- 學位論文
台灣地區肝癌治療療效與醫療資源利用探討
The Outcomes and Resource Utilization of Hepatocellular Carcinoma Patients in Taiwan
摘要
研究背景： 以性別排名癌症死因，肝癌則是位居台灣男性第一位、女性第二位的疾病。臨床上，依病患條件的差異，肝癌治療方式亦有所不同，但是「肝切除術」則是被視為最具治癒性與積極性之治療方式。現階段，「栓塞治療」是台灣地區內科治療比例最高的處置方式。目前國內、外相關研究鮮少利用行政資料庫以肝癌患者為研究對象，進行長期性療效與醫療資源利用分析。因此，本研究利用全民健康保險資料庫，以台灣地區接受肝切除術與栓塞治療之原發性肝癌患者為研究對象，進行肝癌患者接受肝切除術與栓塞治療療效與醫療資源利用相關研究。 研究方法： 本研究採回溯性次級資料分析，以全民健保資料庫2000年1月至2004年12月(五年)間，18歲以上原發性肝癌病患曾接受肝切除術(4,148位)與栓塞療法(TACE 5,979、TAE 4,730)之病患，共計14,857位研究樣本。本研究包含四個研究目的：(1)探討2000年至2004年各年度肝癌病患特質、就醫醫院特質、治療方式與其當次住院之治療療效、醫療資源利用分佈趨勢。(2)不同肝癌治療方式之病患特質、就醫醫院特質、治療療效及醫療資源利用的評估。(3)探討影響肝癌病患治療療效之因子。(4)探討影響肝癌治療病患住院醫療資源利用之因子。因此，以SPSS 12.0統計軟體，利用t-test、卡方檢定、對數迴歸及複迴歸分析，進行資料分析與驗證研究假設。 研究結果： 研究結果發現，2000~2004年台灣地區肝癌病患住院個案不斷增加，整體增加量約30%。TACE與TAE治療個案呈現消長之趨勢、平均醫療費用亦呈現下降趨勢且差距逐漸減少。不同肝癌治療方式在醫療機構特性上有顯著差異：公立醫院執行手術切除略高於財團法人醫院；而財團法人醫院採取TACE/TAE治療較多。合併症與併發症為肝癌治療病患治療療效與醫療資源耗用之影響因子。以「肝切除術」為例：有併發症者，其死亡風險為無併發症的14.8倍；若能減少併發症，將可降低10.34天的住院天數與170,316元醫療費用。以「栓塞治療」為例：有併發症者，其死亡風險為無併發症者的12.36倍；減少併發症，可降低10.91天的住院天數與71,199元醫療費用。都市化分類亦為肝切除術術後療效與醫療資源利用之影響因子：在次都會區與非都會區中的死亡風險為都會區的3.29倍與1.88倍；而在非都會區治療相較於都會區，其醫療費用將增加16,433元。此外，本研究亦發現：TACE之療效優於TAE。就校正疾病嚴重度與併發症等相關因素模式而言，病患採用TACE治療的死亡風險為TAE治療的0.65倍。 結論： 本研究發現肝切除術的死亡率、住院天數皆隨著時間而有下降趨勢，其平均醫療費用五年間變化不大。而栓塞治療的死亡率、住院天數與平均醫療費用皆隨著時間而有下降趨勢。此外，亦發現合併症與併發症是肝癌治療病患治療療效與醫療資源耗用之顯著影響因子。整體而言，相較於其他變項，併發症係影響肝癌治療療效與醫療資源耗用最重要之影響因子。因此，本研究建議應透過有效的病患照護與管理，注意病患合併症且降低可避免的併發症，將有助於提高肝癌治療療效與醫療資源之利用。
並列摘要
Background: Hepatocellular carcinoma (HCC) was found to be the most common neoplasm and also among the leading cause of death in Taiwan. The medical treatments are adopted according to different conditions of patients. While Hepatic resection is well documented as the best curative therapy for HCC, Transcatheter embolization/chemoembolization (TAE/TACE) is widely used in the treatment of unresectable hepatic tumors in Taiwan. Although clinical reports showed that improve outcomes over time associated with low mortality rates and short hospital stay. There is lack of reporting about the treatment outcome and resource utilization among those patients based on longitudinal studies. Accordingly, the aim of this study was to characterize trends in the use and outcomes of hepatocellular carcinoma patients underwent hepatic resection and TAE/TACE in Taiwan during recent 5-year period, and evaluate the risk factors for mortality, length of stay and in-hospital medical costs. Method: This study was adopting prospective study design from Jan. 2000 to Dec. 2004. There were 74,822 adult patients aged 18 and over, with a diagnosis code for Liver cancer and procedures code for hepatic resection and TAE/TACE coexistent in the Nationwide Inpatient Database, included in the study. This study focused on characteristics of patients, hospitals, therapies and outcome variables of in-hospital mortality, length of stay and medical costs. Comparisons of patient and hospital characteristics and outcomes variables were performed using the chi-square test, t-test, simple logistic regression, and simple linear regression where appropriate. The identified variables associated with outcome variables (p value < 0.05) further analyzed by multivariate analyses to evaluate the predictive power of each determinant. All statistical tests were two tailed, and p value < 0.05 was considered to indicate statistical significance. All statistical analyses were performed using SPSS 12.0. Result: There was a 30% increase of hospital admissions for HCC during 2000-2004 in Taiwan. There was a significant difference between treatments hepatic resection, TAE and TACE in public and non-profit proprietary hospitals. The most important factors to hepatocellular carcinoma patients underwent hepatic resection and TAE/TACE were both comorbidity and complication, which could increase mortality, length of stay and in-hospital medical costs. Compared with urban areas, suburbs and rural areas had higher risk of mortality and increase of medical costs among hepatocellular carcinoma patients underwent hepatic resection. The treatment outcome of TACE was better than TAE because the lower mortality was found after TACE. Conclusion: In-hospital mortality and length of stay for hepatic resection and TAE/TACE were found to decrease over time, but medical costs decreased only in TAE/TACE. Moreover, complication was found to be the most important factor to hepatocellular carcinoma patients underwent hepatic resection and TAE/TACE. For a better treatment outcome and medical resource utilization, it is essential to improve patient care and pay more attention to comorbidity and complication after hepatic resection and TAE/TACE.