研究背景
台灣正面臨快速人口老化，對高品質臨終照護的需求與日俱增。雖然台灣的全民健康保險已逐步擴大安寧緩和醫療的適用範圍，從最初僅限末期癌症患者，至自2009年起已擴及八類非癌症末期疾病。然而，在安寧利用的可近性與臨終照護結果，例如死亡地點的分布，癌症與非癌症族群的差距是否縮小仍不明確；此外，在失智症等慢性疾病上，不同資料來源的案例界定可能系統性改變族群層次的臨終指標估計，亞洲地區缺乏系統性證據。上述問題不僅關乎政策效果的評估，更直接影響我們對弱勢族群的辨識能力與照護資源配置的合理性。本論文旨在從「服務利用趨勢」、「死亡地點分布與決定因子」到「測量方法論驗證」三個維度，系統性評估台灣老年人臨終照護的診斷別差異及其政策意涵。
研究方法
本論文包含三項以全國人口為基礎的研究，使用健保申報資料及全國死亡原因統計資料庫之串聯資料，並透過衛生福利資料科學中心進行分析。研究一分析2010至2020年間死亡之老年人（年齡≥65歲，共588,010人）的安寧照護利用長期趨勢，採泊松迴歸估計各年趨勢，並以多變量羅吉斯迴歸評估死亡原因與安寧照護利用之關聯。研究二探討2014至2023年間死亡老年人（共 632,920人）的死亡地點分布及其決定因子，以多項式羅吉斯迴歸分析疾病診斷、專科安寧居家照護及一般居家照護對死亡地點的影響。研究三比較三種失智症病例定義來源:原死因、多重死因，以及健保申報資料，對2014至2023年間老年死亡者失智症族群組成及死亡地點估計的影響，採標準化均差、分層分析、平均邊際效果之多項式羅吉斯迴歸，以及廣義估計方程式處理跨資料來源的樣本相依結構。
研究結果
在臨終照護可近性方面，研究一發現，2010年至2020年間安寧緩和醫療的使用率顯著上升（由11.4%增至44.3%），但癌症與非癌症死亡者之間的使用差異仍然明顯存在：至2020年，癌症死亡者的使用率為63.2%，非癌死亡者則為23.5%；在調整相關共變項後，非癌死亡者接受安寧緩和醫療的可能性仍顯著較低，約降低 88%（adjusted odds ratio, aOR = 0.12；95% 信賴區間 [confidence interval, CI]：0.12–0.13）。在死亡地點分布與決定因子方面，研究二顯示2014至2023年間醫院與居家為主要死亡地點，醫院死亡比例上升（42.1%至44.6%），居家死亡下降（46.1%至38.5%）；相較癌症死亡者，非癌死亡者居家死亡（aOR=0.69，95% CI: 0.68–0.70）與住院安寧病房死亡（aOR=0.45，95% CI: 0.43–0.46）勝算較低，而長照機構死亡勝算較高（aOR=1.81，95% CI: 1.74–1.89）。其中，專科安寧居家照護是促成居家死亡最重要的可調整服務模式（aOR=5.44，95% CI: 5.30–5.58）。在不同資料來源的案例界定方面，研究三共辨識出269,016位跨三種來源的獨特失智症老年死亡者，其中僅4.7%同時被三種來源收錄。健保申報資料辨識族群最大（共259,843人，占總聯集96.6%），原死因辨識族群最小（20,406人）。與原死因相比，健保申報資料所辨識之族群在住院安寧病房死亡（aOR = 0.33，95% CI：0.31–0.35）、居家死亡（aOR = 0.79，95% CI: 0.76–0.81）及長期照護機構死亡（aOR = 0.63，95% CI: 0.60–0.66）的調整後勝算均顯著較低。在絕對尺度上，以健保申報資料（相較於多重死因）定義失智症族群時，預測的醫院死亡機率高出11.9個百分點（95% CI: 11.3–12.4），居家死亡機率則低5.1個百分點（95% CI: -5.6至-4.6）。
結論
本論文以全國資料顯示：即使在全民健保制度下，台灣老年死亡者在安寧照護利用與死亡地點仍存在持續的診斷別差異；在失智症族群中，案例界定來源也會系統性改變臨終指標估計。全民健保所提供的財務保障是支持臨終照護可近性的必要條件，但仍不足以確保不同診斷族群皆能獲得符合需求的臨終照護。未來政策應建立更清楚且診斷中立的轉介路徑，強化並更精準配置社區照護量能（尤其是專科安寧居家照護與一般居家照護），並建置多來源整合的監測系統，以支持更準確的政策評估與資源配置。

Background
Taiwan is experiencing rapid population ageing, with a growing demand for high-quality end-of-life (EOL) care. Although Taiwan’s National Health Insurance (NHI) has progressively expanded eligibility for palliative care, from an initial focus on terminal cancer to the inclusion of eight categories of terminal non-cancer conditions since 2009, it remains unclear whether gaps between cancer and non-cancer populations have narrowed in terms of access to palliative care and EOL outcomes such as place of death (PoD). In addition, for chronic conditions such as dementia, case ascertainment based on different data sources may systematically alter population-level estimates of EOL indicators; however, systematic evidence from Asia remains limited. These issues are not only central to evaluating the effectiveness of policy reforms, but also to our ability to identify vulnerable populations and allocate care resources appropriately. This dissertation therefore aims to systematically assess disparities in EOL care among older adults in Taiwan and its policy implications across three dimensions: trends in service utilization, distributions and determinants of PoD, and methodological validation of measurement approaches.
Methods
This dissertation comprises three population-based studies using linked data from Taiwan's NHI claims database and national death registry, accessed through the Health and Welfare Data Science Center. Study 1 examined secular trends in palliative care utilization among older adults (aged ≥65 years) who died between 2010 and 2020 (N = 588,010), using Poisson regression to estimate annual trends and multivariable logistic regression to assess the association between cause of death and palliative care utilization. Study 2 investigated PoD distribution and its determinants among older adults who died between 2014 and 2023 (N=632,920), using multinomial logistic regression to examine the roles of diagnosis, specialist palliative care, and generalist home care. Study 3 compared how three dementia ascertainment sources, namely underlying cause of death (UCOD), multiple causes of death (MCOD), and NHI claims, define different populations of older adult decedents with dementia (2014–2023) and generate divergent PoD estimates, using standardized mean differences, stratified analyses, multinomial logistic regression with average marginal effects, and generalized estimating equations to account for cross-source sample dependence.
Results
Regarding access to EOL care, Study 1 showed that palliative care utilization increased substantially between 2010 and 2020 (from 11.4% to 44.3%), yet diagnosis-based disparities remained pronounced: by 2020, utilization was 63.2% among cancer decedents compared with 23.5% among non-cancer decedents. After covariate adjustment, non-cancer decedents remained significantly less likely to receive palliative care (adjusted odds ratio [aOR] = 0.12, 95% confidence interval [CI]: 0.12–0.13), corresponding to an approximately 88% reduction in odds. Regarding the distribution and determinants of PoD, Study 2 revealed that hospital and home deaths were the predominant PoDs across the study period, with hospital deaths increasing (42.1% to 44.6%) and home deaths declining (46.1% to 38.5%) between 2014 and 2023. After adjustment, non-cancer decedents were less likely to die at home (aOR = 0.69, 95% CI: 0.68–0.70) or in inpatient palliative care units (aOR = 0.45, 95% CI: 0.43–0.46) but more likely to die in long-term care facilities (aOR = 1.81, 95% CI: 1.74–1.89) compared to cancer decedents. Specialist palliative home care was the strongest modifiable predictor of home death (aOR = 5.44, 95% CI: 5.30–5.58). Regarding case ascertainment across data sources, Study 3 identified 269,016 unique older decedents with dementia across three sources, of whom only 4.7% were captured by all three simultaneously. NHI claims identified the largest cohort (N = 259,843; 96.6% of total), while UCOD identified the smallest (N = 20,406). Compared with UCOD, NHI ascertainment was associated with significantly lower adjusted odds of inpatient palliative care unit death (aOR = 0.33; 95% CI: 0.31-0.35), home death (aOR = 0.79; 95% CI: 0.76-0.81), and long-term care facility death (aOR = 0.63; 95% CI: 0.60-0.66). On an absolute scale, NHI-based ascertainment (vs MCOD) predicted 11.9 percentage-point higher hospital death probability (95% CI: 11.3-12.4) and 5.1 percentage-point lower home death probability (95% CI: -5.6 to -4.6).
Conclusions
Using nationwide linked data, this dissertation demonstrates that, even under universal health coverage, persistent diagnosis-based disparities remain in palliative care utilization and PoD among older adults in Taiwan, and that in dementia populations, the choice of ascertainment source can systematically shift population-level estimates of EOL indicators. Universal financial entitlement is a necessary but insufficient condition to ensure comparable access to EOL care across diagnostic groups. Reducing these structural disparities will require the establishment of needs-based, diagnosis-neutral referral pathways; strengthening and equitable distribution of community-based care capacity (particularly specialist palliative home care and generalist home care); and the development of integrated, multisource surveillance systems to support more accurate policy evaluation and rational resource allocation.

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