 糞便潛血篩檢 ； 成本效果分析

並列摘要

Abstract
Purpose

Taiwan’s Ministry of Health and Welfare National Health began recommending colorectal cancer screening for people 50∼69 years old, an average risk population, in 2004. In 2013, that age group was expanded to 50 ~ 74 years old. Since 2010 Taiwan has used fecal occult blood tests (FOBTs) to screen for colorectal cancer. However, it is not known to what extent FOBT screening affects the cost effectiveness, utilization of medical resources, mortality rate and complication rate associated with the treatment of this cancer.

Methods

Tapping Taiwan’s National Health Insurance database, we retrospectively collected and analyzed claims data reported for colorectal patients who had received FOBTs and those who had not. Between June 1, 2009 and December 31, 2012, 2399 patients received a new diagnosis of colorectal cancer (CRC). We used binary logistic regression to perform propensity score matching (PSM) FOBT group (n=417) with non FOBT group (n=834) (1:2 ratio). We compared total cost of each inpatient admission, time of catastrophic illness designation, and outcomes, including treatments needed, complication rate, mortality rate and length-of-stay. We performed analyses of research medical resource utilization and cost-effectiveness, expressed as treatment-cost ratio. Differences were analyzed inferentially by chi-square, t-test, independent sample t-test, ANOVA test. All statistical operations were performed using SPSS 22.0 statistical software.

Results

According to the complications of admission, We found that those who had not received FOBTs to have a significantly higher rate of complications than those who had (83 vs. 17 patients; chi-square: 15.321; p = .002) and a mortality rate (2.9% vs. 0.72%; chi-square: 6.132, P = .013). We found no significant difference in average medical costs per hospitalization, though the total treatment cost was significantly higher for those who had not received FOBT (333,255.183 cost points vs. 271,587.062; F value: 7.913; p =.005). With regard to specific procedures, while we found no significant difference in surgeries received, we did find that the non-FOBT group had more chemotherapy and radiation than the FOBT group (98 vs. 18 patients; chi-square: 18.580; p =.0001). In addition, incremental cost-effectiveness ratios results revealed that cost effectiveness better for the FOBT group when analyzed for number complications (+246,62 points), mortality rate (+6852 points) and length-of-stay (-220,243 points).

Conclusion and recommendation

In conclusion, the use of FOBTs can reduce the total cost of medical care and make for better cost effectiveness in the treatment of patients with colorectal cancer. It reduces complication and mortality. Thus, it is recommended that all people between 50 and 74 years old receive fecal occult blood tests.

Key words: colorectal cancer; fecal occult blood tests (FOBTs); incremental cost-effectiveness ratio (ICER)

並列關鍵字

colorectal cancer ； fecal occult blood test ； incremental cost effectiveness ratio(ICER)

參考文獻

1.英文文獻

Barouni, M., Larizadeh, M. H., Sabermahani, A., & Ghaderi, H. (2012). Markov's modeling for screening strategies for colorectal cancer. Asian Pacific Journal of Cancer Prevention, 13(10), 5125-5129.

Bond, J. H., & Gastroenterology, P. P. C. o. t. A. C. o. (2000). Polyp guideline: diagnosis, treatment, and surveillance for patients with colorectal polyps. The American journal of gastroenterology, 95(11), 3053-3063.

Butterworth, A. S., Higgins, J. P., & Pharoah, P. (2006). Relative and absolute risk of colorectal cancer for individuals with a family history: a meta-analysis. European journal of cancer, 42(2), 216-227.

Chen, L.-S., Liao, C.-S., Chang, S.-H., Lai, H.-C., & Chen, T. H.-H. (2007). Cost-effectiveness analysis for determining optimal cut-off of immunochemical faecal occult blood test for population-based colorectal cancer screening (KCIS 16). Journal of medical screening, 14(4), 191-199.