臺灣博碩士論文加值系統

摘要
動機：台灣2013年十大死因之死亡人數約占總死亡人數之77.2%，其中以慢性疾病為主，惡性腫瘤自1982年起連續32年高居國人死因第一位。其中又以肺癌、肝癌、結腸直腸癌為癌症死亡的主因。
目的：本研究主要的目的乃在於探討桃竹苗地區公私立區域醫院大腸直腸癌患者對健保醫療資源耗用之情形，並瞭解其癌症因治療情況的不同對醫療耗用情形之差異；及罹患癌症的病患在不同特性的醫院治療時，其醫療耗用情形的差異。
方法：本研究以2008年至2012年四年之大腸直腸癌住院病患為主要對象，所使用之資料來自國家衛生研究院，為學術研究用而提供之全民健康保險，資料依照國際疾病診斷分類第九版臨床修正版為主，診斷碼前三碼為153與154之大腸直腸癌患者住院天數與相關之變項進行統計分析，收集國家衛生研究院全民健保險資料庫之特定主題─住院醫療費用清單明細檔（DD）、基本資料檔-重大傷病證明明細檔（HV）、醫事機構基本資料檔（HOSB）等資料庫加以整理分析。以SPSS19.0進行統計分析。首先以描述性統計分析病患特性（如年齡層、性別），分析範圍涵蓋就醫人數、性別、就醫特性，並以醫療機構類別（公私立醫院、區域醫院）和就醫科別（直腸外科、外科）分別醫療費用、住院天數的平均數與標準差，後以t-test、One-Way ANOVA方式分析顯著性並輔以事後檢定，找出各組別之差異，本研究統計顯著差異值（α）定義為0.05。
結果：研究資料中顯示桃竹苗地區公私立區域醫院大腸直腸癌收案病人有533人，共1799住院人次。平均就醫次數，公立醫院為3.68次，私立醫院為3.06次，公立醫院病人住院年齡平均為68.97歲，私立醫院平均為65.50歲，達顯著差異。公立醫院病人住院年齡平均為70.06歲，私立醫院平均為64.60歲，以縣市別區分，苗栗住14.36天，桃園住13.53天，新竹住10.16天，達顯著差異。病患出院狀況以改門診治療最多，佔87.8%（1580人次），在就醫科別方面，則以直腸外科佔最多36.6%、其次為血液腫瘤科佔24.5%，外科佔22.0%，權屬別以公立醫院此類病患住院人次最多，佔55.5%（998人次），病患特質在住院次數方面，以住院1次為209人的占最多39.2%，其次是住院2次為118人占22.1%。
結論：大腸直腸癌新病人第1年的住院醫療利用以公立醫院病人住院次數較私立醫院多（0.62次），公立醫院收治病人年齡較私立醫院高（3.47歲），性別及部分負擔則無顯著差異。
關鍵字：大腸直腸癌、醫療資源利用、醫院權屬別

Abstrast
　　Purposes: Top ten death causes were chronic diseases and they conducted 77.2% of the total death cases in 2013 at Taiwan. The major purpose for this study was evaluated the utilization between public or private hospitals at north Taiwan.
Methods: Regional hospital at north Taiwan, there discharge data on colon-rectum cancer patients (n=533) were analyzed. Dataset from the national health insurance research database, there are includes Registry for contracted medical facilities (HOSB), Inpatient expenditures by admissions (DD), and Registry for catastrophic illness patients (HV). The student t-test, one-way ANOVA and chi-squire test were used and to account within these 12 hospitals.
Results: There were 1,799 inpatient times during the first year of 2012. Hospitals differed significantly in length of stay, age; the public hospital has higher than the private hospitals (3.06 vs 3.68; 68.97 vs 65.50), initially. Gender and coinsurance were not different factors in the expenditure data.
Conclusions: No matter for the factors of average length of stay or age, there in the public hospitals were more than private hospital; however, the total charge amount, coinsurance were not differences between the two kinds of hospitals.

Keywords: Colon-rectum Cancer, Utilization Review, Hospitals Differed Significantly

目錄 頁次
誌謝 I
中文摘要 II
英文摘要 IV
目錄 V
圖目錄 VII
表目錄 VIII

第一章 緒論 1
1.1研究背景 1
1.2研究動機 1
1.3研究目的 2
第二章 文獻探討 3
2.1全民健康保險資料庫 3
2.1.1健保資料結構 3
2.1.2醫療利用類 3
2.1.3住院醫令系統檔 4
2.2醫療服務利用的理論模式 4
2.2.1第一階段醫療服務利用行為模式 5
2.2.2第二階段醫療服務利用行為模式 6
2.2.3第三階段醫療服務利用行為模式 8
2.2.4第四階段醫療服務利用行為模式 9
2.3大腸直腸癌簡介 10
2.3.1大腸直腸癌的形成及分期 10
2.3.2大腸直腸癌發生相關因素 11
2.3.3大腸直腸癌的診斷 12
2.3.4大腸直腸癌的臨床症狀 14
2.3.5大腸直腸癌的發生率 14
2.4醫院權屬別與醫療資源耗用關係 14
2.5不同類型醫院經營績效之比較 16
2.6癌症醫療費用 17
2.7病患特質影響醫療費用耗用之相關因素 19
2.7.1性別對醫療資源耗用之影響 19
2.7.2年齡對醫療資源耗用之影響 20
2.7.3出院狀況對醫療資源耗用之影響 20
2.7.4醫院整體效率 21
2.7.5實施臨床路徑 21
2.7.6選擇病人 21
2.7.7控制住院天數 22
第三章 研究設計與實施 25
3.1研究假設 25
3.2研究架構 25
3.3研究對象與資料來源 26
3.4研究變項與操作型定義 28
3.5研究分析 31
第四章　研究結果 32
4.1結腸直腸癌病患特性之描述性統計 32
4.2不同病患特性與醫院特性之總醫療資源耗用差異分析 34
第五章　結論與建議 36
5.1結論 36
5.2研究建議 36
參考文獻 38
附錄一、住院醫療費用清單明細檔[適用96~100年資料] 43
附錄二、重大傷病證明明細檔[適用101年以後資料] 50
附件三、健保資料譯碼簿-醫事機構基本資料檔 51

一、英文文獻
1. Andersen, R. A. ( 1968). A behavioral madel of families’ use of health service Research, No. 23, Center for Health Administration Studies. Illinois: University of Chicago.
2. Aday, L. A. and Andersen, R. M. (1974). A Framework for the Study of Access to Medical Care. Health Service Research, 9(3), 208-220.
3. Aday, L. A. and Shortell, S. (1988). Indicators and Predicators of Health Service Utilization. Introduction to Health Service (3rd ed.). New York: A Wiley Medical Publication.
4. Aday, L. A. and Andersen, R. M. (1995). Revisiting the Behavior Model and Access to Medical Care: Dose it Matter? Journal of Health and Social Behavior, 36, 1-10.
5. Angela G.E.M de Boer, W. W. and Hanneke C. J. M. de Haes. (1997). Predictors of health care utilization in the chronically ill: a review of the literarure. Health Policy, 42, 101-115.
6. Baker, C. M., Messmer, P. L., Gyurko, C. C., et al. (2000). Hospital ownership, performance, and outcomes: Assessing the state-of-the-science. J Nurse Adm, 30, 227-240.
7. Chaudhry, R., Goel, V., and Sawka, C. (2001). Breast cancer survival by teaching status of the initial treating hospital. Canadian Medical Association Journal, 164(2), 183-188.
8. Devereaux, P. J., Choi, P. T. L., Lacchetti, C., Weaver, B., Schunemann, H. J.,Haines,T.,
Lavis, J. N., Grant, B. J. B., Haslam, D. R. S., Bhandari, M., Sullivan,T.,Cook, D. J., Walter, S. D., Meade, M., Khan, H., Bhatnagar, N., and Guyatt, G.H. (2004). A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. Canadian Medical Association Journal, 166(11), 1399-1406.
9. Fantini, M. P., Cisbani, L., Manzoli, L., Vertrees, J., and Lorenzoni, L. (2003). On the use of administrative databases to support planning activities: The case of the evaluation of neonatal case-mix in the Emilia–Romagna region using DRG and APR–DRG classification systems. Eur J Public Health,13, 138-145.
10. Forde, K. A. (2006). Colonoscopic screening for colon cancer. Surg Endosc, 20(2), 471-474.
11. Friedman, B., and Shortell, S. (1988). The financial performance of selected investor-owned and not-for-profit system hospitals before and after Medicare prospective payment. Health Services Research, 23(2), 237 –267.
12. Harrington, C., Woolhandler, S., Mullan, J., Carrillo, H., and Himmelstein, D. U. (2001). Does investor ownership of nursing homes compromise the quality of care? American Journal of Public Health, 91(9), 1452-1455.
13. Jemal, A., Siegel, R., Ward, E., Murray, T., Xu, J., (2008). Thun MJ. CA Cancer J Clin, 57(1), 43-66.
14. Li, T., and Rosenman, R. (2001). Cost inefficiency in Washington hospitals: A stochastic frontier approach using panel data. Health Care Management Science, 4(2), 73-81.
15. Liljegren, A., Lindblom, A., Rotstein, S., Nilsson, B., Rubio, C., and Jaramillo, E. (2003). Prevalence and incidence of hyperplastic polyps and adenomas in familial colorectal cancer: correlation between the two types of colon polyps. Gut, 52(8), 1140-1147.
16. Mandelblatt, J., Andrews, H., Kerner, J., Zauber, A., and Burnett, W. (1991). Determinants of late stage diagnosis of breast and cervical cancer: the impact of age, race, social class, and hospital type. American Journal of Public Health, 81(5), 646-649.
17. Matthew, G. K. （1971）, Measuring need and evaluating services.In:G.McLachlan, (2nd ed.). Porfolio for Health Problems and Progress in Medical Care. Oxford University Press: London.
18. McGregor, M. J., Cohen, M., McGrail, K., Broemeling, A. M., Adler, R. N., Schulzer, M., Ronald, L., Cvitkovich, Y., and Beck, M. (2005). Staffing levels in not-for-profit and for-profit long-term care facilities: Does type of ownership matter? Canadian Medical Association Journal, 172(5), 645-649.
19. Olin, G. L., and Rhoades, J. A., (2005). The Five Most Costly Medical Conditions, 84 Estimates for the U.S. Civilian Noninstitutionalized Population Statistical Brief Retrieved May