以決策樹模型比較不同乳癌治療模式之成本效用

Decision-tree modeling of different breast cancer treatments：A Cost-Utilities analysis

廖郁純(Yu-Cun Liao)

指導教授 ： 許弘毅

高雄醫學大學/健康科學院/醫務管理學研究所/碩士(2008年)

https://doi.org/10.6832/KMU.2008.00184

摘要

乳癌為目前最被重視的婦癌之一，女性乳癌所花費的醫療費用正逐年增加，乳癌的不同治療法各有其優缺點，在有限的資源下，何種治療模式對於病患來說較具成本效益，實值得深入思考。
本研究主要目的為分析改良式根治性乳房切除術（Modified Radical Mastectomy，MRM）、乳房保留手術（Breast Conservation Surgery，BCS）之成本效益，是否與全國乳癌病患及國外研究結果有所差異；研究樣本為從2007年6月至2007年11月，在南部兩家醫學中心接受MRM與BCS手術之初次罹患乳癌病患，分析不同治療模式、病患人口特質、病患臨床特質、病患健康行為與術後是否接受輔助治療等變項，是否影響醫療費用分布與代表病患術後自覺健康狀態的SF-36分數，並計算兩種治療模式之成本效用比值，另用民國90年國民健康訪問調查中之乳癌病患，串連全民健康保險資料庫，為與樣本醫院進行比較之全國資料。
本研究重要結果如下列：
1.與全國資料相比，南部醫學中心BCS治療實行率與乳癌病患5年存活率，在這幾年間有大幅提高。
2.BCS手術住院費用較低，但術後必須輔以放射線治療，因此整體醫療費用高於MRM，但主要影響因素在於病患有無接受術後輔助化學治療。
3.病患人口或臨床特質不對醫療費用造成影響，僅對數迴歸模式顯示年齡較大的乳癌病患傾向選擇MRM手術。
4.BCS與MRM病患之ICUR在術後第1年差距最大，經5年效用計算，兩組效用差距拉大，成本效用比值降低，證實長期下，BCS治療與MRM相比可讓病患有較好的術後健康狀態。
5.台灣對乳癌治療之給付遠低於美國，台灣BCS治療與MRM相較，要增加乳癌病患一生活品質調整人年（QALY）所花費之費用為US＄3,814，較美國與挪威便宜許多。

關鍵字

乳癌 ； 改良式根治性乳房切除術 ； 乳房保留手術 ； 國民健康訪問調查 ； SF-36 ； 決策樹 ； 成本效益分析

並列摘要

Today, breast cancer is one of the most fatal cancer of women, and the expenditures of women breast cancer increases year by year. Each treatment of breast cancer has its own benefits and shortcomings. According to limited resources, it is valuable to think deeply what kind of treatment is actually cost-effective to patients.

The main purpose of this study is to analyze the cost-effective between Modified Radical Mastectomy(MRM(and Breast Conservation Surgery(BCS), whether is different in comparision with the national data and other foreign studies to the breast cancer patient. The sample came from two medical centers in south Taiwan. Patients were diagnosed breast cancer in the beginning, and were followed MRM and BCS operation from June to November of 2007. Those patients’ medical expenditures and health state conscience(SF-36) are analyzed by different surgery, character, clinic situation, healthy behavior, and the adjuvant treatments after surgery. And analyze the incremental cost-utilities ratios(ICUR)of two kinds of treatments. Then the study uses the data of breast cancer patients in the National Health Interview Survey in 2007 and is combined with National Health Insurance Research Database to compare with the sample hospitals.
The result of study is following:
Being compared with national data and the southern medical centers, the performing rate of BCS and breast cancer patient's 5 years survival rate is widely increased during these years. The hospitalized and surgical charges of BCS is lower than MRM, but the patients who accepted BCS should be treated by X-ray in outpatient apartment after surgery. The total charges of BCS is higher than MRM instead. But the major factor which influences the medical charges is patients’ acceptation of outpatient adjuvant chemotherapy after surgery. This study still founded that the character and the clinic situation of patients don’t affect the medical expenditures. Only in logistic regression model showed that the older patients would like to select MRM. The ICUR between BCS and MRM is the most expensive in the first year. During 5 years adjustment, the differences of utilities between two treatments were increased to make ICUR reducing. This result proves that BCS brings better health condition to patients after surgery compared with MRM. In Taiwan, the breast cancer therapy expenditures is far lower than in U.S.A.. If BCS would like to increase breast cancer patients one quality-adjusted life year, it should spend US＄3,814 compared to MRM. It is mush cheaper than U.S.A. and Norway.

並列關鍵字

Breast cancer ； Modified Radical Mastectomy ； Breast Conservation Surgery ； National Health Interview Survey ； SF-36 ； Decision Tree ； Cost-Utilities analysis

參考文獻

英文部分

American Joint Committee on Cancer [AJCC]. (2008). AJCC Cancer Staging Manual Sixth Edition-Breast Staging Schema. from http://www.cancerstaging.org/staging/index.html

Barlow WE., Taplin SH., Yoshida CK., Buist DS., Seger D., Brown M. (2001). Cost Comparison of Mastectomy Versus Breast-Conserving Therapy for Early-Stage Breast Cancer. Journal of the National Cancer Institute, 93(6), 447-455.

Brazier J., Roberts J., Deverill M. (2002). The estimation of a preference-based measure of health from the SF-36. Journal of Health Economics, 21(2), 271-292.

Brazier J., Usherwood T., Harper R., Thomas K. (1998). Deriving a Preference-Based Single Index from the UK SF-36 Health Survey. J Clin Epidemiol, 15(11), 1115-1128.