臺灣博碩士論文加值系統

目的：依據我國行政院衛生署國民健康局最新的統計顯示，結腸直腸癌死亡率僅次於肺癌與肝癌，新發病例數高居全癌症之冠，對民眾健康的威脅不容小覷。本研究利用台灣地區全民健保資料，瞭解我國結腸直腸癌病患醫療利用情形與醫療費用，並探討其相關影響因素，包括共病與醫院特性等因素。
方法：本研究為一回溯性世代研究，資料來源為「全民健康保險學術研究資料庫」，分析2006年(n=2597)至2009年之門住診申報資料，並擷取ICD-9-CM code前3碼為153、154之結腸直腸癌住院病患為研究對象。包括「門診處方及治療明細檔」(CD)、「住院醫療費用清單明細檔」(DD)，並結合「醫事機構基本資料檔」（HOSB）進行研究。多變項分析是應用複迴歸統計，共病症嚴重度指標採用Charlson Comobidity Index。
結果：共病嚴重度愈高(分數 1)則結腸直腸癌病患的門住診醫療資源耗用有明顯增加趨勢；醫院特性(包括醫院權屬別、醫院權屬別、醫院所在地區別)在病人尋求醫療照護時也是影響因素。罹病年齡層則好發於60-79歲，但醫療資源耗用卻集中在50-59歲病患，顯示比平均罹癌年齡年輕的患者有較高的醫療照護需求。
研究結果顯示年齡層、共病嚴重度、有無因為罹患結腸直腸癌的手術、醫院權屬別、醫院層級別、醫院所在地區別等，皆對結腸直腸癌病患的醫療資源耗用有明顯的影響。第一年初診斷平均門診次數較低然後逐年增加(自2006年8.9次至2009年11.4次)；相反地，平均住院天數則隨病患觀察期延長，而逐年下降(自7.3天至2.6天)；平均總醫療費用皆呈遞減趨勢，亦即隨病患觀察期延長，其醫療資源耗用則逐年漸漸下降(門診自1,771元至1,653元；住院自11,686元至4,563元)。
結論：本研究探討結腸直腸癌病患的醫療資源耗用趨勢及其影響因素，研究結果具備醫療政策、醫療經濟、流行病學與預防醫學之應用價值，期望能給予醫療衛生政策決策者有效的資訊，對於後續學術研究與制度規劃能有所幫助。

Objectives: Colorectal cancer has become the cancer with the highest incidence and the third leading cause of cancer deaths in Taiwan, following lung cancer and liver cancer. It is critical to evaluate the health care cost for colorectal cancer. This thesis study investigated the expenditures associated with hospital characteristics for the care of colorectal cancer patients, with the consideration of comorbidity using Charlson comorbidity index as the indicator.
Methods: From the Taiwan National Health Insurance claims data with information for one million insured, 2597 patients with colorectal cancer were identified in 2006 (ICD-9-CM code 153 and 154). These patients were followed up until 2009 to evaluate the health care costs annually for the survivals. Only patients identified for twice in the outpatient cares or identified once in the inpatient care were included in the study by the follow-up year. Multivariate regression analysis was used to identify the independent relationships between expenditures and comorbidity (Charlson Comorbidity Index, CCI), hospital types and medical utilization..
Results: Patients with higher comorbidity (CCI score 1) had significantly increased utilization of outpatient and inpatient cares. Patient demographics and hospitals characteristics (ownership, accreditation and location) were significantly associated with medical utilization and costs for caring colorectal cancer patients. The mean costs for both inpatient and outpatient cares were higher at the public hospitals than private hospitals (117 926 vs. 56 225 NTD in 2006 and 60 151 vs. 50 303 NTD in 2009). The regional hospitals charged much more than the local district hospitals (105 002 vs. 33 556 NTD in 2006 and 60 551 vs. 78 200 NTD in 2009).
The prevalence of colorectal cancer was the highest in 60 to 79 years old but the cost for caring the patient was the highest for patients aged 50-59 years. The frequency of outpatient visit after the patients was identified increased by follow-up time, from 8.9 times in 2006 to 11.4 times in 2009. On the contrary, the length of hospitalization stay declined from 7.3 days to 2.6 days. The mean total expenditure was in a decreasing trend. The mean cost for inpatient and outpatient cares per male patient decreased from NTD 99 652 in 2006 to 72 560 in 2009; the corresponding costs per female patient were 76 145 and 40 994.
Conclusions: Age, comorbidity, hospital ownership, hospital accreditation and location were found to be significantly associated with medical utilization and costs. The utilization of health cares decrease for the survivals and the mean costs were thus declining over the follow-up period. This research has provided important information for health policy makers upon making effective strategies in caring colorectal cancer patients.

致謝 ……………………………………………………………………………… i
中文摘要 ………………………………………………………………………… ii
英文摘要 ………………………………………………………………………… iv
表目錄 ………………………………………………………………………… viii
圖目錄 ………………………………………………………………………………xi
第一章 緒論 …………………………………………………………………………1
第一節 研究背景動機與研究動機 ………………………………………… 1
第二節 研究目的 …………………………………………………………… 2
第三節 研究問題與研究假設 ……………………………………………… 3
第四節 名詞界定 …………………………………………………………… 4
第二章 文獻查證 …………………………………………………………………8
第一節 結腸直腸癌定義 …………………………………………………… 8
第二節 結腸直腸癌之流行病學趨勢 ………………………………………10
第三節 醫療費用影響因素 …………………………………………………11
第四節 醫院特性與醫療資源耗用 …………………………………………14
第三章 研究方法 …………………………………………………………………18
第一節 研究設計 ……………………………………………………………18
第二節 研究對象 ……………………………………………………………19
第三節 資料收集過程 ………………………………………………………20
第四節 研究資料來源 ………………………………………………………21
第五節 統計方法 ……………………………………………………………23
第四章 研究結果 ………………………………………………………………… 25
第一節 病患與醫院特性之醫療資源利用分布情形 ………………………25
第二節 癌症病患醫療資源耗用之影響因子 ………………………………28
第五章 討論 ……………………………………………………………………… 48
第六章 結論與建議 ……………………………………………………………… 53
第一節 結論 …………………………………………………………………53
第二節 研究限制 ……………………………………………………………55
第三節 應用與建議 …………………………………………………………56
第七章 參考文獻 ………………………………………………………………… 58

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