| 摘要: | 目的：拜醫療科技進步及國民生活水準提高之賜，台灣國民平均餘命延長，疾病型態改變，尤其是癌症發生率增加，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，在目前醫療服務皆追求高品質與低成本的理念下，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参考。
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觧癌症病患於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傾向因素、需要因素、能力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加以分析。另外為研究癌症患者死亡前一年醫療費用支出這十年來是否有明顯變化，算出1997年至2006年之間每年癌末醫療支出金額及佔總體醫療支出比率、每位癌症病患最後一年醫療耗用平均金額，以trend analysis 統計方法觀察是否有趨勢變化。
結果：從1997年至2006年癌症患者死亡前一年總醫療費用51億元，增加至135億元，同時佔總體醫療費用之比率也由2.15%增加至3.63%，平均每人醫療費用則由147,219元增加至289,200元。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24000-28800元及30300-36300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，同時自1997年至2006年癌症患者死亡前一年不管總醫療費用、每人平均醫療費用或是佔總體醫療費用之比率皆有明顯之成長，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。
Objectives: In virtue of the advancement of medical technology and improvement of the living standard, the average life-span of Taiwanese has been extended. The type of disease changes, especially increase in the prevalence of cancer, has been the leading cause of death, and accompany with the raise of medical expenses. However, economic burden of health care is more and more critical, and under the ideal of pursuit of high-quality and low-cost in medical service, how to improve quality and economize the use of recourses are important tasks. Therefore, this research, as a reference for rationalization of medical resourses distribution, is to examine the factors related to expenditures of NHI by cancer patients in their last one year of life in Taiwan.
Methods：This research collects the cancer files in 1997-2006 from the databases of National Health Research Institutes as secondary data. It applies retrospective and cross-sectional study to interpret the expenditure of NHI in their last one year of life by cancer patients who died in 2005. Except for descriptive analysis and bivariate analysis, it also employes multivariable regression analysis and stepwise regression analysis to take predisposing factors need factors, enabling factors developed by Anderson model and utilization of intensive care factors, supply of medical service factors as independent variables, and then takes logarithm of total medical expenditure, OPD expenditure, ER expenditure, INP expenditure as dependent variables to make correlative analysis.
In addition, this research also studies whether the obvious change in expenditure of cancer patients in their last one year of life or not, and figures rate of cancer expenditure per year from 1997 to 2006, average expense per cancer patient in the last one year of life, and observes trend change through trend analysis.
Results：among the factors affecting the expenditure of cancer patients in their last one year of life, we find male, under age 20, cancer type, insurance amount of money range from NT$.24,000 to NT$.288,000, frequency of OPD, frequency of INP, INP surgery, intensive care, hospice care, chemotherapy, radiotherapy, medical center and public hospital have positive correlation with total medical expenditure.OPD expenditure has positive correlation with male, age from 31 to 40, age from 41 to 50, age from 51 to 60, all cancer types excluding nasopharyngeal cancer, gallbladder cancer, ovarian cancer, insurance amount of money range from NT$.17,400 to NT$.288,000, frequency of OPD, frequency of INP, INP surgery, chemotherapy, radiotherapy, medical center, public hospital. ER expenditure has positive correlation with male, age from 21 to 30, age from 31 to 40, age from 41 to 50, age from 51 to 60, age from 61 to 70, hepatocellular carcinoma, insurance amount of money range from NT$.482,00 to NT$.57,800, the same place of insurance and treatment, frequency of ER, frequency of INP, ventilator treatment, medical center, public hospital. INP expenditure has positive correlation with male, under age 20, all cancer types, major disease, insurance amount of money range from NT$.24,000 to NT$.28,800 and range 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, public hospital. There cost from NT$.5.1 billion increases to NT$.13.5 billion in the expenditure of last one year of life by cancer patients from 1997 to 2006, the ratio from 2.15﹪raise to 3.63, per patient from NT$.147,219 to NT$.289,200 , all above have obvious grow up.
Conclusion：This research points out the relative factors affecting the expenditure of cancer patients in their last one year of life, both in total medical expenditure and percentage of overall NHI budget are remarkable increase. Finally, it suggests to further study appropriation of medical service at the point of death and to make limited resource to get effective utilization. |
