- 學位論文
乳癌手術選擇對於醫療費用支出之影響研究-以高屏地區為例
Influence of Surgical Choices on the Direct Medical Cost of Breast Cancer－Example of Kao-Ping Area
摘要
研究背景與目的：台灣婦女近年來罹患乳癌人數不斷攀升，死亡率也逐年增加，但鑒於國內並沒有乳癌手術病患治療之長期追蹤研究報告，所以本研究目的是探討新診斷為乳癌之病患在選擇不同手術的治療後，對醫療資源耗用的影響。期望能建立國內對於乳癌患者在接受手術治療一年期間所需耗費的直接醫療成本並且經由迴歸校正後，能更有效提供醫療費用評估與衡量的方式。 研究資料與方法：本研究採用回溯性的研究設計，資料來源為南區健保高屏分局2003年11月1日至2005年6月30日之投保病患就醫費用申報檔案。研究對象的篩選方式為半年內不曾以ICD-9-CM 174.0-174.9作為其診斷碼，處置碼必須包含ICD-9-CM 85.11或85.12，並且進一步篩選出231名接受手術治療之乳癌病患。初次手術治療可分為：全部乳房切除術(mastectomy，MST)，共160名；部分乳房切除術 (breast-conserving surgery，BCS)，共71名。BCS由於可能再次手術又分為：單純性部分乳房切除術(Single BCS)，11名；部分乳房切除術併行腋下淋巴廓清術(BCS+ALND)，42名；部份乳房切除術後又再採取全部乳房切除術(BCS+MST)，18名。本研究將病患分為四組，並持續追蹤一年。醫療利用情形在迴歸校正前，為排除首次手術選擇之操控因子，MST組別經由傾向分數和BCS組別配對後篩選出71名具有相似接受BCS治療機率的病患。 研究結果：在追蹤期間之平均總醫療費用其校正後的整體解釋量達93.8 %，發現病患若以BCS+ALND治療其費用會高於Single BCS之 2.7倍，BCS+MST治療則高於Single BCS 之2.4倍，MST治療則高於Single BCS之2.5倍。門診醫療費用以BCS+ALND 最高236,060元，而住院醫療費用是以BCS+MST 最高129,597元。總醫療費用方面，以BCS+MST 最高308,531元，其次依序為BCS+ALND 263,643元、MST 208,364元、Single BCS 最低31,710元。在追蹤期間之平均住院天數經由迴歸校正後的整體解釋量達58.0 %，發現病患若以BCS+ALND治療其住院天數會高於選擇Single BCS之 1.9倍，若以BCS+MST治療則高於Single BCS 之3.2倍，若以MST治療則高於Single BCS之2.2倍。住院天數以BCS+MST 13天為最長，其次依序為MST 7.9天、BCS+ALND 5.5天、Single BCS 2.9天為最短。 結論：追蹤期間之醫療利用，門診醫療費用以BCS+ALND 為最高，而住院醫療費用、總醫療費用與住院天數則是以BCS+MST 為最高。
並列摘要
Background and Objectives: In recent years, the number of Taiwanese women who diagnose breast cancer is increasing and the mortality also increases year by year. There are not long term research of women who received the breast cancer surgical treatment in Taiwan, so the objective of this study is discussing that the influence in medical resource utilization on patients of breast cancer after choosing different operation. It expects that the government could set up a method that patients cost of medical after receiving surgical treatment following one year. To establish regression adjusted models for breast cancer patients using different types of surgery, there is a method to evaluate the medical cost. Methods: The study design was retrospective secondary data analysis. Data wrer extracted between November 1, 2003 and June 30, 2005. The claim data flies gathered from the insured enrollees in National Health Insurance (Kao-Ping branch) affiliated health plans located in the southern Taiwan, during the subject identification period, enrollment was approximately 3.3 million. 231 of breast cancer cases were identified with use of International Classification of Disease, Ninth Revision, Clinical modififcation (ICD-9-CM) diagnosis code between 174.0-174.9 and 85.11-85.12. We than used a decision tree to map the surgery option. 160 of the patients who had a mastectomy (MST) initially underwent subsequent surgical intervention. 71 of the patients who received breast conserving surgery (BCS) for initial treatment underwent some form of a second surgical procedure. There are 11 patients who only received BCS (single BCS). Of these 60 patients, 42 underwent an axillary node dissection as a second surgical procedure (BCS+ALND); and 18 had a mastectomy following their initial BCS (BCS+MST). Confounding is an important problem in non-randomized studies. Propensity score represents the propability of receiving BCS treatment rather than MST, and is based on observed baseline characteristics. So, using propensity score of MST subjects (n=71) are matched with BCS subjects. Results: At following one year after diagnosis, the mean direct medical costs for the four groups differed statistically significantly (P<0.001), with BCS+ALND being more expensive than MST option. The adjusted mean total medical costs were NT$31710, NT$263643, NT$308531, and NT$208364 for single BCS, BCS+ALND, BCS+MST, and MST. The adjusted mean outpatient medical costs were NT$ 5523, NT$236060, NT$182331, and NT$94473 for single BCS, BCS+ALND, BCS+MST, and MST. The adjusted mean inpatient medical costs were NT$ 25464, NT$59723, NT$129597, and NT$94476 for single BCS, BCS+ALND, BCS+MST, and MST. The adjusted mean length of stay were 2.9 days, 5.5 days, 13.0 days, and 7.9 days for single BCS, BCS+ALND, BCS+MST, and MST. Conclusions: The adjusted mean outpatient medical cost for surgical interventions, BCS+ALND was the most expensive option. The adjusted mean total medical cost and inpatient medical cost for surgical interventions, BCS+MST was the most expensive option.