台灣癌症病患於死亡前一年健保醫療費用支出之相關因素分析

Factors Affecting the Expenditure of NHI by Taiwanese Cancer Patients in Their Last Year of Life

目的：台灣癌症發生率增加，成為十大死因第一名，同時跟隨醫療費用增加；但近年來健保財務日趨吃緊，如何提高醫療品質與節省醫療經費都是重要課題；本研究的目的在探討影響台灣癌症病患於死亡前一年健保醫療費用的因素，以作為資源分配合理化之參考。方法：本研究取自國家衛生研究院健保資料庫1997-2006年癌症檔，為次級資料，屬回溯性橫斷面研究設計以了解癌症病患於2005年死亡者其前一年內醫療利用情形。除了描述性分析及雙變項分析外，並運用Anderson醫療服務利用的行為模式的前傾因素、需要因素、能力資源因素再加上加護醫療利用因素及醫療服務供給面因素作為自變項，及取對數的醫療費用包括總體、門診、急診、住院費用為依變項以複迴歸及逐步迴歸加以分析。結果：癌症患者死亡前一年醫療費用影響因素中，發現男癌症患者死亡前一年醫療費用影響因素中，發現男性、20歲以下、癌症類別、有其他重大傷病、投保金額在24,000-28,800元級距者、門診利用次數、住院利用次數、使用住院手術、加護病房、安寧照護、放射治療、化學治療，醫學中心及公立醫院與總醫療費用成正相關。關於門診醫療費用則與男性、31-40歲、41-50歲、51-60歲三組、所有癌症類別除了鼻咽癌、膽囊癌、卵巢癌外、投保金額在17,400-22,800元組、門診利用次數、使用住院手術、放射治療、化學治療，醫學中心及公立醫院成正相關。急診醫療費用則與男性、21-30歲、31-40歲、41-50歲、51-60歲61-70歲五組、肝癌、投保金額在48,200-57,800元組、投保地區與治療地區相同者、急診利用次數、住院利用次數、使用住院手術、使用呼吸治療、醫學中心及公立醫院成正相關。住院醫療費用則與男性、20歲以下、所有癌症、有其他重大傷病、投保金額在24,000-28,800元及30,300-36,300元組、急診利用次數、住院利用次數、使用住院手術、使用加護病房、使用安寧照護、利用放射治療、利用化學治療、醫學中心及公立醫院成正相關。結論：本研究指出影響癌症病患於死亡前一年健保醫療費用之相關因素，並建議未來進一步探討臨終醫療服務之適切性，使有限的醫療資源獲得最有效的運用。

Purposes: The increase in the prevalence of cancer, which has become the leading cause of death, and is accompanied with a rise in medical expenses. However, the economic burden of healthcare is more and more critical, the abilities to improve quality and economically use resources are important tasks. Therefore, this research, as a reference for rationalization of medical resource distribution, aims to examine the factors related to the expenditure of NHI by Taiwanese cancer patients in their last year of life. Methods: This research collected cancer files from between 1997-2006 from the National Health Research Institute databases to use as secondary data. It applied a retrospective and cross-sectional study to interpret the expenditure on NHI in 2005 by cancer patients’ during their last year of life. Except for a descriptive analysis and bivariate analysis, the study also employed a multivariable regression analysis and stepwise regression analysis to examine the predisposing factors, need factors and enabling factors developed by the Anderson model and the utilization of intensive care factors, and the supply of medical service factors as independent variables. It then uses the logarithm of total medical expenditure, OPD expenditure, ER expenditure, INP expenditure as the dependent variables for a correlative analysis. Results: Among the factors affecting the expenditure of cancer patients in their last year of life, we found males, under the age of 20, cancer type, insurance amount ranging from NT24,000 to NT288,000, frequency of OPD, frequency of INP, INP surgical operation, intensive care, hospice care, chemotherapy, radiotherapy, medical center, and public hospital had a positive correlation with total medical expenditure. OPD expenditure had a positive correlation with males, age from 31 to 60, all cancer types (excluding nasopharyngeal carcinoma, gallbladder carcinoma, ovarian carcinoma), insurance amount ranging from NT.17,400 to NT.288,000, frequency of OPD, frequency of INP, INP surgical operation, chemotherapy, radiotherapy, medical center, and public hospital. ER expenditure was positively correlated with males, age from 21 to 70, hepatocellular carcinoma, insurance amount ranging from NT.48,200 to NT.57,800, the same place of insurance and treatment, frequency of ER, frequency of INP, ventilator treatment, medical center, and public hospital. INP expenditure was positively correlated with males, under the age of 20, all cancer types, major disease, insurance amount ranging from NT.24,000 to NT.28,800 and ranging from NT.30,300 to NT.36,300, frequency of ER, frequency of INP, INP surgical operation, intensive care, hospice care, chemotherapy, radiotherapy, medical center, and public hospital. Conclusions: This research points out the relative factors affecting the expenditure of cancer patients in their last year of life. Finally, it suggests further study appropriate to the medical service at the point of death and to make available limited resources to obtain effective utilization.