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研究生:陳珮芬
研究生(外文):Pei-Fen Chen
論文名稱:台灣社區老人接種流行性感冒疫苗與其醫療服務利用之研究
論文名稱(外文):Influenza vaccination and medical care utilization for the community elderly in Taiwan
指導教授:黃文鴻黃文鴻引用關係
指導教授(外文):Weng-Foung Huang
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:衛生福利研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2004
畢業學年度:92
語文別:中文
論文頁數:100
中文關鍵詞:社區老人流行性感冒疫苗接種政策自我選擇工具變項法
外文關鍵詞:community elderlyinfluenzavaccination policyself-selectioninstrumental variable
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我國於民國八十七年首度針對高風險群老人推動流感疫苗之免費接種政策,並於九十年推廣至所有六十五歲以上之老人,包括社區健康老人在內。由於流感疫苗必須年年接種,經費預算龐大。在全球老年人口比例逐漸上升的情況下,各國始對依年齡基準(age-based)提供老人全面接種流感疫苗的政策成本效益加以評估。由於老人會依據自己過去的身體狀況來決定是否接種疫苗,這可能造成疫苗接種之自我選擇作用(self-selection),使接種疫苗的老人呈現較高的醫療利用,亦可能因此低估流感疫苗對接種者產生的效益。在現有的國內外研究中,鮮少針對疫苗接種之自我選擇作用加以控制。因此,本研究嘗試以工具變項法排除自我選擇作用,分析接種疫苗對死亡機率、住院及門診醫療服務利用之影響。
研究樣本是以九十年之「國民健康訪問調查」年滿六十五歲以上之老人為樣本,串連死亡登記檔及全民健保資料檔後進行分析。扣除先前已死亡個案及未串連健保資料者,樣本共計1,700名,平均年齡73歲,年齡標準差為6.3歲;男女比例為50.4比49.6。在統計分析方面,本研究利用工具變項法,以二階段回歸方程式執行。第一階段以工具變項預估個案之疫苗接種機率,第二階段代入預估之疫苗接種機率,以製造假性隨機排除接種疫苗之自我選擇作用。在第二階段回歸模式中,以邏輯司回歸分析死亡機率、住院機率、門診就醫機率等;以波以松回歸分析住院次數;以線性回歸分析住院天數、住院費用、門診次數及門診費用。
研究結果顯示,疫苗接種能有效減少老人之全死因死亡率(OR=0.01)。在醫療利用部分,由於接種疫苗之老人是屬於原健康狀況較差且原醫療利用較高的一群,具有疫苗接種之自我選擇作用。在以工具變項回歸模式排除自我選擇作用後,發現接種組老人與未接種組老人之住院機率無顯著差異。但在住院老人當中,接種組之住院費用、住院天數皆顯著較未接種組低,接種組較未接種組之每人每年住院費用低59萬元(P<0.05);若僅分析因肺部疾病住院費用,接種組則較未接種組低158萬元(P<0.005)。在門診醫療利用方面,疫苗接種組的老人至門診就醫的機率較高(P<0.001),但疫苗接種對就醫老人之門診次數、門診費用等則無顯著影響,P值皆大於0.05。
整體而言,流感疫苗能有效降低住院老人所有疾病及肺部相關疾病的住院醫療費用。減少之效益主要來自於七十五歲以上之高風險群老人,每年每位住院之老老人可減少219萬元的住院費用。因此,未來應極力提高該族群之疫苗接種率,以提升整體疫苗接種效益。
Can a country afford to annually vaccinate its entire aging population with a flu vaccine that may or may not be necessary? Taiwan’s Department of Health’s free influenza vaccination program for the elderly, those at high risk for contracting the disease, was implemented in 1998. In 2001, however, the program was expanded to cover all people 65 years old or older, not just those in that high risk alone, but also those considered healthy. Administering the vaccine annually makes it a considerable financial burden. As the aged grow in proportion to the rest of the nation, the effectiveness of the influenza program and whether to temper that age-based population (65 years or older) with some risk-based criteria has become a recently more popular research topics. It has been shown that one’s medical history often determines whether he or she opts for vaccination, and, therefore, making it a self-selected choice. Previous studies of this program have only used multiple linear regression to analyze the relationship of flu vaccination and medical care expenditures, and found greater medical costs in the vaccinated group than the unvaccinated group. Some researchers suggested using instrumental variables in the statistical methods to clarify to what extent the self-selection is involved and to make pseudo-randomization to compensate for that bias. Some studies have only used multiple linear regression to analyze this relationship, and they will underestimate the effectiveness of the flu vaccination. To solve this problem, this study uses the instrumental variable method to measure the effectiveness of the influenza vaccination program at reducing utilization of medical health care services.
Study samples were taken from the Year 2000 National Health Interview Surveys administered to people 65 years old or older. After excluding those who died before the study period and those who did not agree to have their information linked to the National Health Insurance Database, we were left with a sample of 1,700 (mean age 73 years, SD+/- 6.3 years). In our study, multiple regression was introduced in two stages. In the first stage, the instrumental variable was used to predict every sample’s probability to vaccinate. In the second, the probabilities were used in a regression model for pseudo-randomization. Logistic regression was used to analysis death rate and to estimate the probability of visiting an outpatient department. Poisson regression was used when determining the frequency of the administration; linear regression when determining length-of-stay, administration fee, outpatient department visiting and outpatient fees.
We found the influenza vaccination program for the elderly to reduce the death rate (OR=0.01). While the program did not significantly reduce the general admission rates, it did reduce fees paid for hospital inpatient services (NT$ 588,886 per person year, P<0.05) and the length-of-stay (119.94 days per person year, P<0.05). Outpatient services saw no such reductions. The influenza vaccination program greatly reduced hospitalization expenses for the high-risk group, patients 75 years old or older, whose inpatient services alone were reduced by NT$ 2,188,806 per person year. Based upon these findings, the government should increase the vaccination rate for very old people.
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