乳癌病人死亡前一個月醫療資源利用與費用之探討

The Study on Medical Resource Utilization and Cost of Breast Cancer Patients in Their Last Month of Life

吳宛璇(Wan-Hsuan Wu)

指導教授 ： 張肇松

高雄醫學大學/健康科學院/醫務管理學研究所/碩士(2012年)

摘要

研究背景與目的
台灣於2003年起，乳癌發生率已超過子宮頸癌，依據2008年癌症登記報告，女性乳癌已成為十大癌症發生率之第一位。研究顯示癌症臨終病患越接近死亡時其醫療費用越高，對於病患來說在臨終前所做的治療與處置或相關之急救及侵略性醫療，若能減少這些治療與急救，減輕其病症帶來之痛苦，是否能以安寧療護的方式來減少臨終病患對醫療資源的利用。去思考這些急救是否真的對病患有幫助，而是不是所謂的無效醫療，是值得我們探討。因此探討分析台灣乳癌病人醫療利用與醫療費用情形以及相關影響因子。
研究方法
本研究為世代追蹤研究（cohort study）追蹤期間為1997至2008年，從健保資料庫重大傷病檔中挑選出乳癌患者有登記死亡日期的個案，主要研究對象為死亡前一個月之乳癌病患醫療資源利用與費用，總樣本數為10,444位，單純門診者872人、單純住院者2,653人，同時有門診及住院者6,919人。採用SPSS19.0統計軟體進行統計分析，包括卡方檢定(χ²-test)、獨立樣本t檢定（T-test）、變異數分析（One-way ANOVA）、複迴歸分析（Multiple regression analysis）及對數迴歸分析（Logistic linear regression）進行資料描述性統計及推論性統計分析。
研究結果
本研究樣本從出診斷至死亡平均年齡為58.3±13.9歲，每人平均門診次數2.9±3.0次；平均住院次數1.4±0.8次；平均住院天數14.8±11.0天。每人平均門診醫療費用10,600元；平均住院醫療費用129,823元；平均總醫療費用140,424元。接受放射線治療者有14.5%、化學治療24.4%、電擊3.7%、心肺復甦術13.4%、氣管內插管25.5%、呼吸器治療31.8%、手術15.5%、急診暫留4.0%、急診2.3%、加護病房23.9%及安寧療護16.2%，年齡與積極性治療、急救和侵入性醫療有差異，但手術與年齡沒有差異。
病人特性、醫院特性及有無接受安寧療護對總醫療費用的影響，發現結果顯示年齡及醫院權屬別不影響總醫療費用，合併症分數（CCI）部分，6分者相較於0-5分總醫療費用低7,391元，≧7分者相較於0-5分總醫療費用低13,839元；沒有使用安寧療護者相較於有使用安寧療護者，其總醫療費用高出45,416元；區域醫院相較於地區醫院費用高出14,767元，醫學中心相較於地區醫院費用高出39,082元；北區分局相較於台北分局總醫療費用減少29,944元，中區分局相較於台北分局總醫療費用減少18,463元，南區分局相較於台北分局總醫療費用減少21,731元，高屏分局相較於台北分局總醫療費用減少29,440元。
結論與建議
年齡、合併症、醫院權屬別、醫院地區別以及醫院分局別，為乳癌病患死前一個月醫療利用之預測因子。針對乳癌病患死前一個月情形分析，在病患特性部分，合併症會影響醫療費用，年齡則不影響醫療費用；醫院特性亦會影響醫療費用；病患特性及醫院特性亦會影響醫療利用；是否使用安寧療護也會影響到醫療費用，而有使用安寧療護者確實可以降低醫療成本，台灣民眾對於安寧療的了解及接受情形仍是偏低的，建議政府機關應更加支持安寧療護的發展，加強醫學教育及民眾教育，讓癌症病患在臨終期能接受較合宜的照護方式，且在未增加健保醫療費用支出同時，也能顧及到病患的生活品質。

關鍵字

醫療資源利用 ； 成本 ； 生命末期 ； 乳癌

並列摘要

Background and Objective
The incidence of breast cancer has exceeded that of cervical cancer and become the most common malignancy occurred in Taiwan since 2003. Previous studies shows that the closer to the end of life , the higher medical cost occurs. It was thought that how to reduce the ineffective aggressive treatments and enhance the use of palliative and hospice care during the patient’s end of life would be a proper way to contain the escalating healthcare cost. The purpose of this study is to explore and analyze medical utilization, costs and its relevant impact factors in the late stage of breast cancer patients.
Methods
This cohort study investigates breast cancer patient’s medical resource usage and expense in their life of last month. Patients who were diagnosed as breast cancer and died (according to Registry for Catastrophic Illness Patients of NHI) between 1997 and 2008 were enrolled for study. A total of 10,444 cases were analyzed, which included 872 with outpatient services only, 2,653 with hospitalization only, and 6,919 with both outpatient and inpatient service.The medical utilization and cost including drugs, laboratory test, and treatment in outpatient, inpatient and emergency service were analyzed. Statistical analysis including descriptive statistics and inferential statistics e.g. χ²-test, T-test, ANOVA, multiple regression analysis and logistic linear regression were performed using SPSS 19.0 software.
Results
The mean age of studied samples is 58.3 years old. The results of medical utilization of each patient in his or her last month of life were with 2.9 outpatient visits, 1.4 hospitalizations with an average of 14.8 days of length of stay. The average cost of these patient spent NT$10,600 for outpatient service, NT$129,823 for hospitalization and NT$140,424 for total medical expense. The frequency of medical resource use were as following with radiotherapy14.5%, chemotherapy 24.4%, electric DC shock 3.7%, CPR 13.4%,endotracheal intubation 25.5%, respiratory therapy 31.8%,, and operation 15.5%. There was 23.9% of case admitted to ICU and 16.2 % cases were under hospice care. 4.0% of cases were stayed at emergency room temporary and 2.3% were treated at emergency room. Age was the significant factor to use aggressive treatment, emergency treatment and invasive treatment.
Evaluating patients and hospital characteristics and hospice care enforcement or not, the result shows age and hospital category will not influence total medical expense. in the CCI variables, 6 and≧7points compared to 0-5 the total medical costs were lower than NT $7,391and NT $13,839; did not use hospice care compared to use hospice care patient the total medical costs were higher than NT $45,416 ; Regional hospitals compared with district hospitals the total medical costs were higher than NT $14,767 , the medical center compared to the regional hospital the total medical costs were higher than NT $39,082; Northern, Central, Southern, and Kaoping Division compared to the Taipei Division the total medical costs were lower than NT $29,944, NT $18,463, NT $ 21,731and NT $29,440.
Conclusion and Suggestion
The patient’s Age and CCI and hospital chrateristics including hospital category, hospital location, and hospital branch predict the medical utilization for the last month of breast cancer patients. The patient’s CCI and hospital characteristics have a significant impact on the medical expense of the last month of breast cancer patient, while there is no such a impact about patient’s age. Our study showed low usage of hospice care in Taiwan’s patients, though it showed less medical expense in those cases with hospice care. How to increase the usage of hospice care in breast cancer patient become an important issue to be concerned. Further studies are needed.

並列關鍵字

Medical resource utilization ； Cost ； End of life ； Breast cancer

參考文獻

李宣緯, 葉玲玲, 王金龍, 徐聖輝, & 黃達夫. (2002). 癌症住院病人精神醫療照護服務之醫療利用研究. 臺灣公共衛生雜誌, 21(4), 278-288.

Chu, P.-C., Hwang, J.-S., Wang, J.-D., & Chang, Y.-Y. (2008). Estimation of the Financial Burden to the National Health Insurance for Patients with Major Cancers in Taiwan. Journal of the Formosan Medical Association, 107(1), 54-63. doi: 10.1016/s0929-6646(08)60008-x

Mariotto, A. B., Robin Yabroff, K., Shao, Y., Feuer, E. J., & Brown, M. L. (2011). Projections of the Cost of Cancer Care in the United States: 2010-2020. JNCI Journal of the National Cancer Institute, 103(2), 117-128. doi: 10.1093/jnci/djq495

一、英文參考文獻

Abel, J., Rich, A., Griffin, T., & Purdy, S. (2009). End-of-life care in hospital: a descriptive study of all inpatient deaths in 1 year. Palliative Medicine, 23(7), 616-622.