臺灣博碩士論文加值系統

肺癌是台灣最重要的癌症之一，肺癌死亡率在男性為第二位、女性第一位；2001年肺癌的健保支出約佔所有腫瘤健保支出17％，大約34億元新台幣。有限的醫療資源下，肺癌病人的醫療支出、支出結構、與不同化學治療成本與成本效益是醫療服務提供者極欲了解的重點。
本研究分為兩部份：第一部份利用台大醫院1998年到2000年診斷第四期非小細胞肺癌病人，追蹤至2002年，回溯性分析這群病人在台大醫院住院與門診的終身醫療成本與支出結構，並針對接受不同化學治療的病人進行成本效果分析。第二部份利用美國臨床腫瘤協會（American Society of Clinical Oncology）發表非小細胞肺癌治療指引、最新化療藥品（如erlotinib、pemetrexed、bevacizumab）的大型臨床試驗報告，建立非小細胞肺癌病人的七個治療階段，套入成本評估模式（模式包括四種成本：藥品成本、給藥成本、副作用住院成本與其他腫瘤相關成本），推估各治療階段治療成本；再利用文獻報告與推估之成本進行成本效果分析或成本最小化分析。
在540位病人中，平均存活時間為6.2個月、平均終身醫療成本為328,007元新台幣（標準差為322,878元）。所有醫療成本中，所有住院成本佔55.7％，門診與住院的化學治療佔29.3％。200位2000年診斷的病人中，接受化療的病人（98位）增加一個月的存活時間，比起未接受化療的病人需要多花費176,745元新台幣；接受過二線（以上）化療的病人（42位）增加一個月的存活時間，比起只接受第一線化療的病人（56位）需要多花費125,343元。二線化療中，51％以docetaxel為主，平均終身醫療成本為652,265元，26％以vinorelbine為主，平均終身醫療成本為774,880元。
七個治療階段中，第一階段的Gem/Cis與Cis/Eto醫療成本為260,037元與151,286元；差異的成本效果比（ICER）為72,500（元/月）。第二階段中，Cis/Pac、Cis/Gem、Cis/Doc、Carbo/Pac的醫療成本分別為270,938元、258,950元、239,601元、332,527元。第三階段docetaxel成本為206,696元，與支持性照護相比，ICER為64,034（元/月）。第四、第五階段的gefitinib與erlotinib醫療成本為239,738元與511,500元。第六階段的pemetrexed成本為359,834元、docetaxel為225,595元；第七階段使用十劑量的bevacizumab與6治療週期Carbo/Pac成本為1,911,010元，與接受6治療週期Carbo/Pac那組相比，ICER為644,058（元/月）。
第四期非小細胞肺癌病人醫療成本中，住院相關成本是最大的醫療支出，接著是化學治療成本。在二線化療中，使用docetaxel的病人最多。接受化學治療增加一個月的存活時間需要多使用17萬元新台幣。七個階段的治療中，越新的處置需要越高的醫療成本，ICER也越高。新的治療雖可減低副作用住院比例，但藥品本身成本遠高於減少的住院成本。敏感性分析結果發現副作用住院成本與所接受的化學治療周期是影響醫療成本最重要的因素。此族群病人的終身醫療成本及接受治療的ICER與末期鼻咽癌病人相比很高。第四期非小細胞肺癌病人的終身醫療成本與不同治療的成本對於台灣整體醫療資源應用佔有重要影響。

第一章 前言...1
第二章 文獻探討...3
第一節 非小細胞肺癌及其治療...3
一、 非小細胞肺癌的病源學（etiology）與病理學（pathology）..3
二、 非小細胞肺癌的臨床分期法（clinical staging）...7
三、 第四期非小細胞肺癌的治療...9
第二節 肺癌治療的整體醫療成本...12
一、 利用保險資料分析成本...12
二、 利用治療模式分析成本...15
三、 利用實際支出分析成本...17
第三節 末期非小細胞肺癌治療的成本效果分析（COST-EFFECTIVENESS ANALYSIS）...24
一、 成本效果分析...24
二、 末期非小細胞肺癌病人接受化學治療的成本效果分析...27
第三章 研究目的...36
第四章 研究方法及材料...37
第一節 研究設計...37
第二節 研究方法...38
一、 醫療成本支出結構研究...38
二、 醫療成本評估與成本分析...40
第三節 研究材料...45
一、 研究對象...45
二、 資料來源...46
三、 資料內容...48
第四節 資料分析...56
第五章 研究結果...58
第一節 醫療成本支出結構研究...58
一、 病人基本特徵...59
二、 終身醫療成本與成本結構...61
三、 成本效果分析...66
第二節 醫療成本模式建立與成本分析...67
一、 醫療成本...67
二、 臨床治療效果...72
三、 成本效果分析...76
四、 成本最小化分析...80
第六章 討論...82
第一節 醫療成本支出結構研究...82
第二節 醫療成本評估與成本分析...87
一、 醫療成本與臨床治療效果...87
二、 成本效果分析與成本最小化分析...90
第三節 研究限制...96
第四節 未來研究建議...99
第七章 結論...101
第八章 參考文獻...103
附錄一 各醫療資源之單位成本與估計...114
附錄二 住院醫療資源使用與成本...123
附錄三 不同化學治療階段的成本推估...131
一、 第一階段...131
二、 第二階段...133
三、 第三階段...136
四、 第四、五階段...138
五、 第六階段...139
六、 第七階段...142

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