臺灣博碩士論文加值系統

癌症為台灣地區第一大死因，且每年死於癌症的人數也逐年遞增。安寧療護以人性化的照護方式，提供病患支持性照顧、舒適的護理及維持其原有生活品質。本研究旨在探討接受安寧療護與傳統照護兩種照護型態之癌末病患，對醫療費用與醫療處置利用之差異。
本研究對象為2000年10月1日至2004年12月31日期間，中央健保局住院醫療費用明細檔中病患住院死亡者。病患依照護型態分為兩種類型，病患臨終時接受安寧療護住院服務為研究之實驗組，而臨終時接受傳統住院服務為研究之控制組，控制組再依是否為安寧療護醫院分為兩組，「傳統一」為在安寧療護醫院接受傳統照護者，「傳統二」為在非安寧療護醫院接受傳統照護者。分別串聯兩組病患健保門診、住院費用檔與醫令檔，比較臨終前醫療費用與醫療處置利用之差異。
研究結果顯示，男、女前五大癌症死因個案總計34,587人，接受「安寧療護」照護共6,694人，接受「傳統照護」共27,893人。在控制了病患和醫療機構特質等影響因素後，照護型態別為癌症醫療費用與醫療處置的影響因素。「安寧療護」仍具有費用節省性，且在控制了影響因素後，接受「安寧療護」照護病患仍較不偏好接受手術、化學治療和抗癌藥物。接受「傳統二」照護病患的醫療費用高於接受「傳統一」照護病患的醫療費用。而接受「傳統一」和「傳統二」照護病患則顯著偏好接受手術、化學治療和抗癌藥。在放射線治療利用上，在控制了影響因素後，結直腸癌和肝癌接受「安寧療護」照護之病患較偏好使用放射線治療，而接受「傳統一」和「傳統二」照護病患則顯著較不偏好於使用放射線治療。
整體而言，安寧療護確實有達到有節省成本和減少醫療處置利用的成效。建議對相關法令與給付給予適度修正，並支持安寧療護的發展，加強醫學教育與民眾教育，讓安寧療護的觀念深植人心。

Objective: Cancer has become the leading cause of the death in Taiwan since 1982, and cancer deaths have increased noticeably in recent years. Hospice care provides a support care and high quality of care at the end of life. The purpose of this study is to compare the treatment modules and expenditures between hospice and conventional care for terminal cancer patients.
Methods: The study subjects were terminal cancer patients who deceased during their hospital admission during October 1 2000 to December 31 2004. Data was retrieved from Inpatient Expenditures by Admissions files released by the National Health Research Institutes. The study subjects were divided into two groups in terms of care mode. The study group was patients hospitalized in the hospice care (HC) unit. The control group was patients receiving conventional care (CC). The control group was further separated into two groups according to their setting, one is conventional care in a hospital with hospice care services (CC_H), and the other is conventional care in a hospital without hospice care services (CC_NH). We then trace these patients’ expenditures and treatment modules in all their outpatient, emergency visits and inpatient care up to three months before death. The data sources were from Inpatient Expenditures by Admission file, Ambulatory Care Expenditure by Visits file, Details of Inpatient Orders file, and Details of Ambulatory Care Orders file.
Results: Results of this study showed that there were 34,587 decedents for the male’s and female’s top five leading causes of cancer death. Among these deceased patients, there were 6,694 decedents who chose HC and 27,893 decedents who chose conventional care (include CC_H and CC_NH). Medical expenditures and treatment modules were associated care mode, after controlling for patients demographic characteristics and institutional factors. HC had great savings over conventional care. Patients in HC compare with patients in CC were less likely to receive surgery, chemotherapy and anti-neoplasm drug. Among those patients in conventional group, CC_H patients had higher expenditures and were more likely to undergo surgery, chemotherapy and taking anti-neoplasm drug. HC Patients with colorectal and lung cancer tended to receive radiotherapy compare with CC_H and CC_NH patients.
Conclusion: Hospice care consumed less health care resources and had cost-saving benefit. Related policy should be implemented to promote the acceptance of hospice care among patients/family and medical staff in Taiwan.

致　謝 i
論文摘要 ii
Abstract iii
目　錄 v
表目次 vii
圖目次 ix
第一章　緒論 1
第一節　研究背景與動機 1
第二節　研究重要性 3
第三節　研究目的 4
第二章　文獻探討 5
第一節　安寧療護的緣起與發展 5
第二節　安寧療護臨終醫療費用與處置相關文獻 11
第三節　安寧療護臨終費用、處置之影響因素相關文獻 16
第三章　研究方法 18
第一節　研究架構 18
第二節　研究假說 19
第三節　研究材料與選樣流程 20
第四節　研究變項與操作型定義 23
第五節　資料處理與統計分析方法 27
第四章　研究結果 29
第一節　研究對象基本資料描述 29
第二節　病患特質與醫療費用、醫療處置費用分析 36
第三節　照護型態與醫療處置利用描述 42
第四節　病患特質與醫療費用、醫療處置利用之迴歸分析 44
第五章　討論 61
第一節　樣本特性 61
第二節　病患特性與醫療費用、醫療處置費用分析 62
第三節　病患照護型態與醫療費用迴歸分析 64
第四節　病患照護型態與醫療處置利用羅吉斯迴歸分析 65
第六章　結論與建議 67
第一節　結論 67
第二節　建議 68
第三節　研究限制 69
參考文獻 71
附錄一　附表 79
附錄二　安寧整合性療護療護試辦計畫 197
附錄三　全國安寧病房與居家療護分佈 203

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