臺灣博碩士論文加值系統

癌症病人治療之經濟評估早已具有其重要性，其中以健康相關生活品質為結果之研究亦逐漸被廣泛運用，成為近年國際間癌症治療新興的研究重點。而口腔癌在我國為發生率最高之頭頸部癌症，對個人健康以及社會、國家影響甚鉅，值得深入探討與研究。
本研究之目的在於瞭解影響原發性口腔部惡性腫瘤（口腔癌）病人治療後健康相關生活品質以及確診後醫療費用之因素，並探討治療後健康相關生活品質與確診後醫療費用之相關性。本研究以某癌症專科醫院2002年3月至5月初就診之96名病人為對象，回溯式收集其人口學特質、臨床特性及醫療費用申報檔資料；橫斷式以EORTC QLQ-C30及EORTC QLQ-H&N35中文標準化問卷調查其健康相關生活品質。本研究重要結果如下：
一、 96名病人EORTC QLQ-C30及EORTC QLQ-H&N35問卷評分結果以口乾問題、唾液黏稠問題、牙齒問題及張大嘴巴問題為自訴最嚴重之問題，均為放射治療之長期副作用；複迴歸分析結果顯示，年齡為50歲以下者健康相關生活品質顯著較好。
二、 96名病人診斷、治療、追蹤期平均費用分別為24,901元、260,632元及77,219元，平均診療費用為285,533元，平均總醫療費用為362,751元；診斷、治療、追蹤期費用各佔總醫療費用之6.9%、71.8%及21.3%，以治療期費用所佔比率最高。複迴歸分析結果顯示，臨床期別為III、IV期、腫瘤原發部位為頰或齒齦、治療後曾復發、治療方式為手術＋放療或手術＋放療與同步化學治療者，治療期費用顯著較高，模式校正後解釋力達79.1%；腫瘤原發部位為臼後區者，追蹤期費用顯著較高，模式校正後解釋力達55.4%；而家戶月收入超過6萬元、臨床期別為III、IV期、腫瘤原發部位為頰或齒齦、治療後曾復發、治療方式為手術＋放療或手術＋放療與同步化學治療者，診療費用顯著較高，模式校正後解釋力達78.5%；而教育程度為初中以上、臨床期別為III、IV期、腫瘤原發部位為頰或臼後區、治療後曾復發、治療方式為手術＋放療或手術＋放療與同步化學治療者，總醫療費用顯著較高，模式校正後解釋力達79.8%。
三、 相關分析中，除診斷期費用外，各項費用與各功能評分項目有呈現負相關之趨勢，包括「身體功能」、「角色功能」、「認知功能」及「社交功能」等；而各項費用與各症狀評分項目有呈現正相關之趨勢，其中尤以「吞嚥問題」、「言語問題」、「社交接觸問題」、「社交性進食問題」、「張大嘴巴問題」、「口乾問題」及「唾液黏稠問題」最為明顯。
四、 整體而言，「腫瘤原發部位」、「癌症臨床期別」、「治療方式」及「病人治療後復發與否」為影響口腔癌病人治療後健康相關生活品質及確診後醫療費用之最重要因素；由此突顯「早期發現、早期診斷、早期治療」觀念，以及加強衛生教育與篩檢計畫之重要性。
本研究對衛生主管機關之建議為依重要臨床變項分別訂定口腔癌治療支付標準，並將「癌症期別」納入健保重大傷病檔案。對醫療服務提供者之建議則為適時更新病人資料電腦檔以及建立精確的成本制度。對後續研究者之建議為進行長期追蹤式或跨院際研究、測量病人健康效用值並合併病人存活情形與醫療費用進行分析及以社會觀點收集成本資料。

Economic analysis has been playing an important role in cancer treatment. The studies of Health-Related Quality of Life (HRQoL) of cancer therapy have widely been considered as an essential issue in the world. Oral cavity cancer sustains the most prevalent head and neck malignancy in Taiwan. Therefore, it deserves further investigations on its significant impact on personal health, as well as the wealth of the society and country.
The purposes of this study were to investigate the status of HRQoL and medical expenditures of patients with primary oral cavity cancer and the influencing factors, also to investigate the relationship between HRQoL and medical expenditures. Study sample were 96 patients with primary oral cancer undergoing treatment in one oncology center in Taipei from March to May, 2002. Data were collected by interviewing patient with a specially designed questionnaire which contains the Taiwan (Chinese) versions of EORTC QLQ-C30, EORTC QLQ-H&N35 modules and basic social demographic questions. Additional demographic characteristics, clinical information, and the insurance claims data of medical expenditures of these patients were also retrospectively reviewed.
The major results of this study are as follows:
1. According to the results from EORTC QLQ-C30 and EORTC QLQ-H&N35, “dry mouth”, “sticky saliva”, “teeth problem”, and “trismus” were the most serious problems in EORTC QLQ-C30 and EORTC QLQ-H&N35 scoring systems. All of these problems were related to the long-term side effects of radiotherapy. The results of multiple regression analysis showed that patients younger than 50 years old had significantly better HRQoL.
2. The average medical expenditures in the periods of diagnosis, treatment, and follow-up were NT$24,901, NT$260,632, NT$77,219, respectively. The average diagnosis/treatment medical expenditures and average total medical expenditures were NT$285,533, and NT$362,751, respectively. The proportions of expenditures in different periods comprised 6.9% in diagnosis, 71.8% in treatment, and 21.3% in follow-up periods. From the results of multiple regression analyses, patients at clinical stage III or IV disease, had primary buccal or gingival cancers, had recurrence after first treatment, or received combined treatment modalities including surgery/radiotherapy or surgery/radiotherapy/concomitant chemotherapy, were significantly associated with higher medical expenditures in treatment period, with the adjusted R square of 0.791. Primary retromolar trigone cancer was associated with higher follow-up expenditures, with the adjusted R square of 0.554. Patients with the monthly family income of more than NT$60,000, at clinical stage III or IV, had primary buccal or gingival cancers, had recurrence after first treatment, or received combined treatment modalities including surgery/radiotherapy or surgery/radiotherapy/concomitant chemotherapy, had significantly higher medical expenditures in diagnosis/treatment period, with the adjusted R square of 0.785. The statistically significant factors associated with higher total medical expenditures were patients that had educational level of higher than junior high school, at clinical stage III or IV disease, had primary buccal or retromolar trigone cancers, had recurrence after first treatment, or received combined treatment modalities including surgery/radiotherapy or surgery/radiotherapy/concomitant chemotherapy, with the adjusted R square of 0.798.
3. From the results of the analysis of correlation between medical expenditures and HRQoL, except to the expenditures of diagnosis period, all other expenditures sustained negative correlation with the scores of functional scales, which included “physical functioning”, “role functioning”, “cognitive functioning”, and“ social functioning”. In contrast, positive correlations were shown between the medical expenditures in different periods and the scores of symptom scales/items, especially for “swallowing”, “speech”, “social contact”, “social eating”, ”trismus”, “dry mouth” and “sticky saliva”.
4. In general, primary site of cancer, clinical stage, treatment modality, and disease recurrence, were the most important factors that affect medical expenditures and HRQoL for patients with primary oral cavity cancer undergoing treatment. The findings also implied the essential concept of “early diagnosis and early treatment”, so does the importance of health education and screening program.
Based on the results of this study we suggest that the Department of Health to include the important clinical variables when designing the reimbursement system for oral cavity cancer, and to include cancer stage into the files of health insurance. We also suggest that the health care provider to set up the accurate cost basis by regularly updating the patient data. Finally, for future investigators, we suggest that they could proceed with long-term multi-institutional economic studies, and to combine measurements of utility, survival outcome, and medical expenditures, and the data collection from the societal point of view.

致謝 ………………………………………………………………………………….I
中文摘要 III
Abstract V
目錄 ……………………………………………………………………………...VIII
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第三節 研究重要性 3
第二章 文獻探討 4
第一節 口腔癌流行病學、治療方式與預後 4
第二節 健康相關生活品質之概念與測量方法 7
第三節 疾病成本之概念 12
第四節 癌症治療經濟評估及健康相關生活品質實證研究 14
第五節 綜合討論 19
第三章 研究設計與方法 22
第一節 研究設計 22
第二節 研究假說 24
第三節 研究變項 25
第四節 研究工具與材料 32
第五節 資料處理與分析方法 35
第四章 研究結果 39
第一節 描述性統計分析結果 39
第二節 推論性統計分析結果 45
第五章 討論 75
第一節 研究資料品質 75
第二節 重要結果討論 78
第三節 研究限制 90
第六章 結論與建議 91
第一節 結論 91
第二節 建議 93
參考文獻 95
附錄一 口腔部惡性腫瘤國際疾病分類代碼一覽表 100
附錄二 EORTC QLQ-C30計分公式 102
附錄三 EORTC QLQ-H&N35計分公式 103
附錄四 本研究面訪結構式問卷 104
附錄五 EORTC問卷使用同意書 111
附錄六 專家效度專家名單 112
附錄七 各迴歸模式殘差分佈直方圖及常態P-P圖 113

【中文部分】
中央健康保險局新聞稿：健保給付論質計酬，民生報15版，2001年8月30日。
中央健康保險局網站：九十年重大傷病門診住院費用統計表及八十六至八十九年重大傷病申請費用統計，http://www.nhi.gov.tw/07information/news/data/90/news 0912-1.xls，2002年6月16日。
王榮德、游正芬、鍾智文、姚開屏：廿一世紀之健康照護效性評量-生活品質與生活品質調整後之存活分析。台灣醫學 2000；4（1）：65-74。
行政院衛生署新聞稿：乳癌、口腔癌常在55歲奪命，民生報11版，2002年6月12日。
行政院衛生署新聞稿：頭號殺手癌症，平均15分鐘奪1命，民生報11版，2002年6月11日。
行政院衛生署網站：台灣地區主要癌症死因，http://www.doh.gov.tw/statistic/data/公佈欄資料檔/90死因/台灣癌症90.xls，2002年6月13日。
吳季倫、楊銘欽：肝癌病人罹病成本與其相關因子之探討-以某醫學中心病人為例。中華衛誌 1998；17（2）：148-57。
和信治癌中心醫院：對抗癌症系列（五）征服頭頸癌，台北，天下生活，2001年。
林淑文：另類療法在癌症治療病患之研究及對生活品質之影響-以台大醫院頭頸部及中樞神應系統癌症為例。國立台灣大學醫學院藥學研究所碩士論文，1998年。
林榮第、姚開屏、游芝亭、王榮德：健康相關生活品質之效用測量方法信度與效度的評估：以血液透析之末期腎病病人為例。中華衛誌 1997；16（5）：404-16。
姚開屏：簡介與評論常用的一般性健康相關生活品質量表兼談對未來研究的建議。中國測驗學會測驗年刊 2000；47（2）：111-38。
徐茂銘：頭頸部癌症之認識 初版，三源，1981年。
張彧、謝清麟、王榮德：生活品質之效用測量，http://ha.mc.ntu.edu.tw/~cfyu/pdf/ book/chap08.doc，2002年1月23日。
黃世傑：癌 台二版，台北，正中，1977年。
黃景祥、王榮德：生活品質調整後存活之估計，http://home.mc.ntu.edu.tw/~cfyu/pdf/book/FJM10.doc，2002年7月4日。
韓良俊：檳榔的健康危害，台北，健康文化，2000年。
譚延輝：藥事經濟學入門，台北，九州，2000年6月。
【英文部分】
Aday LA. Designing and Conducting Health Surveys: a Comprehensive Guide New San Francisco California & Oxford London, Jossey-Bass Inc 1989:23 1-51.
Bjordal K, Hammerlid MA-E, de Graeff A, Boysen M, Evensen JF, et al. Quality of Life in Head and Neck Cancer Patients: Validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-H&N35. J of Clinical Oncology 1999; 17(3):1008-19.
Bjordal K, de Graeff A, Hammerlid FE, Pottelsberghe C, Curran D, Maher EJ, et al. A 12 Country Field Study of the EORTC QLQ-C30(version 3.0)and the Head and Neck Cancer Specific Module(EORTC QLQ-H&N35) in Head and Neck Patients. European J of Cancer 2000; 36:1798-807.
Bjordal K, Elmqvist MA, Hammerlid E, et al. A Prospective Study of Quality of Life in Head and Neck Cancer Patients. Part II: Longitudinal Data. The Laryngoscope 2001; 111:1440-52.
Blanchard CG, Albrfecht T, Ruckdeschel J, Grant CH, Malcolm HR. The Role of Social Support on Adaptation to Cancer and Survival. J Psychosocial Oncol 1995; 13:75-95.
Bloom AS, Knorr RS, Evans AE. The Epidemiology of Disease Expense: the Costs of Caring Children With Cancer. JAMA 1985; 253(16):2393-7.
Bonneterre J, Schraub S, Lecomte S, Mercier M. Quality of Life as an Outcome in Breast Cancer. Pharmacoeconomics 1996; 9 Suppl 2:23-9.
Brown GC, Sharma S, Brown MM, Garrett S. Evidence-Based Medicine and Cost-Effectiveness. J of Health Care Finance 1999; Winter:14-23.
Brown J, Sculpher M. Benefit Valuation in Economic Evaluation of Cancer Therapies. A Systematic Review of the Published Literature. Pharmacoeconomics 1999; 16(1):17-31.
Brown ML. The National Economic Burden of Cancer: an Update. JNCI 1990; 82(23):1811-4.
Chie WC, Hong RL, Lai CC, Ting LL, Hsu MM, Quality of Life in Patients of Nasopharyngeal Carcinoma: Translation and Validation of the Taiwan Chinese Version of EORTC QLQ-C30 and EORTC QLQ-H&N35. Quality of Life Research 2002; in press.
Chie WC, Huang CS, Chen JH, Chang KJ. Measurement of the Quality of Life During Different Clinical Phase of Breast Cancer. J Formos Med Assoc 1999; 98(4):254-60.
Chie WC, Huang CS, Chen JH, Chang KJ. Utility Assessment for Different Clinical Phase of Breast Cancer in Taiwan. J Formos Med Assoc 2000;99(9):677-83.
Cragle SP, Brandenburg JH. Laser Cordectomy or Radioltherapy: Cure Rates, Communication, and Cost. Otolaryngology-Head and Neck Surg 1993; 108(6): 648-54.
de Graeff A, de Leeuw JR, Ros WJ, Hordijk GJ, Blijham GH, Winnubst JA. Long-Term Quality of Life of Patients With Head and Neck Cancer. Laryngoscope 2000; 110:98-106.
de Graeff A, de Leeuw JR, Ros WJ, Hordijk GJ, Blijham GH, Winnubst JA. Sociodemographic Factors and Quality of Life as Prognostic Indicators in Head and Neck Cancer. Eur J Cancer 2001; 37:332-9.
Drummond Ma, O’Brien BJ, Stoddart GL, Torrance GW. Cost-Utility Analysis. In: Drummond MF, O’Brien BJ, Stoddart GL, Torrance GW. Methods for The Economic Evaluation of Health Care Programmes Second Edition. Oxford :Oxford University Press 1987:139-204.
Drummond Mb, Stoddart G, Labelle R, Cushman R. Health Economics: An Introduction for Clinicians. Annals of Internal Medicine 1987; 107:88-92.
EORTC：EORTC—Review of Translations, http://www.eortc.be/home/qol/ Translations% 20%20 Validated%20Modules.doc, June 17, 2002.
Fayer P, Aaronson N, Bjordal K, Sullivan M. EORTC QLQ-C30 Scoring Manual. EORTC Quality of Life Study Group 1999.
Fleming ID, Cooper JS, Henson DE, et al. AJCC Cancer Staging Handbook 5th ed. American Joint Committee on Cancer 1997.
Foote RL, Buskirk SJ, Grado GL, Bonner JAl. Has Radiotherapy Become too Expensive to be Considered a Treatment Option for Early Glottic Cancer? Head & Neck 1997; 19(8):692-700.
Funk GF, Hoffman HT, Karnell LH, Karnell LH, Ricks JM, Zimmerman MB, et al. Cost-Identification Analysis in Oral Cavity Cancer Management. Otolaryngology-Head & Neck Surgery 1998; 18(2):211-20.
Goddard M, Drummond M. The Economic Evaluation of Cancer Treatments and Programmes. Eur J Cancer 1991; 27(10):1191-6.
Groenvold M, Klee MC, Spranger MAC, Aaronson NK, Validation of the EORTC QLQ-C30 Quality of Life Questionnaire Through Combined Qualitative and Quantitative Assessment of Patient-Observer Agreement. Clin Epidemol 1997; 50(4):441-50.
Guyatt GH, Naylor CD, Juniper E, Heyland DK, Jaeschke R, Cook DJ. Users’ Guides to the Medical Literature XII. How to Use Articles About Health-Related Quality of Life. JAMA 1997; 227(15):1232-7.
Hammerlida E, Silander RD, Hornestam RN, Sullivan M, Health-Related Quality of Life Three Years After Diagnosis of Head and Neck Cancer-A Longitudinal Study. Head & Neck 2001; 23:113-25.
Hammerlidb E, Bjordal K, Elmqvist MA, et al. A Prospective Study of Quality in Head and Neck Cancer Patients. Part I: at Diagnosis. The Laryngoscope 2001; 111:669-80..
Hayman J, Weeks J, Mauch P. Economic Analysis in Health Care: an Introduction to the Methodology With an Emphasis on Radiation Therapy. Int. J. Radiation Biol. Phys 1996; 35(4):827-41.
Hodder SC, Edward MJ, Brickley MR, Shepherd JP. Multiattribute Utility Assessment of Outcomes of Treatment for Head and Neck Cancer. British J Cancer 1997; 75(6):898-902.
Joung IMA Glerum JJ, van Poppel FWA, Kardaun JWPF, Mackenbach JP. The Contribution of Specific Causes of Death to Mortality Differences by Marital Status in the Netherlands. Eur J Public Health 1996; 6:142-9.
Joung IMA, van de Mheen H, Stronks K, van Poppel FWA. Mackenbach. Differences in Self-Reported Morbidity by Marital Status and by Living Arrangement. Int J Epidemiol 1994; 23:91-7.
Kaplan RM. Quality of Life Assessment for Cost/Utility Studies in Cancer. Cancer Treatment Reviews 1993;19 Suppl A:85-96.
Lamb HM, Wiseman LR. A Pharmacoeconomics Review of Its Use in the Treatment of Metastatic Breast Cancer. Pharmacoeconomics 1998; 14(2):447-59.
Marcy AL, Stracks J, Colangelo L, et al. How Do Head and Neck Patients Prioritize Treatment Outcomes Before Initiating Treatment. J Clinical Oncol 2000; 18(4):
877-84.
Mcdowell I & Newell C. General Health Status and Quality of Life, In: Mcdowell I & Newell C, Measuring Health-a Guide to Rating Scales and Questionnaire 1996:381-92.
McNeil BJ, Weichselbaum R, Pauker SG. Trade-Offs Between Quality of Life and Quantity of Life in Laryngeal Cancer. New England J of Medicine 1981; 305(17):982-7.
Mittal B, Rao DV, Marks JE, Ogura JH. Comparative Cost Analysis of Hemilaryngectomy and Irradiation for Early Glottic Carcinoma. Int J Radiation Oncology Biol Phys 1983; 9:407-8.
Neymark N, Kiebert W, Torfs K, Davies L, Fayers P, Hillner B, Gelber R, et al. Methodological and Statistical Issues of Quality of Life and Economic Evaluation in Cancer Trials: Report of a Workshop. Eur J Cancer 1998; 34(9):1317-33.
Oleson M. Subjectively Perceived Quality of Life. Image 1990; 22:187-90.
Rice DP. Estimating the Cost of Illness. Am J Public Health 1967; 57:424-40.
Rice DP, Hodgson TA, Kopstein AN. The Economic Costs of Illness: a Replication and Update. Health Care Financing Review 1985; 7:61-80.
Rice DP. Cost of Illness Studies: Fact or Fiction? The Lancet 1994; 344(8936):1519-20.
Schueren EVD, Kesteloot K, Cleemput I. Federation of European Cancer Societies. Full Report. Economic Valuation in Cancer Care: Questions and Answers on How to Alleviate Conflicts Between Rising Needs and Expectations and Tightening Budgets. Eur J Cancer 2000; 36:13-36.
Sherman AC, Simonton S, Adams DC, Vural E, Owens B, Hanna E. Assessing Quality of Life in Patients With Head and Neck Cancer. Arch Otolaryngol Head Neck Surg 2000; 126:459-67.
Sherman EJ, Ruchlin HS, Holden JS, Pfister DG. Clinical Economics of Head and Neck Malignancies. Head and Neck Cancer 1999; 13(4): 867-81.
Spiegehalter DJ, Gore SM, Fitzpatrick R, Fletcher AE, Jones DR, Cox DR. Quality of Life in Health Care III: Resource Allocation 1992; 305:1205-9.
Terrell JE. Quality of Life Assessment in Head and Neck Cancer Patients. Head and Neck Cancer 1999; 13(4):849-65.
Torrance GW. Measurement of Health State Utilities for Economic Appraisal. J of Health Economics 1986; 5:1-30.
Velikova G, Stark D, Selby P. Quality of Life Instrument in Oncology. Eur J Cancer 1999; 35(11):1571-80.
Walker Q, Salkeld G, Hall J, O’rourke I, Bull CA, Tiver KW, Langlands AO. The Management of Oesophageal Carcinoma: Radiotherapy or Surgery? Cost Considerations. Eur J cancer Oncol 1989; 25(11):1657-62.
Weymuller EA, Yueh B, Deleyiannis F, Frederic D, Alice K, Ramsey A, et al. Quality of Life Patients With Head and Neck Cancer: Lessons Learned From 549 Prospectively Evaluated Patients. Arch Otolaryngology Head and Neck Surg 2000; 126(3): 329-35.
Wilson IB, Cleary PD. Linking Clinical Variables With Health-Related Quality of Life-a Conceptual Model of Patient Outcomes. JAMA 1995; 273(1): 59-65.