臺灣博碩士論文加值系統

背景與目的：
世界衛生組織指出憂鬱症是導致失能行為的主因，並伴隨過高的死亡率和龐大的花費。在台灣，憂鬱症盛行率約8.9%，卻僅有兩成的患者接受治療。由於憂鬱症會衍生多重層面的問題，需要提早預防。本研究使用健保資料庫分析探討憂鬱症相關醫療利用與費用及共病關係。
方法：
所有分析的資料取自全民健保資料庫，此資料庫根據全民健保之納保人為抽樣母體，而後隨機抽取百萬人為「承保抽樣歸人檔」。本研究對象追蹤時間從2008年至2012年。擷取ICD-9CM碼(296.20~296.24、296.30~296.34、300.4、311、296.8、290.21)之憂鬱症病患。使用門診處方及治療明細檔和住院醫療費用清單明細檔，分析人口屬性、醫療利用與費用及相關共病症。以性別、年齡做分層，以百分比排序就醫科別；以平均值、中位數和標準差，呈現觀察變項分布；以T-檢定進行相關變項檢定，並使用變異數分析探討季節與門診就醫頻率的關聯性。採用Cox比例風險模式估算憂鬱症世代的有無與相關共病症的危險比。
 
結果：
在五年追蹤期間，憂鬱症患者門診就醫科別，不分性別前三名分別為精神科、神經科、家醫科；住院就醫科別，不分性別前五名分別為精神科、腸胃內科、骨科、胸腔內科、內科。大於65歲的年齡層，在門診就醫科別特別有「居家護理」、住院就醫科別特別有「感染科」的分布。醫療利用分析，除了門診2011年觀察人次明顯下降之外，所有患者的就醫總費用與平均費用，呈現逐年上升。春季與夏季對於門診的醫療利用具有相關性。住院醫療利用分析，男性的就醫總費用與平均費用皆高於女性。共病症分析在非精神性疾病，憂鬱症世代合併高血壓、糖尿病、心臟病、腦血管、腸胃相關、肺部、甲狀腺、肝和骨骼疼痛相關疾病等罹病風險高於非憂鬱症世代(p<0.0001)。精神性疾病，除腸躁症(HR=0.90，95%=0.84-0.95)以外，其餘共病症(焦慮症、睡眠障礙、物質成癮和失智症)之HR皆大於1，憂鬱症世代罹患相關共病症風險皆高於非憂鬱症世代。
結論：
研究結果顯示在性別、年齡層和季節於醫療利用有差異性，伴隨相關共病症的確會提高罹病風險。上述研究結果，可提供未來憂鬱症在醫療政策及預防醫學參考，盼對醫療照護與醫療政策建立有所幫助。
關鍵字：憂鬱症、共病症、醫療利用及費用

Background and purpose

According to reports of the World Health Organization, depression is a leading cause of disability accompanied by considerable morbidity, excess mortality and substantial costs. The prevalence of depression is about 8.9%, but only 20% of patients receive treatment, in Taiwan. Since depression extended multiple problems, early prevention and intervention is essential. In this study, we conducted a cohort study to examine the relationship between depression and medical utilization, expenses and comorbidity by using the National Health Insurance Research Database (NHIRD).








Methods

Data analyzed were retrieved from Taiwan NHIRD that comprised claims data of 1,000,000 individuals randomly selected from all insured enrollees. All subjects were followed up from 2008 to 2012. The depression diagnoses were coded according to the International Classification of Disease, Ninth Revision, Clinical Modification (296.20~296.24, 296.30~296.34, 300.4, 311, 296.8, 290.21). The population attributes, medical utilization, expenses and related diseases were retrieved from outpatient prescriptions, treatment details (CD) and inpatient medical billing details (DD). Data was stratified by sex and age, in the order of percentage in medicine; The distribution of the variable was observed mean, median and standard deviation, and the correlation between the seasons and the outpatients’ medical consumption and expenditure was investigated with T-Test. Cox proportional risk model was used to estimate the hazard ratio of the associated common disease and the generation of depression.
 

Results

Five-year depression patients outpatient clinics on the medical the three leading diseases are psychiatry, neurology and home medicine; and the five leading diseases in inpatient on the medical are psychiatry, gastrointestinal medicine, orthopedics, thoracic medicine, internal medicine. More than 65 years old in the outpatient clinics is "home Care", inpatient on the medical is "infection". The analysis of outpatient medical utilization, all patients '' total cost of medical treatment and the average cost, showed a yearly rise, except 2011. Spring and summer are related to outpatient medical utilization. In the analysis of hospitalization utilization, the total cost and average cost of male medical treatment were higher than that of female. The risk for hypertension, diabetes mellitus, heart disease, cerebrovascular, gastrointestinal related, lung, thyroid, liver and bone pain is higher in depression cohort than that of non-depressive cohort (p<0.0001).








Conclusions

The results showed that there are difference in medical utilization in sex, age and season, and increasing the risk of comorbidity in depression cohort. These results could be provided some reference and information for prevention and control policies to maintain public health in the future.






Key words: depression, comorbidity, medical utilization and expenses.

誌謝 i
中文摘要 ii
英文摘要 iv
表目錄 vii
圖目錄 viii
第一章 緒論 1
第一節 研究背景與研究動機 1
第二節 研究的重要性 4
第三節 研究目的 5
第二章 文獻探討 6
第一節 憂鬱症的定義與盛行率 6
第二節 憂鬱症的易感受族群 10
第三節 憂鬱症的危險因子 14
第四節 憂鬱症的醫療照護指標 16
第五節 研究步驟 19
第三章 材料與方法 20
第一節 研究設計 20
第二節 研究對象 22
第三節 研究資料流程處理 28
第四節 資料統計與分析 30
第四章 研究結果 32
第一節 研究對象的基本屬性資料與就醫型態分布 33
第二節 研究對象在門診及住院的醫療利用情形 35
第三節 研究對象之共病症分析 40
第五章 討論 46
第六章 結論與建議 72
第一節 結論 72
第二節 研究限制 74
第三節 應用與建議 75
第七章 參考文獻 76
附錄 106

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