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標題: | 馬祖地區遷徙及預防健康照護對於死亡率及罹病率的影響 Migration, Demographic, and Preventive Health Services Studies on Mortality and Morbidity in Matsu |
作者: | Meng-Kan Chen 陳孟侃 |
指導教授: | 陳秀熙 |
關鍵字: | 移民,性別差異,死亡率,預防健康照護,成本效益分析, Migration,Gender gap,Mortality,Preventive health services,Cost effectiveness analysis, |
出版年 : | 2010 |
學位: | 博士 |
摘要: | 研究背景:許多研究,已經證實居住在較貧瘠的地區的居民有較高的死亡率與罹病率;在大部分的已開發國家或地區中,男女性別間對於死亡率與罹病率的差異也一直存在;許多文獻也已證實預防性的健康照護對於癌症預防的有效性;隔絕於台灣海峽的馬祖列島,許多居民因為經濟考量,移民到台灣,正好提供自然機會去探討移民與非移民主要疾病死亡率與發生率之差別,並深入探究各項預防性健康照護服務對於馬祖地區癌症預防的成本效益。
研究目的: (1)移民研究,在”遷徙至生活較富裕的地區,將導致死亡率及罹病率降低的假說下”,探討馬祖居民移民到生活條件較為富裕的台灣,死亡率是否因而降低?(2)性別差異研究,探討馬祖籍族群男、女間死亡率及特殊死因死亡率,及癌症發生率的差異。(3)探討各項預防性健康照護服務對於馬祖籍族群癌症預防的成本效益分析。 研究對象:以1997年馬祖族群共13,691人納入研究,該族群男性為6,750人,女性為6,941人,進一步畫分為3,666位馬祖籍本地居民與10,025遷徙至台灣的馬祖籍移民。進行三十歲(含)以上的族群性別間死亡率,與移民族群與本地居民間死亡率觀察研究。研究所得的人口學特徵,進一步應用至子宮頸癌、大腸直腸癌與胃癌的疾病自然史進行模擬研究。 測量結果:我們以累積死亡率與標準化死亡率(以1970年台灣人口為標準化人口)進行性別與族群之間的比較;使用波以松迴歸模式檢定性別與族群之間的全死因與特殊死因的死亡率差異。並將主要癌症的累積死亡率拆解成累積疾病發生率與存活率進行性別與族群之間的比較。 針對預防型健康照護服務部分,我們建構馬可夫決策分析模式,進行子宮頸癌、大腸直腸癌與胃癌的不同預防策略相對於基準比較策略(例如:子宮頸癌預防為三年一次的子宮頸抹片檢查,大腸直腸癌與胃癌則為”不做篩檢”) 間的成本效益分析;並採用機率性方式,製畫一系列模擬成本效益點狀圖於成本效益平面象限圖上,並製作不同比較策略的接受度曲線。 結果:(1) 相較於馬祖籍本地居民,馬祖籍移民的全死因死亡率相對危險性為1.24 (95% 信賴區間: 1.08, 1.42),在癌症死亡與糖尿病死亡的方面也呈現相類似的結果,分別的相對危險性為1.25 (95%信賴區間: 1.001, 1.57) 與1.93 (95% CI: 1.20, 3.10)。而在馬祖籍移民族群,也有較高的全癌症與三大癌症(肝細胞癌、胃癌與肺癌)發生率;在癌症存活率部分,除了移民的男性肝細胞癌患者有較差的存活率外,其餘癌症的存活率在馬祖籍本地居民與馬祖籍移民間沒有顯著的差異。 (2) 在性別的研究中,相較於女性,男性的全死因死亡率的相對危險性為1.93 (95%信賴區間:1.68, 2.24);癌症死亡、心血管疾病與意外傷害死亡,在性別間也呈現類似狀態,分別的相對危險性為2.68 (95%信賴區間: 2.11, 3.40)、2.02 (95%信賴區間:1.29, 3.17)與1.98 (95%信賴區間: 1.13, 3.47);而男性相較於女性也有較高的累積癌症及主要癌症(肝細胞癌、胃癌與肺癌)發生率,然而主要癌症的存活率在性別之間沒有顯著性差異。 (3) 在預防性健康照護的成本效益分析部分,相較於三年一次的子宮頸抹片檢查,每年一次的子宮頸抹片檢查為最符合成本效益的策略(增加成本效益比為$30,237-$30,616),接著為三年一次合併人類乳突病毒去氧核醣核酸檢測與子宮頸抹片檢查(增加成本效益比為$34,917-$35,436)與疫苗注射合併三年一次的子宮頸抹片檢查(增加成本效益比為$41,180-$42,543),在$40,000的付費意願值下,分別符合成本效益的機率為67.6-68.56%、55.68-56.3%與40.94-42.84%。若疫苗的價格可以降至$250,疫苗合併三年一次抹片檢查可以與每年一次抹片檢查達到相同的成本效益。 在大腸直腸癌方面,相較於不做篩檢,最符合成本效益的策略為每年一次的免疫法糞便潛血檢查(增加成本效益比為$812),接著為兩年一次的免疫法糞便潛血檢查(增加成本效益比為$2958);相較於每年一次的化學法糞便潛血檢查,在$40,000的付費意願值下,每年一次、每兩年與每三年免疫法糞便潛血檢查符合成本效益的機率分別為100%、87.16%與29.94%。 在胃癌部分,相較於不做篩檢,最符合成本效益的策略為終生一次的幽門螺旋桿菌根除治療(增加成本效益比分別在馬祖籍本地居民為$30,053與在馬祖籍移民為$18,102),接著在馬祖籍本地居民為四年一次的幽門螺旋桿菌根除治療(增加成本效益比$133,567)與在馬祖籍移民為五年一次的幽門螺旋桿菌根除治療(增加成本效益比$78,355);相較於不做篩檢,在$40,000的付費意願值下,終生一次幽門螺旋桿菌根除治療符合成本效益的機率分別在馬祖籍本地居民為55.01%與在馬祖籍移民為61.86%。所有的預防性健康照護服務策略都可造成馬祖族群的癌症死亡率與全死因死亡率的降低。 結論:在移民的研究中,透過移民同文同種的特性來控制基因對疾病的影響,我們觀察到馬祖籍族群的移民有較高死亡率可能來自於較高的重大癌症發生率;這種”遷徙至較富裕地區反而造成較高的死亡率與癌症發生率”的矛盾現象,可能導因於移民所經歷的都市化過程而引進的生活習慣改變與環境改變;而性別間死亡的差異現象,則來自於癌症、心血管疾患與意外死亡相關,而進一步研究亦顯示在癌症的發生率方面,也存在有性別間差異現象,除了以性別間生理差異解釋外,與性別相關的危險行為、暴露與生活習慣都與癌症發生有關;雖然生理性差異是無法改變的,改變性別相關的危險行為或暴露與中斷癌症發生的致癌途徑,將有助於縮小性別間差距。就子宮頸癌預防方面,每年一次的子宮頸抹片篩檢仍是最為符合成本效益的策略,在合理的付費意願閥值下,三年一次的人類乳突病毒去氧核醣核酸檢測與子宮頸抹片檢查也是一個符合成本效益的選擇,而未來在大規模施打人類乳突病毒疫苗的經濟規模下,疫苗注射合併三年一次的子宮頸抹片檢查將有可能符合成本效益。在大腸直腸癌與胃癌預防方面,在合理的付費意願閥值下,每年一次免疫法糞便潛血檢查與終生一次的幽門螺旋桿菌根除治療,為最為符合成本效益的馬祖族群社區預防策略;模擬的結果可以提供,借由預防性健康照護服務中斷癌症發生的致癌機轉來縮短族群間差異的借鏡。 Background and Objectives: To investigate whether mortality decreased as the Matsu people migrated to more affluent areas, which disease accounted for the differences between genders and whether preventive services against cervical cancer, colorectal cancer and gastric cancer are cost-effective in Matsu. Setting and Participants: In 1997, a population of 13,691 people was enrolled. The population (6750 males and 6941 females) was divided into a Matsu resident group, comprising 3,666 individuals, and an emigrant group, comprising 10,025 emigrants from Matsu to Taiwan. Observation of mortality in those above age 30 between genders in the Matsu population was conducted. The demographic characteristics were applied to simulate the natural history of cervical cancer, colorectal cancer and gastric cancer in Matsu. Main outcome measurements: Cumulative and standardized mortality rates between Matsu residents and Matsu emigrants as well as between genders were compared. Poisson models were used to analyze the effects of migration and gender in analyses of mortality. Cancer incidence and survival time of major cancers between the residents and emigrants as well as between genders were compared. Markov decision models were constructed to compare total costs and effectiveness between different preventive strategies against cervical cancer, colorectal cancer and gastric cancer. Probabilistic cost-effectiveness (C-E) analysis was adopted to deal with the uncertainty of parameters. Results: For all causes of mortality, the adjusted relative risk was 1.24 (95% CI: 1.08, 1.42) for emigrants compared to residents. Emigrants also had a higher risk of death from cancer and diabetes. Higher cumulative incidences in emigrants for all cancers and the three leading cancers (hepatocellular carcinoma, gastric cancer and lung cancer) were also observed, but no significant difference in cancer survival time was noted between the two groups, with the exception of male patients with hepatoma. In the study of gender, for all causes of mortality, the adjusted relative risk was 1.93 (95% CI: 1.68, 2.24) for males compared to females. Males had a higher risk of death from cancer, heart disease, and accidents. Higher cumulative incidences in males for all cancers and the three leading cancers were also observed. However, no significant difference in specific cancer survival time was noted between genders. In terms of cervical cancer, compared with triennial Pap smear, the most cost-effective strategy was annual Pap smear (ICER= $30,237-$30,616), followed by HPV DNA testing with Pap smear every 3 years ($34,917-$35,436) and vaccination program with triennial Pap smear screening ($41,180-$42,543) with the corresponding cost-effective probabilities being 67.6-68.56%, 55.68-56.3% and 40.94-42.84% given the threshold of $40,000 of willingness to pay. Vaccination combined with triennial Pap smear would be as cost-effective as annual Pap smear provided the cost of vaccination were lowered to $250 per full course of injection. In terms of colorectal cancer, the most cost-effective strategy was annual immunochemical occult blood test (ICER=$812), followed by biennial immunochemical occult blood test ($2958). In terms of gastric cancer, the most cost-effective strategy was once-only chemoprevention (incremental C-E ratio=$30,053 in Matsu residents and $18,102 in Matsu emigrants), followed by chemoprevention every four years in Matsu residents and chemoprevention every five years in Matsu emigrants. All preventive strategies also demonstrated the reduction in all-cause and cancer specific mortality in the Matsu population. Conclusion: By using the migration study controlling for genetic influence, we observed higher mortality in Matsu emigrants resulting from higher incidence of major cancer. This paradox of “moving to a more affluent area leading to higher mortality and incidence of cancer” may be explained by the emigrants’ experiencing an urbanized environment and lifestyle. The disparity in mortality between genders in the Matsu population could come from the disparity in the incidence of cancer, heart disease and accidents. Although the biological differences cannot be changed, reduction in the difference of gender related risk exposure and interruption of carcinogenesis through the common pathway will help decrease the “gender gap”. For prevention of cervical cancer, annual Pap smear screening program is still the most cost-effective, and additional HPV DNA testing is a cost-effective choice under the reasonable threshold of willingness to pay in the Matsu population. Vaccination program in combination with triennial screening would be cost-effective if the vaccine cost could be greatly reduced on a large economic scale. Under the reasonable threshold of willingness to pay, annual immunochemical blood test and once-only chemoprevention with Helicobacter pylori eradication should be cost-effective in prevention of colorectal cancer and gastric cancer in the Matsu population. The simulation results of all the preventive strategies may demonstrate that reduction of disparity between groups can be achieved by the interruption of the common pathway in the carcinogenesis process. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/47709 |
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