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研究生:陳誼芬
研究生(外文):Yi Fen Chen
論文名稱:B型肝炎患者就醫型態及醫療耗用之分析
論文名稱(外文):Analysis of Patterns of Medical Visits and Consumption among Hepatitis B Virus (HBV) Infected Patients
指導教授:許光宏許光宏引用關係
指導教授(外文):Kuang-Hung Hsu
學位類別:碩士
校院名稱:長庚大學
系所名稱:企業管理研究所
學門:商業及管理學門
學類:企業管理學類
論文種類:學術論文
論文出版年:2008
畢業學年度:96
論文頁數:125
中文關鍵詞:B型肝炎感染治療就醫型態醫療耗用藥品市場
外文關鍵詞:HBV InfectionTreatmentsMedical VisitsMedical ConsumptionsPharmaceutical Market
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B型肝炎在全球是相當普遍的一種傳染性疾病,而且是導致肝硬化及肝癌發生之主要因素。慢性B型肝炎(HBV)的感染造成了社會極沉重的經濟壓力及負擔。在台灣,由於病毒性肝炎的發生率持續的上升,使得肝硬化及肝癌的好發率增加而導致罹病率及死亡率的居高不下。根據調查研究顯示,大多數的慢性病毒性肝炎多半為B型肝炎所引起的,因此,本篇研究選擇B型肝炎感染為主要之研究主題。本研究從現有之HBV相關文獻所發現的三個主要問題作探討: 首先針對於治療B型肝炎,就B肝病患及醫療提供者所呈現之趨勢及特性作探討,其次,對於健康保險提供者針對治療B型肝炎所作的努力及醫療耗用部分做討論,最後則是針對B型肝炎,經由分析醫療保健機構及醫藥公司之適切性及經濟面考量來提出一些建議及可能之未來方向。

本篇論文所使用的研究工具為SAS 9.1,利用此套裝軟體幫助我們從健保資料庫中的疾病分類碼(ICD-9-CM)篩選出B型肝炎(HBV)的患者以作為進一步之分析。爾後,分別就五大屬性:性別、年齡、地理分布、就醫醫院評鑑等級以及專科別分別作探討,再將HBV患者分成門診(OPD)及住院(ADM)兩大類分別就以上所述之五大屬性與慢性B型肝炎常用之五種藥品之相關屬性作進一步之研究分析。分析資料過程中,使用了邏吉斯迴歸,探討各變項對於B型肝炎之治療及醫療耗用之相關。

從1997年到2006年,這十年來累計總共有1,451,514位B型肝炎患者接受治療,而總治療次數達到 3,938,345人次。在醫療耗用及藥品支出部份,這十年間累計花費分別為NT$ 7,103,042,061及NT$ 1,481,953,748。病患屬性部份,接受治療之B型肝炎患者大部分集中在31-50歲,其接受治療的醫院評鑑等級多集中在大城市中的醫學中心及區域級醫院。本研究所選定的藥物中,就B肝病患的年齡、地理分佈、就醫醫院評鑑等級和專科別上都呈現出與治療行為有達到統計上顯著差異。而根據本研究結果,在藥品市場預估上,台灣常用來治療B型肝炎之干擾素及抗病毒藥物仍呈現持續成長的趨勢。本研究結論顯示了台灣B型肝炎患者的就醫型態及醫療耗用之重要相關,期望藉此研究結果可以發展出台灣未來對於B型肝炎預防及治療上的策略,以降低此傳染病帶給全人類的影響。
Hepatitis B is an infectious disease the most common seen in the world, and also the leading cause of liver cirrhosis and hepatocellular carcinoma (HCC). Chronic hepatitis B virus (HBV) infection is a massive economic burden for society. The incidence of hepatitis viral infection is continuously increasing in Taiwan, which leads to higher morbidity and mortality due to liver cirrhosis and liver cancer. According to research, the majority of hepatitis viral infections are due to hepatitis B. Consequently, we have selected hepatitis B infection as the main topic of this research. This thesis analyzes three major issues raised by the existing literatures on hepatitis B. Firstly, the trend and characteristics of both patients and providers conducting treatments for hepatitis B viral infection. Secondly, the efforts and cost spent by the health insurance to the treatments of hepatitis B infection. Thirdly, suggestions can be made by the analyses to both insurance institutes and pharmaceutical industry regarding appropriateness and economic concerns of such disease.

This study used SAS 9.1 software package to manage BNHI database and to extract HBV patients with selected ICD-9-CM code for further analyses. Variables available for HBV infected patients were found as age, sex, geography distribution, level of healthcare institutes, and prescription code. Patients were divided into OPD (out-patient sector) and ADM (in-patient sector) under five selected hepatitis B treatment drugs. Multiple logistic regression analyses were applied to identify factors related to the treatment and medical consumptions.
During the past ten years from 1997 to 2006, 3,938,345 medical visits from 1,451,514 HBV patients received medications. Medical expenditures and drug cost within 10 years were totaled as NT$ 7,103,042,061 and NT$ 1,481,953,748, respectively. The highest likelihood of age group seeking HBV treatment was found between 31 and 50 years old. Most HBV patients received their treatment in medical centers and regional hospitals located in high-urbanization cities. Patient’s age, geographic distribution, level of health care institutes, and specialty were shown as factors associated with treatment behaviors in the selected medication drugs. Market estimation for HBV infection treated drugs such as Interferon and antiviral agents will be continuously increasing in Taiwan’s market. In summary, this study has demonstrated some specific patterns in medical visits and medical consumption of HBV treatments, which offers insights for future strategy in prevention and treatment of HBV infection in Taiwan.
TABLE of CONTENTS

CHAPTER I Introduction…………………………………... 1
1.1 Background and Motives………………………………….. 1
1.2 Objectives………………………………………………….. 3
CHAPTER II Literature Review…………………………………… 4
2.1 Overview of the Liver……………………………………… 4
2.2 Evaluation of Liver Function………………………………. 6
2.3 Viral Hepatitis………………………………………………. 7
2.4 Chronic Hepatitis…………………………………………… 9
2.5 Hepatitis B………………………………………………….. 10
2.6 The Prevalence/Epidemiology of Hepatitis B……………… 15
2.7 The Prevention of Hepatitis B……………………………… 22
2.8 Burden for The Next 20 years……………………………… 25
2.9 The Epidemiology and Prevention in Taiwan……………… 26
2.10 Diagnosis of Hepatitis B…………………………………… 30
2.11 Treatment of Hepatitis B…………………………………… 32
2.12 Summary of Medical Expenditure for Hepatitis B
Virus Infection……………………………………………… 39
CHAPTER III Materials and Methods……………………………… 46
3.1 Research Design……………………………………………. 46
3.2 Research Agenda…………………………………………… 46
3.3 Subjects and Materials……………………………………… 47
3.4 Statistical Methods………………………………………….. 51
3.5 Research Hypotheses………………………………………... 52
CHAPTER IV Results……………………………………………….. 54
4.1 Descriptive Statistics………………………………………… 55
4.2 Medical Expenditure and Drug Cost of HBV Treatment……. 60
4.3 Factors Associated with HBV Treatments…………………… 64
CHAPTER V Discussion……………………………………………... 92
5.1 Influencing Factors…………………………………………… 92
5.2 Medical Expenditure and Drug Cost…………………………. 96
5.3 Market Estimation……………………………………………. 97
5.4 Research Limitation…………………………………………... 100
CHAPTER VI Conclusions and Suggestions…………………………...101
6.1 Conclusions…………………………………………………...101
6.2 Suggestions…………………………………………………...103
REFERENCES………………………………………………………….105





















TABLES

Table 1 Causes of acute hepatitis…………………………………. 8
Table 2 Overview of viral hepatitis……………………………….. 8
Table 3 The survival rate versus the severity of hepatitis B………. 13
Table 4 Prevalence of HBsAg in healthy adults…………………… 19
Table 5 Prevalence of HBeAg in adult carriers of HBsAg………… 22
Table 6 Impact of universal childhood immunization programmes:
carriage rate in preschool and early school aged children
before and after the program………………………………. 25
Table 7 Interpretations of available serologic test results for HBV… 31
Table 8 Approved hepatitis B drugs in the United States…………… 35
Table 9 Medical Expenditure Summary…………………………….. 40
Table 10 ICD-9 Codes of Hepatitis B Virus………………………….. 48
Table 11 Number of HBV Patients…………………………………… 49
Table 12 Medical Visit Frequency of HBV Patients…………………. 49
Table 13 BNHI substations by district……………………………….. 50
Table 14 HBV patient medical visit frequency under BNHI substation. 58
Table 15 HBV patient medical visit frequency in healthcare provider... 59
Table 16 Medical expenditure of HBV infection……………………… 61
Table 17 Drug cost versus total medical expenditure in HBV treatment 63
Table 18 The cost of five targeted drugs for HBV treatment…………. 64
Table 19 Univariate Output Report of Zeffix, Pegasys & Roferon-A in
OPD Sector…………………………………………………. 66
Table 20 Univariate Output Report of Hepsera & Intron A in OPD
Sector……………………………………………………….. 67
Table 21 Univariate Output Report of Zeffix, Intron A in ADM Sector. 68
Table 22 Univariate Output Report of Roferon- A, Pegasys & Hepsera
in ADM Sector………………………………………………. 69
Table 23 Logistic Regression Output Report of Zeffix in OPD sector... 71
Table 24 Logistic Regression Output Report of Hepsera in OPD sector 73
Table 25 Logistic Regression Output Report of Pegasys in OPD sector 75
Table 26 Logistic Regression Output Report of Intron A in OPD sector 77
Table 27 Logistic Regression Output Report of Roferon-A in OPD
Sector……………………………………………………….. 79
Table 28 Logistic Regression Output Report of Zeffix in ADM sector.. 81
Table 29 Logistic Regression Output Report of Hepsera in ADM
sector……………………………………………………….. 82
Table 30 Logistic Regression Output Report of Pegasys in ADM
Sector……………………………………………………….. 83
Table 31 Logistic Regression Output Report of Intron A in ADM
Sector……………………………………………………….. 86
Table 32 Logistic Regression Output Report of Roferon-A in ADM
Sector………………………………………………………. 87
Table 33 Overall result of significant difference in OPD sector……... 89
Table 34 Overall result of significant difference in ADM sector…….. 90
Table 35 Total HBV expenditure versus total BNHI expenditure……. 97





FIGURES

Figure 1 The identification of acute and chronic hepatitis B………. 11
Figure 2 Flow chart of data collection and management…………... 47
Figure 3 HBV patient number per year…………………………….. 55
Figure 4 The age distribution of HBV patients……………………... 56
Figure 5 Number of patients by gender……………………………... 57
Figure 6 HBV patients distribution in healthcare provider level…… 60
Figure 7 Sales trend of targeted HBV drugs………………………... 98
Figure 8 The market estimation…………………………………….. 99
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Vahep?page=basics-09-01
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