全球的癌症或其他非癌症疾病之重症病人遭受的嚴重健康相關痛苦都在增加，導致對安寧療護的需求不斷增長。然而，評估重症病人預後因素和安寧療護對醫療費用影響的研究尚未有一致結論。在臺灣，末期非癌症疾病病人的安寧療護尚未得到廣泛接受，主要是由於末期非癌症疾病的多樣性和預測存活的挑戰。需要延長呼吸器（prolonged mechanical ventilation, PMV）或維持透析（maintenance dialysis, MD）的病人通常面臨高死亡率、顯著的疾病負擔和高昂的醫療費用，這些都會對他們的生活品質產生不利影響。為了調查末期非癌症疾病的預後，本論文進行一項全國性的研究，對於同時接受PMV和MD的病人的存活分析，旨在確定存活率、預期壽命和關鍵預後因素。
自1982年以來，癌症一直是臺灣的主要死亡原因，佔2019年總死亡人數的28.6%。許多研究結果顯示，大多數病人偏好在家中臨終。將末期病人運送到醫院接受治療可能需要大量的時間、金錢和精力。然而，關於安寧居家療護 （home-based palliative care, HPC）成本效益的許多研究尚未得出一致結論。2010年健保署規定安寧居家療護必須提供24小時電話諮詢，2011年手機即時通訊(例如LINE)開始流行。埔里基督教醫院因此越來越多比例是透過LINE提供24小時即時諮詢，本論文稱之為遠距醫療輔助安寧居家療護（tele-assisted home-based palliative care, THPC）。這服務提供支持給這些病人及其家人，降低去醫院就診的可能性。因此我進行了第二項研究，評估THPC對癌症病人臨終前的醫療利用和成本的影響，並且比較接受和未接受THPC的末期癌症病人的結果差異。
第一項研究中從臺灣全民健康保險（National Health Insurance, NHI）的資料庫中以 1：3.4 的比例對接受呼吸器 （mechanical ventilation, MV）的病人進行了隨機抽樣，納入條件為接受MD治療並接受MV 21天或更長時間的病人，納入年度為 2003年至2007年。研究估計了預期壽命和存活率，並建構了比例風險模式模型(proportional hazard model)來評估各種預後因素的影響，包括年齡、性別、醫院規模和合併症。
根據既有文獻，本研究是第一個使用國家資料庫估計 PMV 和 MD 治療病人的預期壽命和存活率的研究。與其他模型相比，我們的預測方法似乎更容易記住和應用於臨床現場。與單獨接受PMV治療的病人相比，同時接受PMV和MD治療的病人有癌症（5.9% vs.12.4%）或慢性阻塞性肺病COPD（3.5% vs.16.6%）的比例較小。此外，同時接受PMV和MD的病人通常年紀較輕(近一半年齡在70歲以下)，而且有比較多的病人在擁有先進醫療技術和經驗豐富的專業人員的醫學中心接受治療。這些特點可能會帶來預期存活率的不確定性，或者使得是否拒絕心肺復甦術並允許自然死亡的決策過程變得複雜化。超過85%的PMV和MD治療病人在研究一年內死亡。在調整共變數後，以下預後因素具有統計學意義：癌症、敗血症、腦積水、腹膜炎、肝硬化、壞疽、醫療裝置併發症(device complications)和休克。對於具有這些合併症預後因素(comorbid prognostic factors)的病人，可能需要與家庭成員進行有效溝通並儘早開始安寧療護。
第二項研究納入了2012年至2020年在埔里基督教醫院確診死亡的癌症病人，收集有關性別、年齡、居住地址、死亡前的疾病診斷（ICD-9）和死因的資料。醫療費用的記錄包括全民健保的所有申報費用、民眾的自付費用。此外研究計算了死亡前最後一周、兩周和一個月內的門診、急診（ED）、住院和加護病房（ICU）的利用率，以及運送病人的時間、開車距離和費用。根據性別、年齡和相同的死亡年，將THPC病人與未接受THPC的病人計算傾向性分數進行匹配(Propensity Score Matching) 。統計分析使用了無母數統計、McNemar檢定和Wilcoxon符號排序檢定，以分析THPC病人與否在樣本特質、醫療利用頻率和各項醫療費用的差異。
與未接受THPC的病人相比， THPC的病人使用急診或住院的機率不到一半。需要入住加護病房的機會降低90%以上，但他們從門診獲得藥物的頻率高出四倍。這些實證證據與服務於鄉村地區和郊區鄉鎮的醫院尤其相關，因為埔里基督教醫院是位於埔里鎮的區域醫院，為埔里鎮和周邊鄉村地區的居民提供服務。鑒於這些地區主要是鄉村和山區，將末期病人運送到醫院接受治療需要大量的時間、精力和資源。結果顯示與未接受THPC的患者比較， THPC的患者的自付費用相當，但是健保費用大約是一半，救護車送到急診的機率和估計費用皆為較低。THPC在患者死亡前的最後一周、最後兩周和最後一個月，有效地降低了末期癌症病人的醫療費用，同時也增加了病人能夠在家中休息和去世的機率，這可能會提高他們的生活品質。
本研究結果顯示末期癌症病人接受安寧居家療護，尤其透過24小時的遠距手機即時通訊(例如LINE)或電話諮詢，減少了病人的急診就醫或住院，在病人過世前一個月可以減少約40%以上的健保支出與估算的交通成本，也減少了在急診或加護病房接受臨終前心肺復甦術，與院內死亡的機率。然而THPC需要醫病雙方透過手機即時通訊傳遞病人的影像、圖片、聲音、文字或病歷等，詳細的討論與指導病人照顧者來給藥、調藥或護理等，來改善病人的症狀與增加病人在家臨終的機會；由於是24小時的即時諮詢，提供服務的醫護人員極為辛苦，各醫院礙於經濟誘因常找不到人擔任，在偏鄉地區尤其更是困難。建議政府主管單位對遠距安寧療護的服務增訂支付標準，以符合THPC的實際成本和價值，回饋提供本項服務的醫院及醫護人員之付出，才能增加醫護人員投入偏鄉安寧居家療護的意願。建議為THPC 服務建立單獨的支付項目，服務的定義應包括透過電話或即時訊息進行 24 小時遠距安寧醫療諮詢、症狀監測和藥物調整、安寧護理衛教指導、心理支持與家庭參與，並為鼓勵偏鄉保險人接受遠距臨終關懷服務，提供免部分負擔等各項優待，以提升偏鄉末期病人及家屬的生活品質。

Serious health-related suffering among individuals with cancer and other critical illnesses is increasing worldwide, leading to a growing demand for palliative care. However, studies evaluating prognostic factors for critically ill patients and the impact of palliative care on medical costs have yielded inconclusive results. In Taiwan, palliative care for terminal non-cancer patients has not yet gained widespread acceptance, primarily due to the diverse nature of terminal non-cancer diseases and the challenges associated with predicting survival outcomes. Patients requiring prolonged mechanical ventilation (PMV) or maintenance dialysis (MD) often face high mortality rates, significant morbidity, and increased healthcare costs, all of which can adversely affect their quality of life. To investigate the prognosis of advanced non-cancer diseases, I have chosen to conduct a nationwide study aimed at analyzing the survival of patients who receive both PMV and MD, with the goal of determining survival rates, life expectancy, and key prognostic factors.
Cancer has been the leading cause of death in Taiwan since 1982, accounting for 28.6% of total deaths in 2019. Numerous studies indicate that most patients prefer to die at home. However, research on the cost-effectiveness of home-based palliative care (HPC) has yielded inconclusive results. Transporting terminally ill patients to hospitals for treatment can require significant amounts of time, money, and energy. Tele-assisted home-based palliative care (THPC) has the potential to support these patients and their families while reducing the likelihood of hospital visits. We conducted a study to assess the impact of THPC on medical utilization and costs for cancer patients at the end of life, comparing outcomes between terminal cancer patients who received THPC and those who did not.
In the first study, we conducted a random sampling of subjects who received mechanical ventilation (MV) at a ratio of 1:3.4 from the National Health Insurance (NHI) research database of Taiwan, covering the years 2003 to 2007. We included subjects who were treated with MD and received MV for 21 days or longer. We estimated life expectancy and survival rates. Additionally, we constructed a multivariate proportional hazards model to assess the impact of various prognostic factors, including gender, age, comorbidities, and hospital size.
This study represents the first attempt to estimate life expectancies and survival rates for patients treated with both PMV and MD from a national database. Compared to other models, our forecasting approach is more straightforward and easier to implement at the bedside. In contrast to patients receiving PMV alone, a smaller percentage of those treated with both PMV and MD had cancer (5.9% vs. 12.4%) or COPD (3.5% vs. 16.6%). Furthermore, patients receiving both PMV and MD were generally younger, with nearly half being under 70 years old, and a greater proportion were treated in medical centers equipped with advanced technology and experienced professionals. These characteristics may introduce uncertainty or complicate the decision-making process regarding whether to withhold cardiopulmonary resuscitation and allow for natural death. In our study, over 85% of patients treated with both PMV and MD died within one year. After adjusting for covariates, the following prognostic factors were found to be statistically significant: cancer, septicemia, hydrocephalus, peritonitis, cirrhosis of the liver, gangrene, device complications, and shock. Effective communication with family members and the earlier initiation of palliative care may be warranted for patients with these comorbid prognostic factors.
In the second study, we included cancer patients who were confirmed deceased at Puli Christian Hospital (PCH) from 2012 to 2020. We collected data on gender, age, residential address, medical diagnoses prior to death (ICD-9), date of birth, date of death, and the cause of death. Additionally, we gathered information on medical expenses, which included all costs reimbursed by National Health Insurance (NHI) as well as out-of-pocket payments. Furthermore, we calculated the utilization of outpatient visits, emergency department (ED) visits, hospitalizations, and intensive care unit (ICU) admissions. We also estimated transportation time, distance, and expenses incurred in the last week, the last two weeks, and the last month before death. Cancer patients with THPC were matched with those without THPC using a 1:1 propensity score matching method based on gender, age, and year of death. We compared the differences in the measurements using non-parametric statistics. Gender, cancer type, comorbidities, and frequency of medical utilization were analyzed using McNemar's test. Age, transportation time, distance, number of medical utilizations, medical expenses, and transportation expenses were analyzed using the Wilcoxon signed-rank test.
Compared to patients who did not receive THPC, those who did had less than half the likelihood of visiting the emergency department (ED) or being hospitalized. The probability of requiring admission to the intensive care unit (ICU) was over 90% lower; however, patients received their medications from outpatient clinics four times more frequently. This empirical evidence is particularly relevant for hospitals serving rural areas and suburban townships, such as PCH, a regional hospital located in Puli Town that serves the residents of Puli Township and surrounding rural regions. Given that these areas are primarily rural and mountainous, transporting terminally ill patients to PCH for medical care demands considerable time, effort, and resources. While patients who received THPC incurred similar out-of-pocket expenses compared to those who did not, National Health Insurance (NHI) costs were approximately half as much. Additionally, ambulance transport to the emergency room was less likely and less costly for these patients. THPC effectively reduced healthcare costs for terminal cancer patients in the last week, the last two weeks, and the last month before death, while also increasing the likelihood of patients being able to rest and pass away at home, which may enhance their quality of life.

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