原發性肝癌病人重複確診之醫療利用情形及其相關因素探討

Abstract

本研究之目的為探討肝癌病人重複確診及越級就醫之情形及其影響因素。研究資料以全民健保資料庫2005-2007年承保抽樣歸人檔第1-25組共百萬人為基礎，定義門、住診主診斷碼為155、155.0、155.2之肝癌病人為研究對象。 研究結果顯示研究期間2005/3-2007/9內有第一次被確診為肝癌病人共1,282人，其中有重複確診共258人，佔20.12%，而這258人當中，往較高層級醫院重複確診者114人最多，佔44.18%；在醫療資源利用部分，258人累計重複診察費用和重複檢查費用（扣除確診當次）為1,070,765元和3,783,983元，分別佔全體肝癌病人之總診察及總檢查費用的24.01%、20.43%。另外在越級就醫方面，肝癌病人在確診罹病後的三個月內，非肝癌疾病之越級就醫門診人次及因越級就醫額外申報點數方面，相較於確診前三個月分別下降17.62%、21.46%。 影響是否重複確診之因素，以男性、有接受治療者、確診科別為其他科、確診醫院層級為地區醫院及基層診所者較容易有重複確診行為；而以無共病情形（C.C.I.為0分）、確診醫院層級越低者，確診後較會往高層級醫院再次就醫。 影響重複檢查、診察、總醫療費用之因素，以就診醫院家數越多、投保薪資越高、無重大傷病紀錄、無肝炎或肝硬化、接受栓塞療法及手術治療者、確診醫院層級越低及在健保局東區分局確診者會容易有較高的重複費用；進一步發現共病情形較為嚴重（C.C.I.為2分及以上）、接受化學治療、栓塞療法、手術及移植及確診醫院在醫學中心者，其第一家重複確診醫院所花費之檢查費用會顯著高於確診醫院（p<0.01）。而影響越級就醫之因素，以投保薪資越高、無肝炎或肝硬化、確診於基層診所及確診在健保局東區分局者較傾向於確診後增加越級就醫行為。 結論：本研究之肝癌病人確診後三個月內約20.1%的病患有重複確診的情形，但確診後相較於確診前，因輕病而越級就醫的百分比則有下降的情況。

The purpose of the study was to understand hepatocellular carcinoma patients’ behavior of repeated medical utilization for disease confirmation and its related factors. Data were came from the longitudinal inpatient and outpatient claims of 100 million sampled registry from Taiwan National Health Insurance Research Database with patients suffering from hepatocellular carcinoma (ICD-9-CM 155, 155.0, 155.2) from 2005 to 2007. There were 1,282 new hepatocellular carcinoma patients in the data and 258 of them (20.12%) were classified as having repeated disease confirmation. Among those 258 patients, 114 patients (44.18%) switched from lower level hospital to higher ones to verify their diagnosis again. In terms of medical utilization, total repeated diagnosis fee and repeated examination fee (excluded the first time disease confirmation fee) were NT$1,272,765 and NT$3,783,983, respectively. The expenditures three months before and after hepatocellular carcinoma patients’ first time diagnosis, there was a 17.62% decrease of outpatient visits and 21.46% decrease of medical costs. Factors associated with repeated disease confirmation were male, received therapy, and first time visit at unspecified department, private and regional hospital. Patients whose Charlson comorbidity index was zero or disease confirmation at lower level hospital had greater chance of seeking reconfirmation at higher level hospital. Hepatocellular carcinoma patients with duplicated medical expenditure tended to have multiple hospital visits, high level of enrollment payroll, did not have a major illness card, without hepatitis and cirrhosis, received embolization and surgical operation, and confirmation in lower level hospital, or hospitals lacated in Eastern Taiwan. Besides, the expenditure of examination in the first-repeated confirmation hospital was higher than that of first-diagnosis hospital (p<0.01), and highly related to having a Charlson comorbidity index greater than two, received chemotherapy, embolization, surgical operation and confirmation in medical center. Moreover, patients who skipped to higher level of hospitals for outpatient visit after confirmation was significantly related to high level of enrollment payroll, didn’t have hepatitis, and confirmation hospital located in eastern Taiwan. Conclusions： Although 20.1% of hepatocellular carcinoma patients had repeated medical utilization to confirm their diagnosis within three months after first time diagnosis, but the percentage of outpatients skipped to higher level of hospitals declined.