臺灣博碩士論文加值系統

背景與動機：
隨著醫療科技的進步，使人類的壽命延長。當疾病變的不可治癒時，企圖使用多種維生醫療延續病人生命，除了造成病人身心靈上的磨難與病痛、生活品質差、家屬飽受煎熬外，更是有一筆龐大的臨終花費。研究顯示生命末期最後一年的醫療費用有三分之一集中在最後一個月，且病人在死亡前有「高臨終成本」的現象，這些費用主要多來自維生醫療的使用，如呼吸器、心肺復甦等。
目的：
鑒於維生醫療的重要性，本研究企圖描述死亡病人於臨終前一個月有無使用維生醫療之病人特性與分布，並進一步觀察臨終前一個月之醫療利用與費用，且針對各項維生醫療使用組合描述病人特性及臨終前一個月之醫療利用與費用。
方法：
本研究採回溯性次級資料分析，資料來源為衛生福利部健康資料加值應用協作中心2005年世代2007~2011年兩百萬人抽樣檔，研究對象取自死因統計檔2008年至2011年死亡者，經過排除後，研究樣本總數為49,068人。本研究維生醫療定義為呼吸器、心肺復甦術(CPR)、升壓劑、主動脈內氣球幫浦(IABP)、體外膜氧合器(ECMO)、透析等六大維生醫療項目。依據臨終前一個月內於急診或住院有無使用維生醫療之處置碼，分成曾使用維生醫療者、未曾使用維生醫療者，曾使用者再細分成各項維生醫療使用組合，未曾使用者依據臨終前一個月內有無醫療紀錄再細分成兩組。分別描述有無使用維生醫療之病人特性，並將研究對象之死亡日期往前推30日，觀察臨終前一個月內之醫療利用情形。針對各項維生醫療使用組合，依據病人使用情形分成單一、兩種、三種、四種以上(含四種)，分別描述病人特性及臨終前一個月內之醫療利用情形。統計方法為描述性統計，使用統計軟體SAS9.4分析。
結果：
台灣2008~2011年死亡者臨終前一個月有使用維生醫療的比例為53.58%。未使用者在臨終前一個月仍有其他醫療使用占整體27.67%，完全沒有醫療使用則占18.76%。有使用維生醫療者有將近9成使用加護病房；未使用維生醫療但有其他醫療使用者有近7成6使用安寧療護。未使用維生醫療但有其他醫療使用者較有使用維生醫療者平均住院天數減少2天、加護病房住院天數平均減少3天、總醫療費用平均節省66,742元。使用維生醫療比例上以升壓劑使用最高(42.37%)，其次為呼吸器(31.63%)、CPR(20.09%)、透析(4.96%)，主動脈內氣球幫浦(IABP)及體外膜氧合器(ECMO)均不到一成。單ㄧ使用維生醫療有6,618人(25%)、兩種使用有9,346人(36%)、三種使用有9,237人(35%)、四種使用(含以上)僅有1,088人(4%)。四種使用(含以上)其加護病房住院總天數、總醫療費用、住院費用、門診費用、急診費用均較其他維生醫療使用組合天數多、花費多。
結論：
台灣死亡者於臨終前一個月有使用維生醫療將近一半，且有使用維生醫療其醫療利用較未使用者高。本研究僅描述台灣臨終前一個月使用維生醫療之現況，建議後續研究者可進一步探討可能存在的無效醫療。

Background
With the rapid development of medical technology, human life as measured by life expectancy is steadily increasing. However, part of the extended life can be attributable to the use of life-sustaining treatment. Life supported by these treatments sometimes comes with pain and poor quality of life to the patients and their families. More importantly, they will spend a lot on end of life.Life-sustaining treatment is usually used in the end stage of life, accounting for one-third of the lifetime medical use.
Objective
The purpose of this study was to investigate the use of life-sustaining treatment and to estimate medical utilization for people during their final month before death. This study further investigated the use of different combinations of life-sustaining treatment for the users.
Study Design
This descriptive study retrospectively used 2007 to 2012 claims data from the National Health Insurance Research Database. The original sample was two million people randomly drawn from the total population in 2005. The study sample included 49,068 deaths between 2008 and 2011. Life-sustaining treatment was defined as the use of mechanical ventilation, cardiopulmonary resuscitation, vasopressor, intraaortic balloon pumping, extra-corporeal membrane oxygenation and hemodialysis for patients at the critical conditions. According to their use of life-sustaining treatment in the final month before death. Study sample was divided into the use or no use groups. Besides, the use group was further divided into several subgroups based on the use of different life-sustaining treatment. The no use group was further divided into medical subgroup and no medical use subgroup. This study will use SAS 9.4 to descript the study population about medical utilization in the final month before death.
Results
In the study sample, there were 53.58% people who had used life-sustaining treatment, 27.67% people who did not use life-sustaining treatment had medical use, and 18.76% people who both did not use life-sustaining treatment and had no medical use. About 90% of the use group also used ICU service. In the no use group about 76% of medical use subgroup used hospice. The use group had higher lenth of stay, lenth of stay in ICU, and medical costs than the no use group. Vasopressor was often used in the group who had used life-sustaining treatment. In the subgroups of the use of different life-sustaining treatment, 25% used only one, 36% had two, 35% had three, and 4% need four life-sustaing treatments. Furthermore, the use of four life-sustaining treatment had higher lenth of stay in ICU and medical costs.
Conclusion
In Taiwan, there are about 50% usage of life-sustaining treatment for patients in the final month before death. We suggest that further research is needed to better examine the futile treatment potentially existing in the life-sustaining treatments.

誌 謝...................................................i
中文摘要................................................ii
英文摘要................................................iv
目錄...................................................vi
圖目錄...............................................viii
表目錄.................................................ix
第一章 緒論..............................................1
第一節 研究背景與動機....................................1
第二節 研究問題.........................................6
第三節 研究目的.........................................7
第四節 研究重要性........................................7
第二章 文獻探討..........................................8
第一節 維生醫療之概述....................................8
第二節 醫療資源利用之影響因素.............................9
第三節 生命末期醫療耗用之實證研究........................11
第四節 維生醫療耗用之實證研究............................16
第五節 文獻小結........................................21
第三章 研究設計與方法....................................22
第一節 研究架構........................................22
第二節 研究假設........................................24
第三節 研究資料來源與研究對象............................25
第四節 研究變項與操作型定義..............................30
第五節 統計分析方法.....................................40
第四章 研究結果.........................................41
第一節 研究樣本特質描述.................................41
第二節 有無使用維生醫療之情形分布........................43
第三節 有無使用維生醫療者於臨終前
一個月醫療利用與醫療費用之分布.....................50
第四節 各項維生醫療之使用情形與病人特質描述...............61
第五節 各項維生醫療使用組合之病人特質與臨終
前一個月醫療利用與醫療費用之分布...................64
第五章 討論.............................................82
第一節 有無使用維生醫療之情形分佈與
臨終前一個月醫療耗用..............................82
第二節 各項維生醫療使用情形與臨終前一個月醫療耗用..........84
第三節 假說驗證........................................85
第四節 研究限制........................................86
第六章 結論與建議........................................87
第一節 結論............................................87
第二節 建議............................................88
附 錄..................................................89
參考文獻...............................................101


圖目錄
圖 1-1台灣2006-2013年國人常見死因人數分布.................. 4
圖 1-2台灣2006-2013年20~39歲國人常見死因人數分布........... 4
圖 1-3台灣2006-2013年40~64歲國人常見死因人數分布........... 5
圖 1-4台灣2006-2013年65歲以上國人常見死因人數分布.......... 5
圖 1-5台灣2006年~2013年國人平均餘命....................... 6
圖 2-1Andersen第一階段之醫療服務利用行為模式..............10
圖 3-1研究架構..........................................23
圖 3-2研究對象資料處理流程 ...............................29
圖 4-1有無使用維生醫療之死因分布..........................49
圖 4-2各項維生醫療之使用情形..............................62
圖 4-3各項維生醫療組合之使用情形..........................68
圖 4-4單一使用之分布(N=6,618)............................68
圖 4-5兩種使用之分布(N=9,346)............................69
圖 4-6三種使用之分布(N=9,237)............................69
圖 4-7各維生醫療組合之醫療利用分布........................72
圖 4-8各維生醫療組合之醫療費用分布........................73


表目錄
表 1-1台灣2006年~2013年國人總死亡人數與死亡率..............3
表 1-2台灣2006年~2013年國人總死亡人數與死亡率(以性別分).....3
表 1-3台灣2010年透析、呼吸器及葉克膜使用情形 ................3
表 3-1研究資料使用內容...................................25
表 3-2研究對象定義......................................27
表 3-3維生醫療項目之健保處置碼............................30
表 3-4查爾森共病指數疾病加權數............................34
表 3-5研究變項之操作型定義...............................38
表 4-1研究樣本特質分布...................................42
表 4-2有無使用維生醫療之特性..............................46
表 4-3未使用維生醫療之特性 ...............................47
表 4-4有無使用維生醫療之特性(占整體分布)...................48
表 4-5有無使用維生醫療者之死因診斷(占整體分布).............49
表 4-6有無維生醫療者使用加護病房/安寧療護/
呼吸照護病房(中心)之分布.................................55
表 4-7有無使用維生醫療者於臨終前一個月醫療利用
與醫療費用比較..........................................56
表 4-8有使用維生醫療者於臨終前一個月之醫療利用
與醫療費用(N=26,289)....................................57
表 4-9未使用維生醫療但有醫療使用者於臨終前一個月
之醫療利用與醫療費用(N=13,575)...........................59
表 4-10各項維生醫療之使用分布.............................62
表 4-11各項維生醫療使用之病人特性.........................63
表 4-12各維生醫療使用組合之病人特性 .......................70
表 4-13各維生醫療使用組合醫療利用與醫療費用之比較...........72
表 4-14單一使用者於臨終前一個月之醫療利用與醫療費用.........74
表 4-15兩種使用者於臨終前一個月之醫療利用與醫療費用.........76
表 4-16三種使用者於臨終前一個月之醫療利用與醫療費用.........78
表 4-17四種以上使用者於臨終前一個月之醫療利用與醫療費用.....80
附錄表1單一使用維生醫療之病人特性.........................89
附錄表2兩種使用維生醫療之病人特性.........................90
附錄表3三種使用維生醫療之病人特性.........................91
附錄表4單一使用維生醫療(呼吸器)之醫療利用與醫療費用.........92
附錄表5單一使用維生醫療(升壓劑)之醫療利用與醫療費用.........93
附錄表6單一使用維生醫療(透析)之醫療利用與醫療費用...........94
附錄表7單一使用維生醫療(CPR)之醫療利用與醫療費用............95
附錄表8兩種使用維生醫療(呼吸器+升壓劑)之醫療利用與醫療費用...96
附錄表9兩種使用維生醫療(CPR+升壓劑)之醫療利用與醫療費用.....97
附錄表10兩種使用維生醫療(升壓劑+透析)之醫療利用與醫療費用....98
附錄表11三種使用維生醫療(呼吸器+CPR+升壓劑)
之醫療利用與醫療費用.....................................99
附錄表12三種使用維生醫療(呼吸器+升壓劑+透析)
之醫療利用與醫療費用....................................100

中文部分
1.統計處(2014年09月04日)。民國102年死因統計年報。衛生福利部。2015年05月15日，取自：http://www.mohw.gov.tw/CHT/DOS/Statistic.aspx?f_list_no=312&;fod_list_no=5150
2.統計處(2014年)。內政統計年報-簡易生命表。內政部。2015年05月15日，取自：http://sowf.moi.gov.tw/stat/year/list.htm
3.中央健康保險署(2011年09月04日)。洗腎、呼吸器治療及葉克膜健保給付之綜合說明。衛生福利部。2015年04月06日，取自：http://hpe.org.tw/1.1_tsai.pdf
4.劉嘉年, 楊銘欽, &; 楊志良. (2001). 台灣成年民眾於死亡前三個月健保醫療費用支出之影響因素分析. [Factors Affecting the Expenditure of NHI by Adult Beneficiaries in Their Last Three Months of Life in Taiwan]. 臺灣公共衛生雜誌, 20(6), 451-462.
5.吳志鴻. (2006). 科技是延續生命抑或延長死亡. [It is to Be Continued in the Life or the Lengthened in the Death by the Science and Technology]. 哲學與文化, 33(4), 105-118.
6.黃馨葆, 蔡兆勳, 陳慶餘, &; 邱泰源. (2011). 生命末期照顧如何達到好的成本效益. [How to Optimize Cost-Effectiveness in End-of-Life Care]. 安寧療護雜誌, 16(2), 205-216.
7.吳春桂, 林宏茂, 林芳如, 林亞陵, 蔡紋苓, 廖婉伶, 鄭博文,&; 黃勝堅. (2011). 重症生命末期照護之新趨勢. 台灣醫學, 15(1), 37-47.
8.蔡甫昌, 方震中, 陳麗光, &; 王榮德. (2012). 長期呼吸器依賴病患撤除維生治療之倫理法律議題. 台灣醫學, 16(2), 156-173.

英文部分
9.Aizawa, K., Asai, A., &; Bito, S. (2013). Defining futile life-prolonging treatments through Neo-Socratic Dialogue. BMC Med Ethics, 14, 51. doi: 10.1186/1472-6939-14-51
10.Alan M. Garber, T. M., Mark McClellan. (1999). . Frontiers in Health Policy research,, 2, 77-98.
11.Alpert, H. R., &; Emanuel, L. (1998). Comparing utilization of life-sustaining treatments with patient and public preferences. J Gen Intern Med, 13(3), 175-181.
12.Andersen, R. (1968). A behavioral model of families' use of health services. Research Series, 25.
13.Angus, D. C., Barnato, A. E., Linde-Zwirble, W. T., Weissfeld, L. A., Watson, R. S., Rickert, T., &; Rubenfeld, G. D. (2004). Use of intensive care at the end of life in the United States: An epidemiologic study. Critical Care Medicine, 32(3), 638-643. doi: 10.1097/01.ccm.0000114816.62331.08
14.Asch, D. A., Faber-Langendoen, K., Shea, J. A., &; Christakis, N. A. (1999). The sequence of withdrawing life-sustaining treatment from patients. Am J Med, 107(2), 153-156.
15.Barnato, A. E., McClellan, M. B., Kagay, C. R., &; Garber, A. M. (2004). Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Serv Res, 39(2), 363-375. doi: 10.1111/j.1475-6773.2004.00232.x
16.Bentur, N., Resnizky, S., Balicer, R., &; Eilat-Tsanani, T. (2014). Utilization and cost of services in the last 6 months of life of patients with cancer - with and without home hospice care. Am J Hosp Palliat Care, 31(7), 723-725. doi: 10.1177/1049909113499604
17.British Medical Association (2008). Withholding and Withdrawing Life-prolonging Medical Treatment: Guidance for decision making. London: BMJ Books.
18.California HealthCare Foundation. (2013). Measuring up? End-of-life cancer care in california.
19.Chen, J. S., Wang, H. M., Wu, S. C., Liu, T. W., Hung, Y. N., &; Tang, S. T. (2009). A population-based study on the prevalence and determinants of cardiopulmonary resuscitation in the last month of life for Taiwanese cancer decedents, 2001-2006. Resuscitation, 80(12), 1388-1393. doi: 10.1016/j.resuscitation.2009.08.015
20.Charlson, M. E., Pompei, P., Ales, K. L., &; MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis, 40(5), 373-383.
21.D'Hoore, W., Sicotte, C., &; Tilquin, C. (1993). Risk adjustment in outcome assessment: the Charlson comorbidity index. Methods Inf Med, 32(5), 382-387.
22.Danis, M., Mutran, E., Garrett, J. M., Stearns, S. C., Slifkin, R. T., Hanson, L., . . . Churchill, L. R. (1996). A prospective study of the impact of patient preferences on life-sustaining treatment and hospital cost. Crit Care Med, 24(11), 1811-1817.
23.David C. Goodman, A. R. E., Elliott S. Fisher,Chiang-Hua Chang. (2011). Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness.pdf. Dartmouth Institute for Health Policy &; Clinical Practice, 1-44.
24.Deyo, R. A., Cherkin, D. C., &; Ciol, M. A. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol, 45(6), 613-619.
25.Earle, C. C., Neville, B. A., Landrum, M. B., Ayanian, J. Z., Block, S. D., &; Weeks, J. C. (2004). Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol, 22(2), 315-321. doi: 10.1200/JCO.2004.08.136
26.Emanuel, E. J., Ash, A., Yu, W., Gazelle, G., Levinsky, N. G., Saynina, O., . . . Moskowitz, M. (2002). Managed care, hospice use, site of death, and medical expenditures in the last year of life. Arch Intern Med, 162(15), 1722-1728.
27.Esteban, A., Gordo, F., Solsona, J. F., Alia, I., Caballero, J., Bouza, C., . . . Balerdi, B. (2001). Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre observational study. Intensive Care Med, 27(11), 1744-1749. doi: 10.1007/s00134-001-1111-7
28.Gillon, R. (2012). Sanctity of life law has gone too far. Bmj, 345, e4637. doi: 10.1136/bmj.e4637
29.Gilmer, T., Schneiderman, L. J., Teetzel, H., Blustein, J., Briggs, K., Cohn, F., . . . Young, E. (2005). The costs of nonbeneficial treatment in the intensive care setting. Health Aff (Millwood), 24(4), 961-971.
30.Ginzberg, E. (1980). The high costs of dying. Inquiry, 17(4), 293-295.
31.Hatziandreu E, Archontakis F, Daly A, et al. National Audit Office. The potential cost savings of greater use of homeand hospice-based end of life care in England. Cambridge: RAND Corporation, 2008.
32.Jox, R. J., Krebs, M., Fegg, M., Reiter-Theil, S., Frey, L., Eisenmenger, W., &; Borasio, G. D. (2010). Limiting life-sustaining treatment in German intensive care units: a multiprofessional survey. J Crit Care, 25(3), 413-419. doi: 10.1016/j.jcrc.2009.06.012
33.Kinzbrunner BM, Weinreb NJ, Policzer JS. (2002). End of life Care. New York: McGraw-Hill, 29-46.
34.Laishram Ladusingh, A. P. (2013). The High Cost of Dying. Economic &; Political Weekly, xlviiI 11, 44-49.
35.Langton, J. M., Blanch, B., Drew, A. K., Haas, M., Ingham, J. M., &; Pearson, S. A. (2014). Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review. Palliat Med, 28(10), 1167-1196. doi: 10.1177/0269216314533813
36.Liu, C. N., &; Yang, M. C. (2002). National health insurance expenditure for adult beneficiaries in Taiwan in their last year of life. J Formos Med Assoc, 101(8), 552-559.
37.Lubitz, J. D., &; Riley, G. F. (1993). Trends in Medicare payments in the last year of life. N Engl J Med, 328(15), 1092-1096. doi: 10.1056/nejm199304153281506
38.Lunney, J. R., Lynn, J., &; Hogan, C. (2002). Profiles of older medicare decedents. J Am Geriatr Soc, 50(6), 1108-1112.
39.Ottawa. (2007). Health Care Use at the End of Life in Western Canada. Canadian Institute for Health Information, 1-115.
40.Polder, J. J., Barendregt, J. J., &; van Oers, H. (2006). Health care costs in the last year of life--the Dutch experience. Soc Sci Med, 63(7), 1720-1731. doi: 10.1016/j.socscimed.2006.04.018
41.Pronovost, P., &; Angus, D. C. (2001). Economics of end-of-life care in the intensive care unit. Crit Care Med, 29(2 Suppl), N46-51.
42.Rao, J. K., Anderson, L. A., &; Smith, S. M. (2002). End of life is a public health issue. Am J Prev Med, 23(3), 215-220.
43.Reich, O., Signorell, A., &; Busato, A. (2013). Place of death and health care utilization for people in the last 6 months of life in Switzerland: a retrospective analysis using administrative data. BMC Health Serv Res, 13, 116. doi: 10.1186/1472-6963-13-116
44.Rhodes, A., Ferdinande, P., Flaatten, H., Guidet, B., Metnitz, P. G., &; Moreno, R. P. (2012). The variability of critical care bed numbers in Europe. Intensive Care Med, 38(10), 1647-1653. doi: 10.1007/s00134-012-2627-8
45.Riley, G. F., &; Lubitz, J. D. (2010). Long-term trends in Medicare payments in the last year of life. Health Serv Res, 45(2), 565-576. doi: 10.1111/j.1475-6773.2010.01082.x
46.Romano, P. S., Roos, L. L., &; Jollis, J. G. (1993). Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. J Clin Epidemiol, 46(10), 1075-1079; discussion 1081-1090.
47.Shortell S.M. (1984). Factors associated with the use of health service. Edited by Williams, S.J., &; Torrens, P.R., Introduction to Health Service. 2: 49-88.
48.Tanuseputro, P., Wodchis, W. P., Fowler, R., Walker, P., Bai, Y. Q., Bronskill, S. E., &; Manuel, D. (2015). The health care cost of dying: a population-based retrospective cohort study of the last year of life in Ontario, Canada. PLoS One, 10(3), e0121759. doi: 10.1371/journal.pone.0121759
49.Van den Block, L., Deschepper, R., Bossuyt, N., Drieskens, K., Bauwens, S., Van Casteren, V., &; Deliens, L. (2008). Care for patients in the last months of life: the Belgian Sentinel Network Monitoring End-of-Life Care study. Arch Intern Med, 168(16), 1747-1754. doi: 10.1001/archinte.168.16.1747
50.van der Heide, A., Deliens, L., Faisst, K., Nilstun, T., Norup, M., Paci, E., . . . van der Maas, P. J. (2003). End-of-life decision-making in six European countries: descriptive study. Lancet, 362(9381), 345-350. doi: 10.1016/s0140-6736(03)14019-6
51.Verena Menec, L. L., Carmen Steinbach,Okechukwu Ekuma,Monica Sirski,Matt Dahl,Ruth-Ann Soodeen. (2004). Patterns of Health Care Use and Cost at the End of Life.pdf. Manitoba Centre for Health Policy, 1-112.
52.Vincent, J. L. (1999). Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med, 27(8), 1626-1633.
53.Vincent, J.L. (2011). Intensive Care Medicine: Annual Update 2010. Springer New York.
54.Wennberg, J. E., Fisher, E. S., Stukel, T. A., Skinner, J. S., Sharp, S. M., &; Bronner, K. K. (2004). Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States. Bmj, 328(7440), 607. doi: 10.1136/bmj.328.7440.607