多發性骨髓瘤病患醫療資源利用與臨床成效分析

The study of medical resource utilization and clinical outcome in Patient with multiple myeloma

葉淑婷(Shu-Ting Yeh)

指導教授 ： 李金德

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(2018年)

摘要

研究目的
多發性骨髓瘤（Multiple Myeloma，簡稱MM）是骨髓中漿細胞不正常增生的一種血液惡性疾病，疾病初期多半沒有症狀，但病情加重時病人常見貧血、感染、腎損傷或骨破壞。好發於70歲左右之老年人，難有效被治癒，病程反反覆覆，一旦罹病將會消耗大量的醫療資源及成本。
本研究為探討單一醫學中心其多發性骨髓瘤病患醫療資源利用及臨床成效分析，是目前國內唯一針對此疾病不同治療方式，病人在門診及住院費用花費的研究，並將費用分為自費及健保兩方面，並與人口學特性、臨床特性、就醫特性做進一步的影響因子分析，同時探討病人存活、復發及併發症。

擬定之研究目的如下：
1.探討多發性骨髓瘤病患之醫療資源利用。
2.探討多發性骨髓瘤病患之臨床成效分析。

研究方法
本研究為回溯性之研究設計(Retrospective study)，研究樣本取自單一醫學中心2010年1月1日至2017年12月31日，期間共8年被新診斷為多發性骨髓瘤病人，且治療超過1年以上者共140名。

研究結果
多發生骨髓瘤病人平均年齡為64.89 ± 11.60歲，男性80人（57.1%）女性60人（42.9%），男性高於女性，89.29%會接受治療，研究結果顯示不同治療型態與醫療資源利用有顯著差異。
醫療資源利用方面：死亡者的醫療總費用為新台幣1,329,592.189 ± 986,084.793元，存活者的醫療總費用為新台幣2,008,594.422 ± 1,159,969.183元；無復發者的醫療總費用為新台幣849,838.07± 731,333.781元，有復發者醫療總費用為新台幣1,625,399.00± 1,095,999.392元，顯示無復發與復發與醫療總費用有顯著差異而死亡最後一年的醫療費用佔總費用的75.4%，顯示病人臨終前一年的醫療花費為最高。
雖然造血幹細胞移植總費用為新台幣2,339,409.73±982,243.35元，但以存活天數計算，每存活一天的花費是新台幣2,368.707±1,308.801元，比不接受治療的病人新台幣5,138.287±8,430.909元及化學合併標靶治療新台幣5,031.924±11,674.644元，相較之下花費為最低。
臨床成效方面：病人接受治療及造血幹細胞移植之一年存活率為92.86%，但是不接受治療的人第1年為存活率只有40%。第5年造血幹細胞移植還有65.48%的存活，但不接受治療的人無存活者。

結論與建議
2015年台灣罹患多發性骨髓瘤的人數為604人，死亡人數為358人，2016年全球人口成長40.4%，人口老齡化增加52.9%。最近40年來，台灣人民平均壽命的延長加上診斷方法的進步，使得新病人數增加了4倍之多，因疾病初期無明顯症狀而延遲就診，一旦罹病將會耗費大量的醫療資源，希望此研究結果可以提供給為臨床醫療人員及衛生主管機關做為未來研究參考之依據。

關鍵字

多發性骨髓瘤 ； 醫療資源利用 ； 臨床成效分析

並列摘要

Objectives of Research
Multiple Myeloma (abbreviated as MM) is a hematologic malignancy characterized by abnormal growth of malignant plasma cells in the bone marrow. This disease may progress without obvious clinical manifestation. When the disease gets worse, patients would suffer from anemia, infection, kidney injury or bone destruction. MM mainly affects elderly patients; the median age of diagnosis is 70 years. Due to its remission and relapse clinical course, it would consume a lot of medical resources and costs after diagnosis.
The purpose of this study is to investigate medical resources utilization and to analyze clinical outcomes of MM patients in a single medical center. To our best knowledge, it is currently the only domestic research focusing on the different treatment methods, and the cost of outpatient and hospitalization expenses for this disease. The expense is divided into two aspects: self-paid and covered by health insurance. In addition, we also evaluate other factors including demographic, clinical and medical characteristics. The analysis of survival, recurrence and complications of treatment is also performed.
The objectives of the study are as follows:
1. Investigate the medical resources utilization of patients with MM.
2. Investigate the clinical outcome of patients with MM.
Research Methods
This study was a retrospective study. The data for this study was collected by reviewing medical record in a single medical center from January 1, 2010 to December 31, 2017. There was a total of 140 newly diagnosed MM patients with follow-up of at least 1 year after treatment for further analysis.
Research Results
The average age of newly diagnosed MM patients was 64.89 ± 11.60, with 80 males (57.1%) and 60 females (42.9%). Among these patients, 89.29% received MM treatment. We observed that there were significant differences between different kinds of treatment and medical resources utilization.
With respect to medical resources utilization: The total medical cost of the deceased was NTD$1,329,592.189 ± NTD$986,084.793. The total medical cost of the survivors was NTD$2,008,594.422 ± NTD$1,159,969.183. If we stratify the patients by disease status, the total medical cost of patients without recurrence was NTD$849,838.07 ± NTD$731,333.781, which was lower than the total medical cost of patients with recurrent MM (NTD$1,625,399 ± NTD$1,095,999.392). The medical costs in the last year before death accounted for 75.4% of the total cost, indicating that the medical costs of the patient in the year before his/her death were the highest.
Although the total cost of hematopoietic stem cell transplantation was NTD$2,339,409.73 ± NTD$982,243.35. The cost per day of survival is NTD$2,368.707 ± NTD$1,308.801, which was less than the patients without accepting treatment (NTD$5,138.287 ± NTD$8,430.909) and patients who received combination of chemotherapeutic agent and target therapy (NTD$5,031.924 ± NTD$11,674.644).
In terms of clinical outcome, the 1- year overall survival of patients who received treatment and hematopoietic stem cell transplantation was 92.86%. However, the 1-year overall survival for patient did not receive treatment was only 40%. After follow-up of five year, there were 65.48% of transplant patients survived. No survivor was observed in patients who didn’t receive treatment.
Conclusions and Recommendations
In 2015, there were 604 newly diagnosed MM patients in Taiwan, In addition, there were 358 patients dead due to MM. In 2016, the global population grew by 40.4%, accompanied with increase of aging population by 52.9%. With increased average life span and advance in diagnostic tool, the number of newly diagnosed MM patients had increased by 4 times in the past three decades. Because a proportion of patients have indolent clinical course, anti-MM treatment would be delayed. However, the consumption medical resources would increase significantly if the disease progresses. The finding of this study could provide useful information for future research.

並列關鍵字

multiple myeloma ； medical resources utilization ； clinical outcome analysis

參考文獻

劉介宇, 洪永泰, 莊義利, 陳怡如, 翁文舜, 劉季鑫, & 梁賡義. (2006). 台灣地區鄉鎮市區發展類型應用於大型健康調查抽樣設計之研究. 健康管理學刊, 4(1), 1-22.

參考文獻

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