Title

「全民健康保險B型肝炎帶原者及C型肝炎感染者醫療給付改善方案」之成效評估

Translated Titles

The Impacts of the Pay-for-Performance Program for Chronic Hepatitis B and C Patients Under National Health Insurance in Taiwan

Authors

朱育增

Key Words

肝炎 ; 論質計酬 ; hepatitis ; pay-for-performance

PublicationName

國立臺灣大學健康政策與管理研究所學位論文

Volume or Term/Year and Month of Publication

2014年

Academic Degree Category

博士

Advisor

賴美淑

Content Language

英文

Chinese Abstract

研究背景與目的: 為提升醫療照護品質,愈來愈多國家健康照護系統採用論質計酬方案,然過去研究顯示論質計酬方案會有挑選病人的問題,對能否提升品質亦尚無定論,尤其缺乏論質計酬方案成本效益之實證研究。慢性病毒性肝炎一直是全世界及台灣重要的公共衛生問題。中央健保署於2010年推行「全民健康保險B型肝炎帶原者及C型肝炎感染者醫療給付改善方案」,增加醫療過程面指標給付的方式,鼓勵醫療提供者提升照護品質,藉由定期超音波篩檢與肝功能檢測,早期發現肝癌。目前針對此計畫進行之評估有限,因此本研究主要目的是探討影響病人加入方案的因素,論質計酬方案對過程面品質指標之影響,與進行論質計酬方案之經濟評估。 研究方法: 本研究使用2002~2011年健保申報檔。第一部分以廣義估計方程式,針對於有加入論質計酬方案院所就醫之40,978人加入方案與73,489人未加入方案者,分析影響病人加入方案之病人層次與醫療院所層次因素。第二部分則以準實驗研究設計,先分析全部符合論質計酬方案之病人,定義2010年加入試辦計畫之慢性肝炎病人39,894人為研究組,用傾向分數1:1配對出從未加入計畫之對照組,利用差異中之差異法及廣義估計方程式比較加入方案前後之慢性肝炎超音波與肝功能檢查過程指標之變化。再進一步分析於有加入論質計酬方案院所就醫之有參與方案與未參與方案之病人。第三部分則利用馬可夫模式,以健康醫療保險給付者觀點,評估慢性肝炎論質計酬方案之成本效性。 研究結果: 2010年符合慢性肝炎醫療給付改善方案者有257,654人。第一部分結果顯示共病分數愈高與併發腹水、食道靜脈曲張者,較不易被納入論質計酬方案。區域醫院、地區醫院及診所較醫學中心不易納入非酒精性肝硬化病人。第二部分結果之研究組超音波檢查完成率,顯著高於對照組。再進一步分析有加入論質計酬之院所病人,醫學中心未加入方案病人之超音波及肝功能檢查指標完成率亦顯著增加。診所在過程品質指標顯著增加超音波之完成率,肝功能檢測則未顯著改變。第三部分成本效性敏感度分析結果顯示,納入方案之肝硬化病人比例從0~100%,慢性B肝論質計酬方案之遞增成本效果比從NTD3,953,544元至NTD1,172,225元。慢性C肝之遞增成本效果比則從NTD2,904,536元至NTD 831,852元。 結論: 本研究發現B型肝炎帶原者及C型肝炎感染者醫療給付改善方案,仍有選擇疾病嚴重度較輕的病人加入方案的情形,區域醫院、地區醫院及診所較醫學中心不易納入非酒精性肝硬化病人,且診所僅顯著增加超音波之完成率,肝功能檢情形則未顯著改變。是否納入肝硬化之高危險群病人是次級預防介入是否具有成本效果的決定因素。建議政府應針對高危險群病人推動肝炎論質計酬方案。

English Abstract

Background: P4P is a payment scheme designed to enhance performance. It has become popular and implemented in more and more countries. However, the effects of the P4P are still controversial and worth exploring, and there is also a lack of economic analysis of the P4P program. Taiwan is a hyperendemic area of liver diseases, especially in chronic viral hepatitis B- (CHB) or C- (CHC) related hepatocellular carcinoma. Since year 2010, the Bureau of National Health Insurance initiated the pay-for-performance program for CHB and CHC patients. This program emphasize on the secondary prevention of HCC by the regular follow up with ultrasonography. Taiwan is the only country that using P4P to improve the secondary prevention of HCC around the world. However, there is limited research of the P4P program for chronic hepatitis B or C patients in Taiwan. Thus, the purpose of this retrospective using national datasets is (1). To assess the factors associated with patient enrollment and evaluate whether there is the problem of adverse selection; (2). To evaluate the effects of the pay-for-performance program; (3). To provide economic analysis of the pay-for-performance program. Methods: This is a retrospective cohort study. The data used in this analysis come from the national datasets. In part one, generalized linear model (GEE) was used to test whether patient inclusion in the pay-for-performance is associated to patient and provider institution characteristics. In part two, in order to control selection bias, and create participant and non- participant cohorts of similar clinical characteristics, propensity score were used to match participants with non-participants (1:1 match). Process quality indicators, completeness of ultrasonography or blood tests, were examined between participant and non- participant cohorts using difference in difference method and GEE models. In part three, evaluate the cost-effectiveness of the pay-for-performance program from the third party payer perspective. Computerized economic modeling techniques of Markov analytic models were established. Results: In 2010, 257,654 patients met the criterion of the P4P program, 40,978 P4P patients (P4P) and 73,489 patients not participate in the P4P program (non-P4P) from the hospitals that joined the P4P program. The results showed that patients with higher comorbidity index, ascites, and esophageal varices were less likely to be included in the P4P program. Regional hospitals, district hospitals and clinics were less likely to include patients with non-alcoholic liver cirrhosis than medical centers. For the completeness of ultrasonography, patients enrolled in the P4P program had better process quality than nonenrollees after controlling for confounding factors. After selecting patients from the hospitals that joined the P4P program, patients not enrolled in the P4P program improved more than nonenrollees in medical centers. Clinics significantly improved the completeness of ultrasonography; however, the completeness of blood tests was not significantly improved. One-way sensitivity analysis showed that if the percent of cirrhosis patients followed in the P4P program from 0~100%, the incremental cost-effectiveness ratio (ICER) would from NTD 3,953,544 to NTD 1,172,225 for CHB patients. For CHC patients, the ICER would from NTD2,904,536 to NTD 831,852. Conclusion: This study found the adverse selection during P4P program for CHB and CHC patient selection process. Regional hospitals, district hospitals and clinics were less likely to include patients with non-alcoholic liver cirrhosis than medical centers. Clinics significantly improved the completeness of ultrasonography; however, the completeness of blood tests was not significantly improved. The important factor of the cost-effectiveness analysis is the percent of cirrhosis patients followed in the P4P program. This P4P program should encourage or emphasize on the enrollment of high risk groups fist for the intention to early HCC detection.

Topic Category 醫藥衛生 > 預防保健與衛生學
公共衛生學院 > 健康政策與管理研究所
社會科學 > 政治學
Reference
  1. Alter, M. J., Kruszon-Moran, D., Nainan, O. V., McQuillan, G. M., Gao, F., Moyer, L. A., . . . Margolis, H. S. (1999). The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. New England Journal of Medicine, 341(8), 556-562.
    連結:
  2. An, L. C., Bluhm, J. H., Foldes, S. S., Alesci, N. L., Klatt, C. M., Center, B. A., . . . Manley, M. W. (2008). A randomized trial of a pay-for-performance program targeting clinician referral to a state tobacco quitline. Archives of Internal Medicine, 168(18), 1993.
    連結:
  3. Ando, E., Kuromatsu, R., Tanaka, M., Takada, A., Fukushima, N., Sumie, S., . . . Torimura, T. (2006). Surveillance program for early detection of hepatocellular carcinoma in Japan: results of specialized department of liver disease. Journal of clinical gastroenterology, 40(10), 942-948.
    連結:
  4. Arguedas, M. R., Chen, V. K., Eloubeidi, M. A., & Fallon, M. B. (2003). Screening for hepatocellular carcinoma in patients with hepatitis C cirrhosis: a cost-utility analysis. The American journal of gastroenterology, 98(3), 679-690.
    連結:
  5. Armstrong, G. L., Wasley, A., Simard, E. P., McQuillan, G. M., Kuhnert, W. L., & Alter, M. J. (2006). The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Annals of internal medicine, 144(10), 705.
    連結:
  6. Beasley, R. P. (1988). Hepatitis B virus. The major etiology of hepatocellular carcinoma. Cancer, 61(10), 1942-1956.
    連結:
  7. Bolondi, L., Sofia, S., Siringo, S., Gaiani, S., Casali, A., Zironi, G., . . . Sherman, M. (2001). Surveillance programme of cirrhotic patients for early diagnosis and treatment of hepatocellular carcinoma: a cost effectiveness analysis. Gut, 48(2), 251-259.
    連結:
  8. Bruix, J., & Sherman, M. (2005). Management of hepatocellular carcinoma. Hepatology, 42(5), 1208-1236.
    連結:
  9. Bruix, J., & Sherman, M. (2011). Management of hepatocellular carcinoma: an update. Hepatology, 53(3), 1020-1022.
    連結:
  10. Bruix, J., Sherman, M., Llovet, J. M., Beaugrand, M., Lencioni, R., Burroughs, A. K., . . . Rodes, J. (2001). Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. Journal of hepatology, 35(3), 421-430.
    連結:
  11. Chan, C., Lee, S. D., & Lo, K. J. (2004). Legend of hepatitis B vaccination: the Taiwan experience. Journal of gastroenterology and hepatology, 19(2), 121-126.
    連結:
  12. Chang, M. H., Chen, C. J., Lai, M. S., Hsu, H. M., Wu, T. C., Kong, M. S., . . . Chen, D. S. (1997). Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. New England Journal of Medicine, 336(26), 1855-1859.
    連結:
  13. Chang, R. E., Lin, S. P., & Aron, D. C. (2012). A Pay-For-Performance Program In Taiwan Improved Care For Some Diabetes Patients, But Doctors May Have Excluded Sicker Ones. Health Affairs, 31(1), 93-102.
    連結:
  14. Chen, Chen, C. J., Yen, M. F., Lu, S. N., Sun, C. A., Huang, G. T., . . . Duffy, S. W. (2002). Ultrasound screening and risk factors for death from hepatocellular carcinoma in a high risk group in Taiwan. International journal of cancer, 98(2), 257-261.
    連結:
  15. Chen, C. H., Yang, P. M., Huang, G. T., Lee, H. S., Sung, J. L., & Sheu, J. C. (2007). Estimation of seroprevalence of hepatitis B virus and hepatitis C virus in Taiwan from a large-scale survey of free hepatitis screening participants. Journal of the Formosan Medical Association, 106(2), 148-155.
    連結:
  16. Chen, C. J., Wang, L. Y., & Yu, M. W. (2002). Epidemiology of hepatitis B virus infection in the Asia–Pacific region. Journal of gastroenterology and hepatology, 15(s2), E3-E6.
    連結:
  17. Chen, D. S. (2007). Hepatocellular carcinoma in Taiwan. Hepatology Research, 37, S101-S105.
    連結:
  18. Chen, T. H. H., Chen, C. J., Yen, M. F., Lu, S. N., Sun, C. A., Huang, G. T., . . . Duffy, S. W. (2002). Ultrasound screening and risk factors for death from hepatocellular carcinoma in a high risk group in Taiwan. International journal of cancer, 98(2), 257-261.
    連結:
  19. Chen, T. T., Chung, K. P., Lin, I. C., & Lai, M. S. (2011). The unintended consequence of Diabetes Mellitus pay-for-performance program in Taiwan: are patients with more comorbidities or more severe conditions likely to be excluded from the P4P program.
    連結:
  20. Cheng, S. H., Lee, T. T., & Chen, C. C. (2012). A longitudinal examination of a pay-for-performance program for diabetes care: evidence from a natural experiment. Medical Care, 50(2), 109.
    連結:
  21. Chien, Y. C., Jan, C. F., Kuo, H. S., & Chen, C. J. (2006). Nationwide hepatitis B vaccination program in Taiwan: effectiveness in the 20 years after it was launched. Epidemiologic reviews, 28(1), 126-135.
    連結:
  22. Chong, C. A. K. Y., Gulamhussein, A., Heathcote, E. J., Lilly, L., Sherman, M., Naglie, G., & Krahn, M. (2003). Health-state utilities and quality of life in hepatitis C patients. The American journal of gastroenterology, 98(3), 630-638.
    連結:
  23. Collier, J., & Sherman, M. (1998). Screening for hepatocellular carcinoma. Hepatology, 27(1), 273-278.
    連結:
  24. Curtin, K., Beckman, H., Pankow, G., Milillo, Y., & Greene, R. (2006). Return on investment in pay for performance: a diabetes case study. Journal of Healthcare Management, 51(6), 365.
    連結:
  25. De Masi, S., Tosti, M. E., & Mele, A. (2005). Screening for hepatocellular carcinoma. Digestive and liver disease, 37(4), 260-268.
    連結:
  26. Dhanasekaran, R., Limaye, A., & Cabrera, R. (2012). Hepatocellular carcinoma: current trends in worldwide epidemiology, risk factors, diagnosis, and therapeutics. Hepatic Medicine: Evidence and Research, 4, 19-37.
    連結:
  27. Dienstag, J. L. (2008). Hepatitis B virus infection. New England Journal of Medicine, 359(14), 1486-1500.
    連結:
  28. Doran, T., Fullwood, C., Reeves, D., Gravelle, H., & Roland, M. (2008). Exclusion of patients from pay-for-performance targets by English physicians. New England Journal of Medicine, 359(3), 274-284.
    連結:
  29. Dowling, B., & Richardson, R. (1997). Evaluating performance-related pay for managers in the National Health Service. International Journal of Human Resource Management, 8(3), 348-366.
    連結:
  30. Eijkenaar, F. (2012). Pay for performance in health care: an international overview of initiatives. [Comparative Study
    連結:
  31. Review]. Med Care Res Rev, 69(3), 251-276. doi: 10.1177/1077558711432891
    連結:
  32. Gupta, S., Bent, S., & Kohlwes, J. (2003). Test characteristics of alpha-fetoprotein for detecting hepatocellular carcinoma in patients with hepatitis C. A systematic review and critical analysis. Annals of internal medicine, 139(1), 46.
    連結:
  33. Hsieh, C. R., & Kuo, C. W. (2004). Cost of chronic hepatitis B virus infection in Taiwan. [Research Support, Non-U.S. Gov't]. J Clin Gastroenterol, 38(10 Suppl 3), S148-152.
    連結:
  34. Hsu, H. M., Lu, C. F., Lee, S. C., Lin, S. R., & Chen, D. S. (1999). Seroepidemiologic survey for hepatitis B virus infection in Taiwan: the effect of hepatitis B mass immunization. Journal of Infectious Diseases, 179(2), 367-370.
    連結:
  35. Hung, H.-F., & Chen, T. H.-H. (2009). Probabilistic cost-effectiveness analysis of the long-term effect of universal hepatitis B vaccination: an experience from Taiwan with high hepatitis B virus infection and Hepatitis B e Antigen positive prevalence. Vaccine, 27(48), 6770-6776.
    連結:
  36. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century: National Academies Press.
    連結:
  37. Jan, C. F., Chen, C. J. E. N., & Chen, H. H. S. I. (2004). Causes of increased mortality from hepatocellular carcinoma in high incidence country: Taiwan experience. Journal of gastroenterology and hepatology, 20(4), 521-526.
    連結:
  38. Jorge A, M., & Hashem B, E. S. (2011). Alpha‐fetoprotein should be included in the hepatocellular carcinoma surveillance guidelines of the american association for the study of liver diseases. Hepatology, 53(3), 1060-1061.
    連結:
  39. Kanwal, F., Farid, M., Martin, P., Chen, G., Gralnek, I. M., Dulai, G. S., & Spiegel, B. M. (2006). Treatment alternatives for hepatitis B cirrhosis: a cost-effectiveness analysis. The American journal of gastroenterology, 101(9), 2076-2089.
    連結:
  40. Kanwal, F., Gralnek, I. M., Martin, P., Dulai, G. S., Farid, M., & Spiegel, B. M. (2005a). Treatment alternatives for chronic hepatitis B virus infection: a cost-effectiveness analysis. Annals of Internal Medicine, 142(10), 821-831.
    連結:
  41. Kanwal, F., Gralnek, I. M., Martin, P., Dulai, G. S., Farid, M., & Spiegel, B. M. (2005b). Treatment alternatives for chronic hepatitis B virus infection: a cost-effectiveness analysis. Ann Intern Med, 142(10), 821-831.
    連結:
  42. Kao, J. H. (2008). Diagnosis of hepatitis B virus infection through serological and virological markers.
    連結:
  43. Kuo, R. N. C., Chung, K. P., & Lai, M. S. (2011). Effect of the pay-for-performance program for breast cancer care in taiwan. Journal of Oncology Practice, 7(3S), e8s-e15s.
    連結:
  44. Kwon, H., & Lok, A. S. (2011). Does antiviral therapy prevent hepatocellular carcinoma? Antiviral therapy, 16(6), 787-795.
    連結:
  45. Lai, C. L., & Yuen, M. F. (2008). Chronic hepatitis B—new goals, new treatment. New England Journal of Medicine, 359(23), 2488-2491.
    連結:
  46. Lee, Han, M. A., Lee, H. Y., Jun, J. K., Choi, K. S., & Park, E. C. (2010). Liver cancer screening in Korea: a report on the 2008 National Cancer Screening Programme. Asian Pac J Cancer Prev, 11, 1305-1310.
    連結:
  47. Lee, C. M., Lu, S. N., Changchien, C. S., Yeh, C. T., Hsu, T. T., Tang, J. H., . . . Chen, W. J. (2000). Age, gender, and local geographic variations of viral etiology of hepatocellular carcinoma in a hyperendemic area for hepatitis B virus infection. Cancer, 86(7), 1143-1150.
    連結:
  48. Li, Y. H., Tsai, W. C., Khan, M., Yang, W. T., Lee, T. F., Wu, Y. C., & Kung, P. T. (2010). The effects of pay-for-performance on tuberculosis treatment in Taiwan. Health policy and planning, 25(4), 334-341.
    連結:
  49. Lin, O., Keeffe, E., Sanders, G., & Owens, D. (2004). Cost‐effectiveness of screening for hepatocellular carcinoma in patients with cirrhosis due to chronic hepatitis C. Alimentary pharmacology & therapeutics, 19(11), 1159-1172.
    連結:
  50. LIN, W. A., TARN, Y. H., & TANG, S. L. (2006). Cost–utility analysis of different peg‐interferon alpha‐2b plus ribavirin treatment strategies as initial therapy for naive Chinese patients with chronic hepatitis C. Alimentary pharmacology & therapeutics, 24(10), 1483-1493.
    連結:
  51. Liu, C. Y., Hung, Y. T., Chuang, Y. L., Chen, Y. J., Weng, W. S., Liu, J. S., Liang, K. Y. (2006). Incorporating development stratification of Taiwan townships into sampling design of large scale health interview survey. Journal of Health Management, 4, 1-22.
    連結:
  52. Lok, A. S. F. (2011). Does antiviral therapy for hepatitis B and C prevent hepatocellular carcinoma? Journal of gastroenterology and hepatology, 26(2), 221-227.
    連結:
  53. Lu, S. N., Su, W. W., Yang, S. S., Chang, T. T., Cheng, K. S., Wu, J. C., . . . Changchien, C. S. (2006). Secular trends and geographic variations of hepatitis B virus and hepatitis C virus‐associated hepatocellular carcinoma in Taiwan. International journal of cancer, 119(8), 1946-1952.
    連結:
  54. Mei-Hsuan, L., Yang, H. I., Lu, S. N., Jen, C. L., Yeh, S. H., Liu, C. J., . . . Chen, W. J. (2010). Hepatitis C virus seromarkers and subsequent risk of hepatocellular carcinoma: long-term predictors from a community-based cohort study. Journal of Clinical Oncology, 28(30), 4587-4593.
    連結:
  55. Ni, Y. H., & Chen, D. S. (2010). Hepatitis B vaccination in children: the Taiwan experience. Pathologie et biologie, 58(4), 296-300.
    連結:
  56. Parkin, D. M. (2006). The global health burden of infection‐associated cancers in the year 2002. International journal of cancer, 118(12), 3030-3044.
    連結:
  57. Petersen, L. A., Woodard, L. C. D., Urech, T., Daw, C., & Sookanan, S. (2006). Does pay-for-performance improve the quality of health care? Annals of internal medicine, 145(4), 265.
    連結:
  58. Pham, H. H., Schrag, D., O'Malley, A. S., Wu, B., & Bach, P. B. (2007). Care patterns in Medicare and their implications for pay for performance. New England Journal of Medicine, 356(11), 1130-1139.
    連結:
  59. Re III, V. L., & Kostman, J. (2005). Management of chronic hepatitis C. Postgraduate medical journal, 81(956), 376-382.
    連結:
  60. Robinson, J. C. (2001). Theory and practice in the design of physician payment incentives. Milbank Quarterly, 79(2), 149-177.
    連結:
  61. Shen, Y. (2003). Selection incentives in a performance-based contracting system. [Research Support, U.S. Gov't, P.H.S.]. Health Serv Res, 38(2), 535-552.
    連結:
  62. Shepard, C. W., Finelli, L., & Alter, M. J. (2005). Global epidemiology of hepatitis C virus infection. The Lancet infectious diseases, 5(9), 558-567.
    連結:
  63. Sherman, K. E., Sherman, S. N., Chenier, T., & Tsevat, J. (2004). Health values of patients with chronic hepatitis C infection. Archives of internal medicine, 164(21), 2377-2382.
    連結:
  64. Sherman, M. (2010). Serological surveillance for hepatocellular carcinoma: time to quit. Journal of hepatology, 52(4), 614-615.
    連結:
  65. Siebert, U., Sroczynski, G., Rossol, S., Wasem, J., Ravens-Sieberer, U., Kurth, B., . . . Wong, J. (2003). Cost effectiveness of peginterferon α-2b plus ribavirin versus interferon α-2b plus ribavirin for initial treatment of chronic hepatitis C. Gut, 52(3), 425-432.
    連結:
  66. Stevens, C. E., Beasley, R. P., Tsui, J., & Lee, W. C. (1975). Vertical transmission of hepatitis B antigen in Taiwan. New England Journal of Medicine, 292(15), 771-774.
    連結:
  67. Thein, H. H., Krahn, M., Kaldor, J. M., & Dore, G. J. (2005). Estimation of utilities for chronic hepatitis C from SF-36 scores. The American journal of gastroenterology, 100(3), 643-651.
    連結:
  68. Thomas, D. L., Astemborski, J., Rai, R. M., Anania, F. A., Schaeffer, M., Galai, N., . . . Johnson, L. (2000). The natural history of hepatitis C virus infection. JAMA: The Journal of the American Medical Association, 284(4), 450-456.
    連結:
  69. Tong, M. J., El-Farra, N. S., Reikes, A. R., & Co, R. L. (1995). Clinical outcomes after transfusion-associated hepatitis C. New England Journal of Medicine, 332(22), 1463-1466.
    連結:
  70. Town, R., Wholey, D. R., Kralewski, J., & Dowd, B. (2004). Assessing the influence of incentives on physicians and medical groups. Medical Care Research and Review, 61(3 suppl), 80S-118S.
    連結:
  71. Trevisani, F., De Notariis, S., Rapaccini, G., Farinati, F., Benvegnu, L., Zoli, M., . . . Bernardi, M. (2002). Semiannual and annual surveillance of cirrhotic patients for hepatocellular carcinoma: effects on cancer stage and patient survival (Italian experience). The American journal of gastroenterology, 97(3), 734-744.
    連結:
  72. Tsai, W. C., Kung, P. T., Khan, M., Campbell, C., Yang, W. T., Lee, T. F., & Li, Y. H. (2010). Effects of pay-for-performance system on tuberculosis default cases control and treatment in Taiwan. Journal of Infection, 61(3), 235-243.
    連結:
  73. Uto, H., Stuver, S. O., Hayashi, K., Kumagai, K., Sasaki, F., Kanmura, S., . . . Oketani, M. (2009). Increased rate of death related to presence of viremia among hepatitis C virus antibody–positive subjects in a community‐based cohort study. Hepatology, 50(2), 393-399.
    連結:
  74. Wong, J. B., Koff, R. S., Tine, F., & Pauker, S. G. (1995). Cost-effectiveness of interferon-alpha 2b treatment for hepatitis B e antigen-positive chronic hepatitis B. [Meta-Analysis]. Ann Intern Med, 122(9), 664-675.
    連結:
  75. Wong, V., & Chan, H. (2012). Prevention of hepatocellular carcinoma: a concise review of contemporary issues. Ann Hepatol, 11(3), 284-293.
    連結:
  76. Younossi, Z. M., Boparai, N., McCormick, M., Price, L. L., & Guyatt, G. (2001). Assessment of utilities and health-related quality of life in patients with chronic liver disease. The American journal of gastroenterology, 96(2), 579-583.
    連結:
  77. Zhang, B. H., Yang, B. H., & Tang, Z. Y. (2004). Randomized controlled trial of screening for hepatocellular carcinoma. Journal of cancer research and clinical oncology, 130(7), 417-422.
    連結:
  78. Beasley, R. P. (1982). Hepatitis B virus as the etiologic agent in hepatocellular carcinoma: epidemiologic considerations. Hepatology, 2(2), 1.
  79. Chen, C., Lu, S., You, S., Wu, M., Wang, L., Lee, L., . . . Lee, H. (1995). Community-based hepatocellular carcinoma screening in seven townships in Taiwan]. Journal of the Formosan Medical Association= Taiwan yi zhi, 94, S94.
  80. Ghany, M. G. (2011). Hepatitis B Epidemiology, Pathogenesis, Diagnosis, and Natural History
  81. Joseph, L., Emmett, K., & Louw-Potgieter, J. (2012). A formative evaluation of a pay-for-performance system. SA Journal of Human Resource Management, 10(3), 12 pages.
  82. Pwu, R. F. (2002). Cost-effectiveness Analysis in Pertussis Vaccination and Treatment of Chronic Viral Hepatitis in Taiwan. Doctoral, National Taiwan University, Taiwan.
  83. Pwu, R. F., & Chan, K. A. (2002). Cost-effectiveness analysis of interferon-alpha therapy in the treatment of chronic hepatitis B in Taiwan. J Formos Med Assoc, 101(9), 632-641.