臺灣博碩士論文加值系統

研究目的：本研究目的在了解單一醫療機構鼻咽癌醫療的診療費用成本，治療效果，與成本效益，並進一步探討影響診療費用與效果的因素，及不同療法間成果效果的差異。
研究材料與方法：本研究的研究對象來自於某癌症專科醫院，於1995年4月至1998年12月間，診斷為鼻咽癌，且於該醫院接受完整治療及追蹤，共計207位病人納入分析。費用資料來自於該院所的收據資料檔，由研究對象初診日期至2002年2月底止的所有資料。臨床資料則由病歷中登錄，並追蹤病人癌病控制情況至費用資料最後登錄日期。費用的計算以診斷期、治療期、追蹤期、診療期，及醫療總費用分別呈現，醫療效果以五年整體存活率與無病存活率表示，成本效果的計算方式為每拯救人年的醫療總費用，或每增加1百分點五年存活率的診療費用。診療費用的影響變項採用直線迴歸相關模型分析，治療效果的影響變項以存活率的Cox迴歸模型分析。
研究結果：所有研究對象的中位數追蹤時間為50.1個月，五年存活率與無病存活率分別為72.2%與75.1%。平均每人診斷費用為38,437.1元，治療費用為276,530.5元，追蹤費用為125,618.5元，診療費用為314,967.7元，醫療總費用為440,617.3元。使用放射治療的型式，使用化學治療的型式，治療急性副作用程度，鼻咽癌期別，及年齡，是影響診療費用及治療費用的具統計意義變項。鼻咽癌期別及來院前是否已確定診斷，是影響診斷費用的有意義變項。治療效果的迴歸分析中，鼻咽癌期別和放射治療後的輔助化學治療是有統計意義的影響變項，若以合併放射化學治療組合種類來看，則較個別放射治療或化學治療型式，有更高的相關性。每延長一人年的醫療費用，依序為第一期99,588.4元，第二期A 99329.8元，第二期B 161,773.0元，第三期 149,982.9元，第四期A 214,210.7元，第四期B 261,119.0元，第四期C 470,191.2元。第一至二期B早期鼻咽癌的不同治療組合間，以第一類治療組合較符合成本效果原則，第三至第四期B晚期鼻咽癌的不同治療組合間，則以第三類治療組合較具成本效果。
結論：鼻咽癌期別、治療型式與治療副作用程度是影響鼻咽癌診療費用的重要變項。鼻咽癌醫療成本效果符合臨床觀察中不同期別的預後差異。不同療法間對同一期別病人的醫療亦符合臨床觀點預期的成本效果。成本效果的評估方式可成為制定支付制度或評估臨床療法上重要的參考依據。

Purpose: This study is to calculate the charge-based cost, outcome, and cost-effectiveness (CE) of diagnosis and treatment for nasopharyngeal cancer (NPC), to investigate the factors impacting cost and outcome, and to demonstrate the difference in CE between treatment protocols at a single oncology center.
Materials and Methods: From April 1995 to December 1998, 207 patients who were diagnosed with NPC and completed full-course therapy and follow-up were enrolled. Charge-based cost data was retrieved from the receipt files from the first visit day to February 28, 2002. Clinical information was obtained and updated accordingly, from the medical records for each patient. The cause and date of death were also verified with the Death Registration Database from the Department of Health. Charge-based cost was described as total cost or separate costs in different periods. Treatment outcome was estimated by 5-year overall survival rate and disease-free survival rate. CE was calculated both for total cost per life year saved, and diagnosis/treatment cost per one percent increase in 5-year survival rate. Linear regression model was used to evaluate variables impacting diagnosis and/or treatment costs. Cox regression model was used to evaluate variables impacting survival outcomes.
Results: Median follow-up interval was 50.1 months. The 5-year overall survival and disease-free survival rates were 72.2% and 75.1%, respectively. The average costs in diagnosis, treatment, follow-up, diagnosis/treatment, and all three periods were 38,437.1, 276,530.5, 125,618.5, 314,967.7, and 440,617.3 dollars, respectively. Type of radiotherapy, type of chemotherapy, grading of acute side effects, stage, and age were statistically significant factors correlating with diagnosis/treatment and treatment costs. Stage and the diagnosis confirmed before the first visit were factors significantly impacting diagnosis cost, with R square of 0.093. Both treatment protocol and stage were significantly associated with diagnosis/treatment cost for stage I-IVB patients, with R square of 0.650. In Cox regression model stage and post-radiotherapy adjuvant chemotherapy were significant factors impacting survival. Treatment protocol sustained stronger correlation with survival than type of radiotherapy or chemotherapy did. Dollars per life year saved were 99,588.4 for stage I, 99,329.8 for stage IIA, 161,773.0 for stage IIB, 149,982.9 for stage III, 214,210.7 for stage IVA, 261,119.0 for stage IVB, and 470,191.2 for stage IVC patients. The best choices with CE were protocol no.1 for stage I-IIB patients, and protocol no.3 for stage III-IVB patients.
Conclusion: Stage, type of treatment or protocol, and severity of acute side effects were important factors impacting diagnosis/treatment cost. The difference in CE among different stages was similar to that in clinical prognosis. The preference based on CE between different treatment protocols was close to that in evidence-based clinical medicine. CE may be used as an important reference in the design of reimbursement policy or selection of treatment protocols.

中文摘要 3
ABSTRACT 5
表目錄 8
圖目錄 9
第一章 前言 10
第一節 研究背景 10
第二節 研究目的 12
第三節 研究預期貢獻 12
第二章 文獻探討 14
第一節 醫療經濟評估方法 14
第二節 癌症篩檢的醫療經濟分析 16
第三節 癌症治療的醫療經濟分析 21
第四節 以保險申報費用為基準的醫療經濟分析 22
第五節 鼻咽癌診療相關文獻 24
第三章 研究方法 26
第一節 研究設計與研究架構 26
第二節 研究假說 27
第三節 研究變項 27
第四節 研究材料 30
第四章 研究結果 35
第一節 研究對象基本資料描述 35
第二節 醫療費用資料統計分析 36
第三節 鼻咽癌醫療效果分析 40
第四節 鼻咽癌醫療的成本效果分析 42
第五章 討論 44
第一節 鼻咽癌醫療費用成本的討論 44
第二節 鼻咽癌醫療效果的討論 47
第三節 鼻咽癌醫療成本效果的討論 49
第四節 綜合討論 53
第五節 研究限制 55
第六章 結論與建議 57
第一節 結論 57
第二節 建議 58
英文參考文獻 80
中文參考文獻 84

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