| 摘要: | 背景:
腸病毒感染已經列為台灣第三類型法定通報之傳染病，高危險群為嬰兒與幼童，且越年幼的孩童或是新生兒病情嚴重程度越高，其嚴重的併發症會導致幼兒死亡。 1998年台灣爆發了史上最大規模也最嚴重的腸病毒感染疫情，之後亞太地區也爆發了腸病毒的疫情，如日本、韓國、越南、中國等也因為腸病毒感染大流行造成高額醫療費用支出，各國政府皆投入大量資源以防範腸病毒的流行。
目的:
探討腸病毒感染流行病學及各年齡層分別在不同嚴重程度之的醫療利用率，並包含醫療費用，作為未來疫苗施打政策與防範政策介入的參考。
方法:
本研究所使用資料為申請衛生福利部衛生福利資料科學中心（Health and Welfare Data Science Center Database，HWDC）之資料檔進行回溯性世代研究設計(retrospective cohort study) 並使用 SAS 9.4 (statistical analysis system) 進行統計分析。
結果:
在2010-2015年資料庫中依據本研究之定義腸病毒感染事件，共計有1,516,596筆。在併發症的嚴重程度分期與年齡分佈觀察結果發現，男性重症的比例大於女性(p<0.001)。
中樞神經系統傷害多好發於0到1歲，佔58.53%。其中以肌躍型抽搐最高，佔83.02%，其次為其他中樞神經性系統，佔12.47% 和腦炎或腸病毒性腦膜炎，佔7.84%。嚴重程度心肺功能傷害，主要為肺水腫或肺血腫，佔77.88%，其次為心肌炎39.95%和心衰竭 26.03%，整體而言可以觀察到越嚴重個案的過去病史較輕症個案多。在醫療耗用部分，有88.72%使用門診資源，12.00%使用急診資源，以及7.92%使用住院資源。依據事件計算實際平均成本，另校正個案之年齡、性別、過去病史和併發症總類，利用模式計算每一個事件的平均門診成本為2,046元，標準差為1,890元、急診成本為711元，標準差為886元、住院成本為6,304元，標準差為 186,555元、以及總醫療成本4,816元，標準差為208,502元。比較不同嚴重程度之成本，任兩組執行事後檢定，無論在門診、急診、住院以及總醫療成本皆達統計上顯著意義(p<0.001)。
討論:
研究結果顯示在各年齡層的發生率與全死因死亡率及嚴重程度從2010年至2015年呈現下降的趨勢，下降的改變百分比(change percentage)約達50%。依本研究所定義符合腸病毒感染事件條件，小於2歲以下的孩童，每年發生事件數最高。門診醫療利用率與中國、越南等相近。另外在臨床症狀包括呼吸道疾病、中樞神經系統疾病等發生比率與鄰近國家相比也呈現相近。醫療成本之估算為本研究所定義腸病毒感染事件來計算出腸病毒感染事件起迄期間所發生之醫療利用的直接醫療成本，沒有將自費項目納入統計。研究數據顯示腸病毒感染事件的平均成本為4,816元(約160.5美元)，2010到2015年間，每年的總醫療成本在9.69億至17.08億(約3,230~5,670萬美元)之間，與鄰近國家如中國、越南與韓國等相比較，呈現較低。本研究之醫療成本與上述國家相比較，有很大的差異性，主要是衡量成本的起迄點不同及資料來源與蒐集的方式不同會有所不同。另外，因為各國醫療制度不同，藥價及疾病的治療費用受到醫療制度的影響。全民健保的國家，如台灣，藥價是高度管制的，與自由市場價格相比，往往被壓低，上述原因都可能是造成本研究所估計的腸病毒事件平均成本偏低的原因之一。
Background: Enterovirus infection has been listed as the third type of notifiable disease in Taiwan. The high-risk group in Taiwan includes infants and young children. The younger children, the higher the severity of the disease. Its serious complications can lead to death of children. In 1998, the largest and most serious enterovirus infection broke out in Taiwna. Afterwards, enterovirus epidemics also broke out in Asia-Pacific region, such as Japan, South Korea and Vietnam, etc. It also caused high-cost expenses due to the pandemic of enterovirus infection, Governments of many countries have invested tremendous resources to prevent the epidemic of enterovirus.
Purpose: Evaluation the epidemiology of enterovirus infection and the health care utilization of each age group in different degrees of severity, including medical expenses, as a reference for future vaccine administration and prevention policies.
Method: The data used in this research are from the data file of the Health and Welfare Data Science Center Database (HWDC) of the Ministry of Health and Welfare for retrospective cohort study design using SAS 9.4 (statistical analysis system) for statistics analyze.
Result: According to the enterovirus infection events defined in this study, there were a total of 1,516,596 events in the database from 2010 to 2015. According to the results of the classification of severity and age, it was found that the proportion of boys with severe illness was higher than that of girls (p<0.001). Central nervous system injuries usually occur in infants from 0 to 1 year old, with the percentage 58.53%. The muscle jump type convulsions accounted for 83.02%, followed by other central nervous system for 12.47% and encephalitis or enteroviral meningitis accounted for 7.84%. Severe cardiopulmonary injury group is mainly pulmonary edema or pulmonary hematoma, accounting for 77.88%, followed by myocarditis for 39.95% and heart failure for 26.03%. Overall, it can be observed that the more severe cases have more servious past medical history than mild cases. As for the medical utilization, 88.72% of the events used outpatient resources, 12.00% used emergency resources, and 7.92% used inpatient resources. We could calculate the actual average cost based on the event, and make adjustment with age, gender, past medical history, and general category of complications. The model calculated the average outpatient cost of each event is 2,046 yuan, the standard deviation is 1,890 yuan, The emergency cost is 711 yuan, and the standard deviation is 886 yuan. The hospitalization cost is 6,304 yuan, the standard deviation is 186,555 yuan, and the total medical cost is 4,816 yuan, and the standard deviation is 208,502 yuan. Comparing the costs of different severity levels, any two groups performed post- verification, The total medical costs in outpatient, emergency, hospitalization, and total medical cost reached statistically significant significance (p<0.001).
Conclusion: The results of the study show that the incidence and all-cause mortality and severity of all age groups have a downward trend from 2010 to 2015, and the change percentage of the decline is about 50%. According to the definition of this study, if the conditions for enterovirus infection events are met, the number of events occurring is the highest for children under 2 years old. The medical utilization rate in outpatient clinics is similar to that of China and Vietnam.
The estimation of medical cost based on the definition of enterovirus infection events in this study to include the direct medical costs of medical utilization that occurred during the period from the beginning to the end of the enterovirus infection event, including outpatient, emergency and hospitalization expenses, but self-financed items are not included in the analysis. Compareing with China, Vietnam, and South Korea, it was found that the medical expenditures are much lower. The reason is that the medical systems are different; the price of medicines and the cost of disease treatment are affected by the medical system. In countries with universal health insurance, such as Taiwan, drug prices are highly regulated. Comparing with free market prices, drug prices are often suppressed. This may also be one of the reasons for the low average cost of enterovirus incidents estimated by this study. In addition, because of the different starting and ending points of cost measurement and different ways of collecting data, the above study may causes differences in cost estimates. |
