門診戒菸之成效與成本效果分析:以台灣某醫學中心為例

目的：本研究之目的乃在於探討台灣某醫學中心門診戒菸服務之成效，並進一步分析其醫療成本與分析其成本效果方法：本研究之資料來源乃收集自2002年9月起至2004年12月台灣某醫學中心之門診戒菸個案進行分析。收案之必要條件：凡為十八歲(含)以上之全民健康保險的對象，尼古丁成癮度測試分數（Fagerström Tolerance Questionnaire，FTQ）大於或等於5分，或一天平均吸十支菸及以上，有意願接受門診戒菸治療者。最近三個月有心臟之急性症狀(心肌梗塞、心導管術後、嚴重之心率不整)或懷孕婦女不予收案。總計547人納入分析。介入措施包含首次衛教約20至30分鐘，後續則提供簡短諮詢（3至10分鐘），並同時給予24小時尼古丁貼片之藥物治療。本研究之標準療程為八週，但並無強制性，個案可隨時中止治療。戒菸成功率之評估則以個案之第一次門診戒菸為基準日，在一年後以電訪評估其戒菸情況，並以七日點戒菸率為主要結果指標。電訪時若個案七天內有任何吸菸行為，或無法聯絡之個案則歸為戒菸失敗。戒菸之成本則以門診戒菸產生之醫療費用計算。主要為掛號費用、醫師治療服務費、藥品費之總合。成本效果部份：乃根據一年之戒菸成功率，計算每位成功戒菸者之成本，並依其他國外文獻之參數，以拯救的生命年數（life-year saved）與生活品質調整後生命年數（saved Quality Adjusted Life Year，QALY）之成本(3%折現計算)為主要結果。結果：共有547位個案收案並納入分析，一年之戒菸率為29.8％。個案之年齡分佈範圍為18歲至84 歲，平均年齡47.0 歲（SD =16.5）。男性 495人佔90.5％，女性52人佔9.5％。影響戒菸成功率之因素為(1)每日吸菸支數（p=0.00，aOR＝0.97；95%CI＝0.95-0.99）(2)過去一年內曾戒菸超過24小時（p=0.01，aOR＝1.66；95%CI＝1.13-2.45） (3)家人因素戒菸（p=0.03，aOR＝0.65；95%CI＝0.44-0.95） (4)門診戒菸就診次數(p=0.01，aOR=1.12；95%CI＝1.03-1.21) (5)有皮膚發癢（p=0.01，aOR＝2.18；95%CI＝1.19-3.99）。年齡、菸齡、教育程度與尼古丁成癮量表分數則無顯著影響。依成本計算，平均一名個案成功戒菸花費為7,717元；男性為7564元，女性為10,047元。依成本效果而言，每拯救一生命年數總平均成本為7996元，男性為8,180元，女性為6,351元。若以QALYs計算，每拯救一QALY平均成本為5,078元；男性為5,062元，女性為5,271元。若依年齡別成本效果來看，每拯救一生命年數之成本介於4,423元（年齡層35-39）－19,125元（年齡層45-49）之間，每拯救一QALY之成本介於2,688元（年齡層25-29）－12,557元（年齡層45-49）之間。結論：由本研究可知，有許多因素可影響門診戒菸之戒菸成功率，而其中提高門診戒菸回診次數將可以提高門診戒菸成功率。研究亦顯示，國內門診戒菸之成本效果非常優越，值得推廣。

關鍵字

門診戒菸；成本效果分析；戒菸貼片

並列摘要

Abstract Purpose：The Purpose of this study is to access the effecacy of smoking cessation clinic and to determine the cost and cost-effectiveness in a medicine center in Taiwan. Method：All cases were recruited between September 2002 and December 2004 at smoking cessation clinic in a medicine center in Taiwan. The inclusion criteria were adult patients (≧18 yrs), with public health insurance, and with Fagerström Tolerance Questionnaire（FTQ）score equal to or greater than 5, or smoking 10 or more than 10 cigarettes per day who was attended for smoking cessation clinic therapy. Exclusion criteria were who with acute cardiac condition in recently 3 months( acute myocardiac infaction、cardiac catheterization event、severe cardiac arrthymia) or pregnancy women. Under analysis cases numbers is 547. All cases received first time tobacco cessation education for 20 to 30 mins, and following brief individual counseling；24H nicotine patch was also prescribed in the same time. In our study，standard treatment period was 8 weeks，all subjects were asked to visit the clinic for follow-up every 1 or 2 weeks, but the subject can decide to return clinic as appointment or not by themselves. For evaluating abstinence rate, we contacted with the cases by telephone at the end of one year respectively from their first consultation. Seven-day point abstinence rate was to be evaluated. Any smoking behavior in last seven days or loss of follow-up was defined as failure. Costs include smoking cessation clinic register fee, physicians’ charge and patch prescriptions. Base on one-year smoking cessation rate, we calculate the cost for per successful ex-smoker；by the previous foreign published index, our main outcome was costs per life- year saved and per QALYs saved discounted by 3% annually. Result：There were 547 subjects recruited and analysis in the study, Our results showed that the seven-day point abstinence rate in one year was 29.7% respectively. In all cases, average age is 47 years old（SD= 4.6）, 495 cases were male and 52 were female. Factors which correlated with the abstinence rate was (1) number of cigarettes smoked per day （p=0.00，aOR＝0.97；95%CI＝0.95-0.99）(2) with or without the experience of tobacco cessation above 24hours in the past year（p=0.01，aOR＝1.66；95%CI＝1.13-2.45）(3) quitting smoking for family or not（p=0.03，aOR＝0.65；95%CI＝0.44-0.95） (4) total number of smoking cessation clinic visits(p=0.01，aOR=1.12；95%CI＝1.03-1.21) (5)with or without skin itching condition（p=0.01，aOR＝2.18；95%CI＝1.19-3.99）；There were no significant differences of abstinence rate among various groups of age, duration of smoking, and the educational level、 Fagerström Tolerance Questionnaire (FTQ) score. The average cost per successful ex-smoker is NTD7,717; depending on sex, the cost for per successful male ex-smoker is NTD7,564 and female is NTD10,047. The average cost per life year saved (YLS) is NTD7,996; for male, average cost per YLS is NTD8,180 and female is NTD6,351；The average cost per QALY saved is NTD5,079；for male, average cost per QALY saved is NTD5,062 and female is NTD5,271. Depending on age, the average cost per YLS is NTD 4,423(age 35-39) to 19,125(age 45-49), average cost per QALY saved is NTD2,688(age 25-29) to 12,557(age 45-49). Conculsion：According to our study, it was shown that there were multiple factors correlated with the abstinence rate of smoking. Abstinence rate could be improved in the smokers by their smoking cessation clinic frequent visits.We also revealed smoking cessation clinic in Medicine Center in Taiwan has cost effective value, It is worth to promote.