臺灣造血幹細胞移植之醫療利用與存活分析

Abstract

研究目的：探討臺灣造血幹細胞移植病人之醫療利用與存活情形。 研究設計：回溯性研究分析。 研究對象：全民健保資料庫2003年至2006年間，504位施行一次造血幹細胞移植之病人。 主要結果測量：病人移植當次醫療費用及住院天數、移植100天內之總醫療費用（含門診）及住院天數、移植一年內之總醫療費用（含門診）及住院天數，以及病人移植後之存活情形。 研究結果： 本研究移植病人之醫療利用：成人組較非成人組(<18歲)多、男性略多於女性、疾病類型急性骨髓性白血病最多、共病情形以無共病者(CCI為0分)最多、移植方式以異體較多、幹細胞來源以周邊血造血幹細胞移植較多、醫院層級以醫學中心佔大部分；權屬別方面，公立醫學院校附設醫院、榮民醫院及其他類醫院(法人、私人及軍方) 佔率相當；所在分區別以台北分區較多；是否死亡方面，共有175人於觀察期間死亡，其中23人於移植當次死亡。移植當次住院天數中位數為42天，費用中位數為875,177.00元，移植100天內總住院天數中位數為53天、100天內總醫療費用(含門診)中位數為1,047,356.75元。移植一年內總住院天數中位數為71天、移植一年內總醫療費用(含門診)中位數為1,399,816.00元。 與移植當次住院天數之相關因素，異體高於自體，自體方面為疾病類型與移植時間；異體方面為移植年齡、幹細胞來源、是否死亡、醫院權屬別及分局別。與移植100天內總住院天數之相關因素，異體高於自體，自體方面為疾病類型、醫院權屬別、分局別及是否死亡；異體方面為醫院權屬別與分局別。一年內總住院天數之相關因素，異體移高於自體，自體方面為移植年齡、醫院權屬別、分局別及是否死亡；異體方面為醫院權屬別及分局別。移植當次醫療費用之相關因素，異體高於自體，自體方面為疾病類型、醫院權屬別及是否死亡；異體方面為疾病類型、移植時間、幹細胞來源、醫院權屬別與分局別。移植100天內醫療費用之相關因素，異體高於自體，在自體方面為疾病類型、醫院權屬別及是否死亡；在異體方面為疾病類型、移時時間、幹細胞來源、醫院權屬別、分局別及是否死亡。移植一年內醫療費用之相關因素，異體高於自體，在自體方面為醫院權屬別及是否死亡；異體方面為幹細胞來源、醫院所在分局別及是否死亡。造血幹細胞移植之存活相關因素為疾病類型、共病情形、移植時間及移植方式。 研究結論：與我國造血幹細胞移植之醫療利用相關因素有移植年齡、疾病類型、移植時間、移植方式、幹細胞來源、醫院權屬別、醫院分局別及是否死亡；與造血幹細胞移植之存活相關因素有疾病類型、共病情形、移植時間及移植方式。總體上，控制其他變項後，自體移植之醫療利用顯著較低，且存活情形也顯著較異體好。

Objective: To investigate the medical utilization and survival rate of hematopoietic stem cell transplantation (HSCT) in Taiwan. Design: Retrospective study analysis. Subjects: Data on a total of 504 patients who had undergone hematopoietic stem cell transplantation, excluding those who had a second transplant or more, were collected from National Health Insurance research database (2003 to 2006). Results: In terms of medical resource usage, there were more adults than non-adults (under 18), more males than females. Acute myeloid leukaemia ranked highest among diseases, most patients had a Charlson Comorbidity Index (CCI) score of 0, about 64% of total patients received autologous grafts, the most used stem cell source was peripheral blood. In terms of medical institution selected, the majority of patients received care from medical centers and Taipei Branch. In terms of mortality, 175 patients died during the studied period (23 patients died during the initial transplant period). The median lengths of stay (LOS) was 42 days, with a total medical expenditures of NT $875,177.00, the LOS during the first 100 days after transplantation were 53 days with an expenditure of NT $1,047,356.75, and for the first year, the LOS and expenditure were 71 days and NT $1,399,816.00, respectively. The LOS during the initial transplant period was significantly higher for allogeneic HSCT than that of autologous HSCT. The diagnosis and year of transplantation were the important factors for the LOS of autologous HSCT while age, the stem cell source and survival status were that of allogeneic HSCT. The LOS during the first 100 days was significantly higher for allogeneic HSCT than autologous HSCT, with diagnosis, hospital ownership, hospital regions, and survival status being the important factors associated with the LOS of autologous HSCT. Hospital ownership and hospital regions were the important factors associated with the LOS of allogeneic HSCT. The LOS during the first year for allogeneic HSCT was significantly higher than that of autologous HSCT, with age, hospital ownership, hospital regions, and survival status being the important factors associated with the LOS of autologous HSCT. Hospital ownership and hospital regions were the important factors associated with the LOS of allogeneic HSCT. The medical expenditures during the initial transplant period for allogeneic HSCT was significantly higher than that of autologous HSCT. The important factors associated with the expenditures of autologous HSCT were diagnosis, hospital ownership, and survival status while that for allogeneic HSCT were diagnosis, year of transplantation, the stem cell source, hospital ownership and hospital regions. The expenditures during the first 100 days for allogeneic HSCT was significantly higher than that of autologous HSCT. The important factors associated with the expenditures of autologous HSCT were diagnosis, hospital ownership, and survival status and for allogeneic HSCT were diagnosis, year of transplantation, the stem cell source, hospital ownership, hospital regions, and survival status. The expenditure during the first year for allogeneic HSCT was significantly higher than that of autologous HSCT. The important factors associated with the expenditures of autologous HSCT were hospital ownership and survival status and that for allogeneic HSCT were the stem cell source, hospital regions, and survival status. Diagnosis, CCI scores, year of transplantation and donor type were the important factors associated with survival of HSCT. Conclusions: Age, diagnosis, year of transplantation, donor type, the stem cell source, hospital ownership, hospital regions and survival status were important factors associated with the medical utilization of HSCT. Diagnosis, CCI scores, year of transplantation, and donor type were important factors associated with the survival of HSCT. Finally, autologous HSCT has lower medical utilization and better survival rate than allogeneic.