肝癌(肝細胞癌)是台灣地區第二常見的癌症，而肝動脈化學栓塞是針對無法以手術切除的肝癌中之最主要治療方式。由於人口老化及醫療費用每年的成長已造成健保的財政重大負擔，如何減少醫療利用包括住院天數及住院總醫療費用形成重要的課題。
為了研究接受肝動脈化學栓塞治療的肝癌病患其造成延長住院及增加醫療費用的風險預測因子。了解風險因子將有助於在有限的醫療資源下，進一步改善醫療照護的品質。
從2008年1月至2010月1月間，162位組織學上證實為肝癌的病患(其中男性121位，女性41位)於高雄某一區域教學醫院接受肝動脈化學栓塞治療(共131位)或是接受肝動脈化學栓塞合併置入永久性導管於肝動脈行化學灌注治療(共31位)。延長總住院天數及治療後延長住院定義為住院天數大於所有的中位數(分別是11天及7天)。經由比較延長住院及非延長住院兩組病患的人口學、疾病特質、癌症特質、治療過程及治療後併發症等資料，經由統計分析出顯著影響延長總住院天數及影響治療後延長住院的因子。再利用複迴歸分析以找出延長總住院天數、治療後延長住院及增加住院總醫療費用的風險預測因子。
治療後延長住院的風險因子主要是和治療相關的，包括治療後產生的併發症及治療方法(接受肝動脈化學栓塞同時合併置入永久性導管行肝動脈化學灌注治療相對於僅接受肝動脈化學栓塞治療)( (R2=.367, p<.001);而延長總住院天數的風險因子則包括併發症、肝腦病變、治療方式、Child-Pugh肝硬化分類C級(相對於A級)及年齡((R2=.490, p<.001)。增加住院總醫療費用的風險預測因子包括治療方式、依美國癌症聯合委員會(AJCC)制定的癌症分期第四期及T4期、肝腦病變及併發症(R2=.615, p<.001)，若將總住院天數列入考慮，則最重要的風險因子即為總住院天數。
對治療後延長住院及延長總住院天數而言最強有力的風險預測因子即治療後產生的併發症。不同的治療方式也顯著影響延長住院及醫療費用。為了降低醫療資源利用，我們須盡量避免治療後的併發症，且於治療前須特別留意病患的肝硬化程度及其AJCC的癌症分期，並加強其相關的醫療照護。
此研究的資料可提供給健保局作為調整給付政策及同時給醫療機構控制醫療支出的參考。未來跨院大規模的研究當可解決本研究因局限的樣本而外推性不足的問題。

Hepatocellular carcinoma (HCC) is the second most common cancer in Taiwan and transcatheter arterial chemoembolization (TACE) is now the mainstay of treatment for noncurative HCC. Due to increasing medical costs yearly and financial problem of the Bureau of National Health Insurance, it is important to reduce medical resource utilization including hospital stay and medical costs.
The aim is to figure out the risk factors of extended hospital stay, and increased in-hospital medical costs in hepatocellular carcinoma patients receiving transcatheter arterial chemoembolization. The result of this study should be available for further improvement of medical care quality in the limited medical resource.
From January 2008 to January 2010, 162 patients (121 male and 41 female) with histologically proven hepatocellular carcinoma underwent TACE only (131 pts) or TACE followed by catheter placement for hepatic artery infusion chemotherapy (HAIC) (31pts) at district teaching hospital. The extended hospital stay (EHS) and extended post-procedure stay (EPS) are defined as stay larger than their median values (11 & 7 days respectively). Clinical demographic, disease factors, tumor factors, procedure (TACE)-related factors and complications are used to identify the univariate factors related to EHS and EPS statistically. To find out predictors of EHS, EPS and increased in-hospital medical costs, multiple linear regression analyses are used.
The risk factors for EPS are procedure-related, including complications and procedure methods ( TACE + HAIC related to TACE only) (R2=.367, p<.001), while those for EHS are complications, encephalopathy, procedure methods, Child-Pugh classification C (related to classification A) and age (R2=.490, p<.001). The predictors for increased in-hospital medical costs include procedure methods, AJCC stage IV, T4 stage, hepatoencephalopathy and complications (R2=0.615, p<.001). Taking total hospital stay into consideration, the most important risk factor related to increased medical cost is total hosptial stay itself.
The most powerful risk factor for EPS, EHS is procedure-related complication. The different procedure methods also affect hospital stay and medical costs. In order to reduce medical resource utilization, we should avoid post-procedure complication and pay attention to cirrhotic degree as well as American Joint Committee of Cancer (AJCC) tumor stage system.
The result of this study can provide some ideas to adjust medical expense polices for the Bureau of National Health Insurance and to control medical cost for the hospitals.

第一章 緒論............................................................................1
第一節 研究背景與動機 ......................................................1
第二節 研究目的....................................................................4
第三節 研究重要性................................................................5
第四節 名詞釋義....................................................................6
第二章 文獻探討....................................................................8
第一節 肝癌的人口學特徵及疾病特質................................8
第二節 肝癌患者的癌症特質.............................................10
第三節 動脈化學栓塞治療過程的影響.............................13
第四節 治療後延長住院的相關因素.................................16
第三章 研究材料與方法.....................................................18
第一節 研究設計與研究架構.............................................18
第二節 研究假設.................................................................21
第三節 研究對象與資料來源.............................................22
第四節 研究工具與效度測量.............................................24
第五節 研究變項與操作定義.............................................27
第六節 資料處理及統計分析方法.....................................31
第四章 研究結果.................................................................32
第一節 樣本基本資料的敘述.............................................32
第二節 動脈化學栓塞治療之延長住院及治療後延長住院的影響因素..........................................................................37
第三節 延長住院預測因子.................................................47
第四節 動脈化學栓塞的總住院醫療費用有關的重要因素..........................................................................................49
第五章 研究分析與討論.....................................................53
第一節 探討高雄某一區域教學醫院接受動脈化學栓塞術的肝癌病患特質..................................................................53
第二節 討論動脈化學栓塞治療之延長住院及治療後延長住院的影響因素..................................................................55
第三節 探討延長住院的預測因子.....................................58
第四節 討論動脈化學栓塞的總住院醫療費用有關的重要因素......................................................................................62
第六章 結論與建議.............................................................64
第一節 研究結論.................................................................64
第二節 研究建議.................................................................66
參考文獻..............................................................................68
附錄一 病患審查資料表.....................................................76
附錄二、AJCC分期............................................................80
附錄三、Okuda及CLIP分期.............................................81
附錄四、Charlson Index...................................................82
附錄五、Child-Pugh Classification................................83

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