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2004ASAP從社會福利角度看菸害防制
 

2004ASAP從社會福利角度看菸害防制

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楊銘欽

楊銘欽

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    2004ASAP從社會福利角度看菸害防制 2004ASAP從社會福利角度看菸害防制 Presentation Transcript

    • 從社會福利角度看菸害防制 楊銘欽 台大醫療機構管理研究所 2004-07-12
    • 討論題綱
      • 為什麼要吸菸?
      • 吸菸對健康的影響為何?
      • 吸菸對社會福利的影響為何?
      • 如何估計吸菸的經濟成本?
      • 菸害防制對社會福利的影響為何?
    • 為什麼要吸菸?
      • 心理上
      • 社會上(以及經濟上)
      • 生理上
    • 吸菸對健康的影響?
      • 事故發生當年之影響
        • 民眾要付比較高的健保費
        • 排擠其他民眾接受醫療的機會
      • 事故發生後多年之影響
        • 民眾要付比較高的健保費
        • 排擠其他民眾接受醫療的機會
        • 吸菸孕婦產下低體重嬰兒之教養費
    • 吸菸對社會福利的影響?
      • 事故發生當年的影響
        • 排擠福利的經費
        • 早逝造成的家庭問題與社會支出
      • 事故發生後多年的影響
        • 吸菸孕婦產下低體重嬰兒之教養費
        • 貧窮個人或家庭難以改善生活
    • 如何估計吸菸的經濟成本?
      • 直接成本
        • 醫療費用
        • 因醫療所造成之交通成本
        • 其他因吸菸所造成財物損失
      • 間接成本
        • 因生病所造成之所得損失
        • 因早逝所造成之所得損失
      • 外部成本
    • The Health Consequences of Smoking, A Report of the Surgeon General, 2004
        • 444,000 premature deaths per year were attributable to smoking
        • 13-14 years of life shorter for somkers than non-smokers
        • US$75 billion per year were Spent to cure smoking related diseases
        • US$82.7billion were lost due to health-related economic losses annually
    • Four Major Conclusions of the 2004 Report (1/5)
      • Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general.
    • Four Major Conclusions of the 2004 Report (2/5)
      • Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general.
    • Four Major Conclusions of the 2004 Report (3/5)
      • Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health.
    • Four Major Conclusions of the 2004 Report (4/5)
      • The list of diseases caused by smoking has been expanded to include
        • abdominal aortic aneurysm,
        • acute myeloid leukemia,
        • cataract,
        • cervical cancer,
        • kidney cancer,
        • pancreatic cancer,
        • pneumonia,
        • periodontitis, and
        • stomach cancer.
    • Four Major Conclusions of the 2004 Report (5/5)
      • The above mentioned are in addition to diseases previously known to be caused by smoking, including
        • bladder, esophageal, laryngeal, lung, oral, and throat cancers,
        • chronic lung diseases,
        • coronary heart and
        • cardiovascular diseases,
        • as well as reproductive effects and sudden infant death syndrome.
    • 戒菸的效果
      • 戒菸對健康有立即且持久的益處
      • 65 歲以上吸菸者如果戒菸,可降低死於菸害相關疾病的風險達 50% ;戒菸 5-10 年後,中風的風險將降至和不吸菸者相同
    • 不吸菸活卡久 30 歲前戒菸可避免早死 記者湯慧文、彭迪/洛杉磯報導 2004-6-22 10:54                                                         英國牛津大學一項橫跨半個世紀的調查發現,年輕的吸菸者如果在 30 歲以前戒掉菸癮,就可以避免早死的命運。 這項從 1951 年就開始進行的研究發現,長期吸菸者和非吸菸者比較起來,平均壽命會短 10 年。研究結果顯示,年輕時期就開始吸菸的人,每 4 個中會有 1 人在中年去世。 研究報告也顯示,假使吸菸者在 30 歲前懸崖,大都可以避免早死,如果在 50 歲才開始戒菸,早死的比例還是可以減半。
    • 世界禁菸日 5/31 WHO
      • 2004 年主題:
      • 菸草與貧窮 —
      • 一個惡性循環
    • 菸草與貧窮 – 惡性循環
      • 吸煙每 6.5 秒就奪走一條人命
      • 每一年讓全球經濟損失兩千億美金
      • 目前全球約有 13 億個癮君子,其中 84% 在開發中國家
      • 越貧窮的人越容易染上菸癮
      • 越有可能罹患吸菸相關疾病
      • 看病次數可能更多
      • 經濟負擔更重
      • 排擠教育或改善生活的錢
      • 貧上加貧
    • 如何估計菸害的經濟成本?
      • Smoking attributable expenditures (SAEs) for people aged 35 or older in 2000
      • Ming-Chin Yang
      • Ching-Yuan Fann
      • Chi-Pang Wen
      • Ting-Yuan Cheng
    • Importance of the Study
      • The government of Taiwan has made controlling and preventing the adverse effects of smoking an important priority.
      • To control tobacco use, the public needs to be made aware of the health costs of smoking, or the expenditures attributed to smoking (SAEs).
    • Purpose of the study
      • To estimate the smoking attributable expenditures (SAEs) for people aged 35 or older in 2000 from the health insurer’s viewpoint.
    • Materials and Methods 1
      • A prevalence-based approach shows such social costs as burden to the government or society over a certain period
      • An incidence-based approach shows the lifetime cost to the patients and their families.
      • The prevalence-based approach was more applicable to insurers to estimate excess costs due to smoking.
    • Materials and Methods 2
      • The study design of this study was a secondary data analysis .
      • We estimated the amount of utilization of health care services and expenditures associated with each disease category based on epidemiologic results.
    • Materials and Methods 3
      • The estimation of SAEs of disease associated with smoking involved three steps:
        • Identifying diseases associated with smoking,
        • Deciding types of costs to be estimated, and
        • Estimating the quantity and valuing the medical resources used.
    • 1. Identifying diseases associated with smoking
      • We used the results of two follow-up studies.
      • The merged cohort dataset, initiated by Wen, Tsai (t he civil servants and teachers cohort, the CST cohort ) and Chen et al. (the community cohort ) , contains more than 110,000 study subjects.
      • These studies used relative risk (RR) to identify diseases in which smokers had significantly higher mortality rates than non-smokers.
    • 2. Deciding types of costs to be estimated
      • We only estimated the expenditure of outpatient and inpatient services.
      • Taiwan’s National Health Insurance (NHI) covers more than 97% of the eligible population and will release selected annual claims data.
      • NHI cannot provide information on out-of-pocket expenditures.
    • 3. Estimating the quantity and valuing the medical resources used
      • We used the ICD9-CM code from the relative mortality rate data of the two-cohort studies as the key variable in linking NHI outpatient and inpatient claims data.
      • We chose to study only those nineteen diseases in which smokers had significantly higher mortality rates than non-smokers.
    • 3.1 Expenditure and quantity of hospitalization
      • The expenditures of per admission (for each disease, by sex and age group)
      • = Total inpatient expenditures/total number of admissions (for each subgroup) .
      • Total number of admissions (for each disease, by sex and age group)
      • = The summation of the admission by each sub-group
      • Information on inpatient services was obtained from the database released by the NHRI under the authorization of the BNHI.
    • 3.2 Expenditure and quantity of outpatient visit
      •   The calculation of outpatient expenditure per visit and quantity per disease was similar to that of inpatient service.
      • The datasets provided by the NHRI were sampled at 1 in every 500 cases.
      • To generate a quantity for the entire population, we multiplied the amount by 500.
    • 3.3 Estimating the fraction of services attributable to smoking
      • The quantity of medical services used attributed to cigarette smoking was estimated by using population attributable risk (PAR).
      • P(RR-1)
      • PAR=--------------
      • P(RR-1)+1
            • Where
            • P: the prevalence rate of cigarette smoking in the whole population
            • RR: the relative risk
    • 3.4 Estimating morbidity cost
      • MCiys=Σ[P(MD) iys x Q(MD) iys
      • +P(H) iys x Q(H)iys] x PARiys
      • Where:
      • MC: Medical cost of disease by sex, age group
      • i: type of diseases
      • y: age groups
      • s: sex
      • P(MD): Average expenditure per outpatient visits
      • Q(MD): Total number of outpatient visits
      • P(H): Average expenditure per admission
      • Q(H): Total number of admissions
      • Note: all the utilization or expenditures were for persons aged 35 and older
    • The prevalence rate of smokers in 1990 Sex Aged 35-49 Aged 50-64 Aged 65+ Male 63.95% 65.30% 54.91% Female 4.12% 4.95% 8.35%
    • 3.5 Calculating smoking attributable fraction (SAF)
      • Smoking attributable fraction (SAF) represents the percentage of SAE to the expenditure of the total population
      • SAF = SAE / the total amount expended
    • 3.6 Calculating the mean annual expenditure of the smoker and the non-smoker (1)
      • The excessive annual medical expenditure per smokers
      • = Annual Medical Expenditures of the smokers
      • - Annual Medical Expenditures of the non-smokers
    • 3.6 Calculating the mean annual expenditure of the smoker and the non-smoker (2)
      • Annual Medical Expenditures of the smokers
      • = SAEs + (Total Medical Expenditure of the
      • population – SAEs of smokers)
      • x Prevalence rate of smoking
      •  
      • Annual Medical Expenditures of the non-smokers
      • = (Total Medical Expenditure of the population – SAEs of
      • smokers)
      • x (1-Prevalence rate of smoking)
    • Results
    • Table 1. Population attributable risk due to smoking by disease and age group for both sexes aged 35 and older in Taiwan, 2000
    • Table 2. Smoking-Attributable-Expenditure (SAE) of outpatient by disease and age group for males aged 35 and older in Taiwan, 2000 5%
    • Table 3. Smoking-Attributable-Expenditure (SAE) of outpatient by disease and age group for females aged 35 and older in Taiwan, 2000
    • Table 4. Smoking-Attributable-Expenditure (SAE) of inpatient by disease and age group for males aged 35 and older in Taiwan, 2000
    • Table 5. Smoking-Attributable-Expenditure (SAE) of inpatient by disease and age group for females aged 35 and older in Taiwan, 2000
    • Table 6. Smoking-Attributable-Expenditure (SAE) by disease for both sexes aged 35 and older in Taiwan, 2000
    • Table 7. Smoking-Attributable-Expenditure (SAE) by disease and service type for both sexes aged 35 and older in Taiwan, 2000
    • Table 8 . Smoking-Attributable-Fraction (SAF) of each disease system by service type for males aged 35 and older in Taiwan, 2000
    • Table 9 . Smoking-Attributable-Fraction (SAF) of each disease system by service type for females aged 35 and older in Taiwan, 2000
    • Table 10 . Smoking-Attributable-Fraction (SAF) of each disease system by service type for both sexes aged 35 and older in Taiwan, 2000
    • Table 11. Mean Annual Medical Expenditure for Smokers and Non-Smokers in Taiwan, 2000
    • Summary of the Results
      • Total SAE was US$467.3 million , representing 8.5% of the total medical expenditures for persons aged 35 and older in 2000.
      • The top three most costly diseases were
        • kidney disease (US$ 90.2 million),
        • ischemic heart disease (US$ 63.5 millions)
        • accidents (US$ 47.8 million).
    • US$467.3 Million
    • Discussion 1
      • This study is a major improvement over our first study of SAEs in two ways.
        • The relative risk of smokers versus non-smokers was provided by two large follow-up studies.
        • The amount of medical care utilized by each type of disease and their corresponding expenditures came from the NHI claims files..
    • Discussion 2
      • Percent of SAEs to the total expenditure of each service
      7.4% 10.6% 2000 Taiwan NHI This study 5.6% 11.4% 1993 U.S. Medicare Zhang et al Outpatient Inpatient Study Authors
    • Discussion 3
      • The SAFs of total SAE
      8.5% Taiwan This Study 6 – 8% U.S. Warner et al SAFs Study Authors
    • Discussion 4
      • SAFs
      8.2% 40% Respiratory 19.8% 25% Circulatory 23.5% 20% Neoplasm This study, 2000 Luce and Schweitzer, 1978 SAFsAuthors
    • Discussion 5
      • Kidney diseases accounted for 5% of outpatient expenditures of all diseases for males.
      • About 80% of the renal dialyses are done in hemo-dialyses centers, causing the cost of insurance, reducing the productivity and quality of life of the patient.
      • Kidney disease should be a main concern when discussing the cost of smoking.
    • Limitations
      • We did not estimate SAEs related to Passive smoking or expenditures not covered by NHI.
      • We used relative risk of mortality to estimate the relative risk of morbidity of each disease.
      • We used the prevalence rate of smoking during previous decade instead of that of the current year.
    • 菸害防制對社會福利的影響為何?
      • 社會福利的目標為何?
        • 老人福利
        • 婦女福利
        • 兒童及青少年福利
        • 身心障礙者福利
        • 社會救助
        • 社會保險
    • Thank You for Your Attention!