臺灣博碩士論文加值系統

全民健保開辦至今面對最大的問題即是如何維持財務收支平衡，面對便宜的全民
健保，健保局需支付醫療院所合理報酬，又受到人口老化、醫療科技進步以及民眾就醫
需求增加等因素，健保局應支付的醫療費用逐年增加，同期間保費收入卻因全球經濟蕭
條導致保險人之保費收入遠不及醫療花費來的快。而提高保費或調整藥價基準等，皆會
引起社會民眾的關心、注意與批評。因此如何減少可避免的醫療費用與在有限的醫療資
源進行適當的分配，變得相當重要。
在此文章中，利用成本效能分析(Cost-Effectiveness Analysis)的概念，並加入增量
成本效能比(Incremental Cost-effectiveness Ratio Analysis ； ICER) 與增量淨效益
(Incremental Net Benefit；INB)，對藥物治療與樣本數的計算進行探討。
根據文獻研究，利用增量成本效能比(Incremental Cost-effectiveness Ratio Analysis；
ICER)與增量淨效益(Incremental Net Benefit；INB)並結合顯著水準、檢定力以及信賴區
間的計算，再給定的醫療成本花費或藥物治療效能變化下，得知所需樣本數多寡。經由
得知的樣本數後，亦可利用在實案中進而避免浪費過多的資源與時間尋找樣本數。
關鍵字：成本效能分析、增量成本效能比、增量淨效益、顯著水準、檢定力、信賴區間、
樣本數。

The biggest challenge of National Health Insurance (NHI) in Taiwan is to maintain the
financial balance and provide good quality of medical service because it has to pay necessary
remuneration to medical institutions, but only collect limited inexpensive insurance premium.
The financial status of NHI becomes a concern because its medical budget is increasing year
by year due to some inevitable factors, such as the aging population, expensive medical
research and development and global economic recession. Simply speaking, the premium
income is also far less than medical costs. However, raising premium benchmark or drug
payment adjustment will result in some criticism from the public. Therefore, it is crucial to
avoid unnecessary medical waste and reallocate the limited medical resources appropriately.
This dissertation studies the calculation of sample size in the drug treatment that can be
utilized in the real world to avoid excessive waste of resources and reduce the medical cost in
terms of Cost-Effectiveness Analysis, Incremental Cost-effectiveness Ratio Analysis (ICER)
and Incremental Net Benefit (INB).
Keywords: Cost-Effectiveness Analysis, Incremental Cost-effectiveness Ratio Analysis,
Incremental Net Benefit, significant level, power, confidence interval, sample
size.

目錄
摘要 .......................................................................................................................................... Ⅰ
Abstract AbstractAbstract ................................ ................................ ................................ ................................ ..... Ⅱ
誌謝 ................................ ................................ ................................ ................................ .......... Ⅲ
目錄 ................................ ................................ ................................ ................................ .......... Ⅳ
圖目錄 ................................ ................................ ................................ ................................ ...... Ⅵ
表目錄 ................................ ................................ ................................ ................................ ...... Ⅶ
1. 緒論 ................................ ................................ ................................ ................................ ....... 1
1.1 背景 .............................................................................................................................................. 1
1.2 藥物經濟學 .................................................................................................................................. 1
1.2.1 簡介 ................................................................................................................................... 1
1.2.2 研究分類 ........................................................................................................................... 1
1.2.2.1成本效能分析(Cost-Effectiveness Analysis) ............................................................ 2
1.2.2.2成本效益分析(Cost-Benefit Analysis) ...................................................................... 2
1.2.2.3 成本效用分析(Cost-Utility Analysis) ...................................................................... 2
1.2.2.4最小成本分析(Cost-Minimization Analysis) ............................................................ 3
1.2.3增量成本效能比(Incremental Cost-Effectiveness Ratio) .................................................. 3
1.2.4增量淨效益(Incremental Net Benefit) ............................................................................... 4
1.2.5 應用 ................................................................................................................................... 4
1.3 樣本數 .......................................................................................................................................... 5
1.3.1 影響因素 ........................................................................................................................... 5
1.3.1.1 顯著水準 ................................................................................................................... 5
1.3.1.2 檢定力 ....................................................................................................................... 5
1.3.1.3 抽樣誤差 ................................................................................................................... 5
1.4 研究動機與目的 .......................................................................................................................... 6
1.5 研究架構 ...................................................................................................................................... 6
2. 文獻探討 ................................ ................................ ................................ ............................... 7
2.1成本效能分析(Cost-Effectiveness Analysis；CEA) ................................................................... 7
2.2 Briggs and Gray的方法 ............................................................................................................... 8
2.3 Gardiner et al.的方法 ................................................................................................................. 10
2.4增量淨效益(Incremental Net Benefit)的方法............................................................................ 13
3. 研究方法 ................................ ................................ ................................ ............................. 15
3.1 R軟體介紹 ................................................................................................................................. 15
3.2 Briggs and Gray 演算法 ............................................................................................................ 15
3.2.1 理論推導 ......................................................................................................................... 16
3.2.2 演算法 ............................................................................................................................. 18
V
3.3 Gardiner et al. 演算法................................................................................................................ 19
3.3.1 理論推導 ......................................................................................................................... 20
3.3.2 演算法 ............................................................................................................................. 23
3.4 增量淨效益(Incremental Net Benefit) ...................................................................................... 24
3.4.1 理論推導 ......................................................................................................................... 25
3.4.2 演算法 ............................................................................................................................. 27
4. 演算法之結果 ................................ ................................ ................................ ..................... 29
4.1 Briggs and Gray ........................................................................................................................ 29
4.2 Gardiner et al. ............................................................................................................................. 30
4.3增量淨效益(Incremental Net Benefit) ....................................................................................... 32
5. 結論 ................................ ................................ ................................ ................................ ..... 34
參考文獻 ................................ ................................ ................................ ................................ .. 35
附錄 ................................ ................................ ................................ ................................ .......... 36
A. Briggs and Gray ......................................................................................................................... 36
B. Gardiner et al. ............................................................................................................................... 40
C. Incremental Net Benefit ............................................................................................................. 46
圖目錄 圖目錄
圖2.1 CE plane ........................................................................................................................ 8
圖 2.2 信賴區間盒子圖 ................................ ................................ ................................ ............ 9
圖 2.3 顯著水準與檢定力 ................................ ................................ ................................ ...... 12
表目錄 表目錄
表 4.1 平均數改變與樣本數的關係 ................................ ................................ ....................... 36
表4.2變異數改變與樣本數的關係 ................................ ................................ ....................... 36
表4.3平均數改變與樣本數的關係 ................................ ................................ ....................... 37
表4.4變異數改變與樣本數的關係 ................................ ................................ ....................... 37
表 4.5 平均數改變與樣本數的關係 ................................ ................................ ....................... 38
表4.6變異數改變與樣本數的關係 ................................ ................................ ....................... 38
表 4. 7平均數改變與樣本數的關係 ................................ ................................ ....................... 39
表4.8變異數改變與樣本數的關係 ................................ ................................ ....................... 39
表4.9相關係數改變與樣本數的關係 ................................ ................................ ................... 40
表 4. 10 平均數改變與樣本數的關係 ................................ ................................ ..................... 40
表 4. 11 變異數改變與樣本數的關係 ................................ ................................ ..................... 41
表 4.1 2相關係數改變與樣本數的關係 ................................ ................................ ................. 41
表 4.1 3平均數改變與樣本數的關係 ................................ ................................ ..................... 42
表 4.1 4變異數改變與樣本數的關係 ................................ ................................ ..................... 42
表 4.1 5相關係數改變與樣本數的關係 ................................ ................................ ................. 43
表 4.1 6平均數改變與樣本數的關係 ................................ ................................ ..................... 43
表 4.1 7變異數改變與樣本數的關係 ................................ ................................ ..................... 44
表4.18相關係數改變與樣本數的關係 ................................ ................................ ................. 44
表4.19平均數改變與樣本數的關係 ................................ ................................ ..................... 45
表4.20變異數改變與樣本數的關係 ................................ ................................ ..................... 45
表4.21相關係數改變與樣本數的關係 ................................ ................................ ................. 46
表4.22平均數改變與樣本數的關係 ................................ ................................ ..................... 46
表4.23變異數改變與樣本數的關係 ................................ ................................ ..................... 47
表4.24相關係數改變與樣本數的關係 ................................ ................................ ................. 47
表4.25平均數改變與樣本數的關係 ................................ ................................ ..................... 48
表4.26變異數改變與樣本數的關係 ................................ ................................ ..................... 48
表4.27相關係數改變與樣本數的關係 ................................ ................................ ................. 49
表4.28平均數改變與樣本數的關係 ................................ ................................ ..................... 49
表4.29變異數改變與樣本數的關係 ................................ ................................ ..................... 50
表4.30相關係數改變與樣本數的關係 ................................ ................................ ................. 50
表4.31平均數改變與樣本數的關係 ................................ ................................ ..................... 51
表4.32變異數改變與樣本數的關係 ................................ ................................ ..................... 51

參考文獻
[1] 衛生福利部中央健康保險署 http://www.nhi.gov.tw/
[2] 國民健康/健康檢查/健康知識 http://www.uuuwell.com/mytag.php?id=72356
[3] 新竹生物醫學園區
http://www.hbmsp.sipa.gov.tw:9090/itri/tw/images/NewsList1010222_07.htm
[4] 國家教育研究院 http://terms.naer.edu.tw/
[5] 癌症關懷照護網 http://www.totcare.com.tw/index.asp
[6] 衛生署國民健康局 http://www.bhp.doh.gov.tw/BHPNet/Web/Index/Index.aspx
[7] R. Willan, H. Briggs : Statistical Analysis of Cost-effectiveness Data.,○C 2006 John
Wiley &; Sons, Ltd. ISBN: 0-470-85626-2
[8] 陳景祥 “R軟體應統計方法” 華泰文化
[9] Chien-Hua Wu,Shu-Mei Wan,Yu-Chun Yang,Chiung-Yu Huang.(2008) Sample Size
Algorithms in Clinical Trials. Therapeutic Innovation &; Regulatory Science ,vol. 42 no.
5, 429-439.