||Do the In-Patient Medical Expenditures of Patients with Malignant Neoplasms Vary across Areas
with Different Urbanization Levels along
the Southwestern Coast
||Institute of International Management (IIMBA--Master)(on the job class)
In-patient medical expenditure
在現代國家的醫療服務提供的可近性與使用方面的差距, 目前已成為社會和公共衛生中一個重要的論題。 臺灣民眾普遍認為中央健康保險系統有助建立不同階層之間的差距至最小化。然而在臺灣西南沿海地區評估這一問題的同時, 另考量一個重要的因素就是臺灣西南海岸沿線特定地區發現飲用水中含有高含量的「砷」, 而已經由流行病學研究證明 「砷」可能會導致癌症。因此，對癌症和致癌物質具有高度察覺及能以較有力的癌症篩檢有可能促使早期確診的病人人數增加, 而評估這影響因素之原因則鮮少被研究過。 作者從 2000年-2009 年由中央健康保險局南區業務組之倉儲資料提供應用閘門系統（ISGS）中擷取各年度資料，進行評估都市化程度同時考量飲用水中砷含量與住院醫療費用支出的相關性。
有些臺灣的醫療機構參與中央健康保險制度，但有些卻未參與。本研究建構擷取醫療院所向南區業務組申報之住院醫療費用; 遵循國際疾病分類編碼 (臨床修改第9次修訂) 選擇主診斷及四個次診斷編碼有惡性腫瘤 (癌症) 碼140-208及有化學、放射治療相關診斷的對象都歸納為本研究範圍。研究資料容量846 MB,筆數為572,617筆,以統計軟體SAS 9.2,及SPSS 17.0進行統計分析工作。本研究所將所有的癌症分為 22 組, 比較不同都市化程度並評估都市化對平均住院醫療費用的影響。因此，研究領域分成四個城市化程度：都市化程度最高的「都會區」、都市化程度中等的「縣轄市」、與最低都市化程度但沒有飲用水含高量「砷」之「無流行性砷中毒的鄉鎮」，和最低都市化程度有高砷含量飲用水的 「有流行性砷中毒的鄉鎮」。
性別、 年齡和都市化程度以分層分析詳細說明罹癌病患於醫院及診所住院概況，包括住院病人數和總住院次數、住院率、平均住院次數、平均住院醫療費用, 和平均住院天數（花住在醫院及診所的平均天數）。我們以變異數分析 (ANOVA) 檢定校正進行探討住院醫療費用與四個都市化程度之間的差異。當有顯著差異（p 值 <.05）指出，再進行事後測試並進行研探進一步之間的關聯性。應用 t test 求出每個病患住一次院的平均住院次數、 總住院醫療費用, 與平均住院醫療費用差異。Chi-square (卡方) 則應用求出住院人數與住院次數之差異。
我們發現在2002-2009這段期間, 所有類型的癌症患者其住院率在所有年齡,和各都市化程度間都呈現持續增加的情形。住院率最高的是「有流行性砷中毒的鄉鎮」，次高的是「都會區」，較低的是「縣轄市」，而住院率最低的是 「無流行性砷中毒的鄉鎮」。與此相反，2000年-2001年間最高都市化程度地區之「都會區」 住院率最高。可以斷定的是最低都市化程度之「有流行性砷中毒的鄉鎮」 醫療服務需求已有上升的趨勢。不過，都市化程度和住院醫療費用的相關性，在不同類型的惡性腫瘤的醫療支出似乎是複雜的並可能有不同的因素。這也可能由於受中央健康保險制度包羅萬象的醫療保險範圍而非實質受都市化程度之影響, 或在本研究中發現的差異是基於機率因素。
根據本研究結果提出一些建議。第一，衛生當局應鼓勵市民到醫療院所定期以有效的檢查工具和技術作癌症篩檢。第二，衛生政策制定者可以執行、宣導以及加強於特定都市化程度地區、於特定族群中作特定癌症類型之癌篩。例如住院醫療費用占最高為惡性腫瘤的第13 組 (ICD-9-CM 代碼：179-184的婦女生殖器官癌症), 我們可以加強對40歲以上的婦女健康教育, 和影響更多的婦女進行此類子宮頸早期癌症篩檢。另一項建議是，應進行更大規模的研究，以評估是否本研究的結論可以應用於其他區域以及涵蓋臺灣的全部。
Disparities in the availability and usage of medical service have become an important social and public health issue in modern countries. It is generally believed that the establishment of the National Health Insurance (NHI) system has helped minimized disparities among different segments of the population in Taiwan. Along the southwestern coast of Taiwan, another important factor should be considered in assessing this problem. The drinking water in certain parts of the area contains high levels of arsenic, and epidemiology studies have shown that arsenic can cause malignant neoplasms (cancers). Therefore, higher awareness of cancer and carcinogens and more vigorous cancer screening might lead to an increase in the number of patients diagnosed in the early stages. Few, if any, studies have been conducted to evaluate the effect of this factor. For this reason, the author retrieved yearly data from 2000-2009 through the Information Supplied Gateway System (ISGS) in order to evaluate the correlations of urbanization with in-patient medical expenditures while taking arsenic levels in drinking water into account.
Some medical institutions in Taiwan participate in the NHI system while others do not. The hospitals and clinics that participate in this system submit their claims for reimbursement from the Bureau of the BNHI. This study was constructed based on data from the ISGS under the jurisdiction of Southern Division of the BNHI. In this database, the patients who were diagnosed with cancers can be identified through their assigned codes. This coding system is the International Classification of Diseases, Clinical Modification, the 9th Revision (ICD-9-CM codes) and is used for the classification of all diseases treated in hospitals and clinics. Codes that begin with 140 to 208 indicate cancers. The current study classified all primary cancers into 22 groups and compared different regions with different urbanization levels to assess the effects of urbanization on average in-patient medical expenditures. Accordingly, the study areas were categorized into four groups: “metropolitan cities” (with the highest level of urbanization), “county-controlled cities” (with a moderate level of urbanization), “non-arsenic intoxication endemic villages and towns” (with the lowest level of urbanization but without high arsenic levels in drinking water), and “arsenic intoxication endemic villages and towns” (with the lowest level of urbanization and high arsenic levels in drinking water).
Gender, age, and urbanization levels were stratified for the detail descriptions of hospitals and clinics admissions, including the number of admitted patients and total admissions (hospital/clinic), admission rates, average number of admissions, average in-patient medical expenditures, and average admission days (average days spent in a hospital/clinic). After the adjustment that we explored the differences in in-patient medical expenditures among the four urbanization levels by the analysis of variance (ANOVA). When a significant differences (p-value < .05) was observed, post hoc tests were performed to explore the correlations further. We applied the t test to evalaute the differences in the average admissions per patient, total in-patient medical expenditures, and average in-patient medical expenditures for each hospital/clinic admission per patient. Chi-square was applied to evalaute the differences in proportion.
We found that the admission rates for patients with all kinds of cancer generally increased during the study period for all ages and at all urbanization levels. For 2002-2009, the admission rates were the highest in “arsenic intoxication endemic villages and towns,” which was followed by the “metropolitan cities,” then the “county-controlled cities,” and last were the “non-arsenic intoxication endemic villages and towns”. In contrast, during 2000-2001, the “metropolitan cities” had the highest admission rates. It can be concluded that the “arsenic intoxication endemic villages and towns,” had an increasing trend for seeking medical services. Still, the correlation between urbanization and in-patient medical expenditures appeared to be complicated, and there might be different factors affecting the medical expenditures for different types of malignant neoplasms. It is also possible that, due to the comprehensive coverage of the NHI system, the medical expenditures were not substantially affected by urbanization, and the differences observed in the current study were due to chance.
On the basis of the results, some suggestions can be made. First, the health authority should encourage the public to go for cancer screenings on a regular basis and to seek health providers who use effective examination tools and techniques. Second, health policy makers can implement, promote, and enhance cancer screening for certain types of cancer for certain groups and at certain urbanization levels. For example, the least urbanized areas had the highest in-patient medical expenditures for malignant neoplasm group 13 (ICD-9-CM codes: 179-184; women’s genital organs) starting from 40 year-old. We can enhance health education and influence more women to conduct earlier screenings for this type of cancer. Another suggestion is that a larger study should be conducted to cover the entirety of Taiwan in order to evaluate whether the conclusions of the current study can be applied to other regions as well.
TABLE OF CONTENTS X
LIST OF TABLES XI
LIST OF FIGURES XV
CHAPTER ONE INTRODUCTION 1
CHAPTER TWO LITERATURE REVIEW 8
CHAPTER THREE RESEARCH DESIGN AND METHODOLOGY 20
CHAPTER FOUR RESEARCH RESULTS 25
CHAPTER FIVE CONCLUSIONS AND SUGGESTIONS 163
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