Mental illness and psychological distress is associated with higher rates of medical service usage and treatment of these issues results in more appropriate medical utilization rates. Little research has been conducted in an integrated care clinic, wherein health psychologists or behavioral health specialists work together with physicians to provide patient care. The current study examines the effects of brief behavioral and mental health interventions on patient medical utilization in this setting with care delivered by medical residents and doctoral psychology trainees. Access to the health system’s electronic billing records allowed for objective measures of annual healthcare utilization in terms of inpatient, outpatient, and emergency department use. A quasi-control group was constructed using propensity score matching in order to compare patients who had received a primary care psychology intervention to those who had not. Rates of inpatient utilization decreased significantly among treated patients overall as well as among treated patients identified as frequent attenders; there was no change in inpatient utilization among patients in the control group overall nor among frequent attenders in the control group, indicating that there is likely an effect of behavioral and mental health treatment on rates of inpatient visits. Rates of emergency department use and specialty outpatient visits were comparable between treated and control group patients, suggesting the lack of a treatment effect in these areas. Strengths, limitations, possible mechanisms, and implications for future research are discussed.

Background: Hepatocellular carcinoma (HCC) is the leading cause of cancer in Taiwan, which consumes high medical expense among the total healthcare expenditure and becomes the significant burden to the finance of National Health Insurance (NHI). However, population-based statistics about the cost with the survival rate is rare. Objective: Through analyzing the data from the Bureau of National Health Insurance and hospital clinical files, we estimated the medical expenditure for treating HCC patients and the factors associated with treatment outcome. Methods: The National Health Insurance data from 1996 to 2002 with ICD-9 code 155 were used, which include age, gender, visiting time, and medical cost for inpatient or outpatient visits. The population-based data were analyzed to estimate 1-5 year survival probability and medical cost of HCC patients. In hospital-based data, 189 patients from 1991 to 2004 were recorded by clinical chart and 62 of them diagnosed during 2002 and 2004 were further selected to match the claim data. These informations were used for computing survival or recurrence probability, related factors, and medical cost. Results: For all incident cases in 1997, the average 5-year cumulated cost was NT$ 219,398, while the cumulated cost for those patients survived more than five years was NT$ 491,288. The survival probability was 30.8% for more than one year, 20.9% for more than two years, 15.2% for more than three years, 11.3% for more than four years, and 9.7% for more than five years in 1997 respectively. Female and those age >45-65 years old seemed to have better survival outcomes than male and those age ¡Ø45 years old or >65 years old , the averaged medical cost per treated case surviving more than five years were T$2,457,214 for male and NT$ 1,987,874 for female. Hospital clinical data indicated that TNM stages, therapy choice, liver cirrhosis, and ascites are risk factors for surviving. Although pre-TACE treatment has higher expenditure, its five-year survival probability is better than other treatments in this research. Conclusions: This paper presents medical cost with survival probability and its associated factors for HCC patients and further estimates the medical cost per life saved for treating HCC patients. Our findings can offer the policy-maker, provider, and patient to evaluate the intervention or prevention program in the future.

Medical cost analysis is an important part of treatment evaluation. Since resources are limited in society, it is important new treatments are developed with proper costconsiderations. The mean has been mostly accepted as a measure of the medical cost analysis. However, it is well known that cost data is highly skewed and the mean could be highly influenced by outliers. Therefore, in many situations the mean cost alone cannot offer complete information about medical costs. The quantiles (e.g., the first quartile, median and third quartile) of medical costs could better represent the typical costs paid by a group of individuals, and could provide additional information beyond mean cost. For a specified patient population, cost estimates are generally determined from the beginning of treatments until death or end of the study period. A number of statistical methods have been proposed to estimate medical cost. Since medical cost data are skewed to the right, normal approximation based confidence intervals can have much lower coverage probability than the desired nominal level when the cost data are moderately or severely skewed. Additionally, we note that the variance estimators of the cost estimates are analytically complicated. In order to address some of the above issues, in the first part of the dissertation we propose two empirical likelihood-based confidence intervals for the mean medical costs: One is an empirical likelihood interval (ELI) based on influence function, the other is a jackknife empirical likelihood (JEL) based interval. We prove that under very general conditions, −2log (empirical likelihood ratio) has an asymptotic standard chi squared distribution with one degree of freedom for mean medical cost. Also we show that the log-jackknife empirical likelihood ratio statistics follow standard χ2 distribution with one degree of freedom for mean medical cost. In the second part of the dissertation, we propose an influence function-based empirical likelihood method to construct a confidence region for the vector of regression parameters in mean cost regression models with censored data. The proposed confidence region can be used to obtain a confidence interval for the expected total cost of a patient with given covariates. The new method has sound asymptotic property (Wilks Theorem). In the third part of the dissertation we propose empirical likelihood method based on influence function to construct confidence intervals for quantile medical costs with censored data. We prove that under very general conditions, −2log (empirical likelihood ratio) has an asymptotic standard chi squared distribution with one degree of freedom for quantile medical cost. Simulation studies are conducted to compare coverage probabilities and interval lengths of the proposed confidence intervals with the existing confidence intervals. The proposed methods are observed to have better finite sample performances than existing methods. The new methods are also illustrated through a real example.

The cost of health care continues to increase. Based on the biopsychosocial model of heath care, it has been shown that the treatment of psychological and social problems can have a cost offset effect on the cost of medical care. While this offset effect has been shown in an MFT population, there are no known studies that have looked at predictors of the change in medical use by those that receive marital and family therapy. This study looked at psychological and social measures of individuals who received marital and family therapy. These measures were evaluated based on the change from intake to one year post intake using best subsets multiple regression. The model for males showed variables that could be affected using a cognitive or cognitive-behavioral model of therapy. The model for females showed variables that could be affected using the emotionally focused model of therapy. The implications of this study are that a therapist could be the most effective in conjoint therapy if they apply concepts from both cognitive and emotionally focused therapeutic models.

近年來台灣國人十大死因以慢性疾病為主，其中惡性腫瘤（俗稱之癌症）自1982年起已連續32年位居國人死因首位；而在台灣人民所罹患之惡性腫瘤中，女性乳癌為發生率最高之病症。本研究自國衛院全民健保資料庫所提供之2005承保抽樣歸人檔，使用承保資料檔（ID）、住院醫療費用清單明細檔（DD）、住院醫療費用醫令清單明細檔（DO）、門診處方及治療明細檔（CD）、門診處方醫令明細檔（OO），對台灣女性乳癌患者進行病症相關分析，以國際疾病分類號的病症編號，挑選診斷代碼為174到1749，共10種類型之女性乳癌診斷結果之患者資料，藉由從2005年至2011年的資料，逐年分析其乳癌患者年齡分佈及患症趨勢、就醫後門診與住院所使用之相關診療方式、所花費之成本，進行資料彙整與分析，並分析乳房造影術及超音波兩種診療方式篩檢乳癌之成效，以及利用歷年資料推估未來一年的罹癌人數與死亡人數。 　　本研究結果顯示，台灣女性乳癌患者主要在40歲以上，好發年齡層為40～59歲之間，乳癌之盛行率逐年漸增，但死亡率卻無特別趨勢。門診部份，費用集中於用藥明細與診療明細點數，並以50～59歲為花費最高的年齡層；門診的診療方式主要以乳癌篩檢的項目為主。住院方面，費用集中在葯費、檢查費、病房費與手術費，各年齡層各年花費的波動很大，但主要以40歲以上的三組年齡層花費比例較高；而住院的診療方式則是以切除乳房的手術為主。乳房造影術與超音波在50～59及60歲以上兩組年齡層的篩檢率最高。在估計未來一年患病與死亡人數上，利用類似中央極限定理概念的CLT法以及無母數的拔靴法兩種方式來估計，其中以CLT法的估計方式對未來的人數估計較為準確。

Physical activity has several advantages for health. The first objective of this research was to determine the relationship between physical activity and selected physical and psychological health components. The physical components include: diabetes risk, obesity, cholesterol and cardiovascular disease. The psychological health components include stress and depression. Secondly, this research aimed to determine the relationship between physical activity and medical costs. Medical costs were divided into pharmaceutical, general practitioners and hospital claims. A total of 9 860 employees of the same financial institution in South Africa, between the ages 18 and 64 (x̄ = 35.3 ± 18.6 years), participated in the study and participation was voluntary. No differentiation was made between race groups. The assessment of selected health risk factors and physical activity was done by using the Health Risk Assessment (HRA) methodology developed by the company, Monitored Health Risk (MHM). Assessment included a physical activity, diabetes risk and cardiovascular risk questionnaire, BMI and random blood glucose measurements, as well as stress and depression scores. The amount of days absent from work in the past six months was also determined by the questionnaire. Participants was categorised in three groups – low, moderate and high physical activity participation. Medical expenditure data was obtained from Monitored Health Risk Management Pty (Ltd). Hospital, pharmaceutical and general practitioners (GP) claims included all costs occurring during a six month period. The majority of the study group showed low physical activity participation (78.27%). The results also showed that both men and women showed an increased risk for diabetes, and high physical activity levels have a practically and statistically significant effect on the reduction of diabetes risk. In this study all the physical activity groups of both males and females showed an increased average body mass index (BMI) and therefore are considered to be an increased risk according to the classification as stipulated by the study perimeters. The average means for cholesterol in all groups are categorised as low risk. No significant differences are seen between the female groups as well as between the different male groups. The men in the study group showed higher cardiovascular risk than women. There are no statistically significant differences between the women’s groups. However, regarding the male groups, the low physically active male group showed significant differences to the high physical active male group. Thus, in this study it appears that the men participating in high levels of physical activity show the lowest risk for cardiovascular disease and therefore appear to be influenced by physical activity. The majority of the study group is shown to be in the high stress category (55.48%). It seems that work issues (82%), financial problems (74%) and family problems (69%) contribute most to the population’s high stress levels and depression experience. The Physical activity index (PAI) in relation to stress only shows practical significance in moderate and high physical women. The PAI and stress-related index reports statistically (p≤0.05; 0.001) significant and practice significant difference within the population. There was also a statistically significant (p≤0.05) relation between stress and physical activity in relation to days absent. Although high levels of stress and low levels of physical activity are present in the population, the relation become statistically significant in relation with depression. The study group was divided into two groups when the medical cost was examined. One group consisted of those individuals who do not use chronic medication and the other group, those individuals that use chronic medication. The majority of the study group (chronic and nonchronic medication use), show low physical activity participation (average of 78.80%). The results show statistically and practically significant differences between the groups that do not use chronic medication and the groups that use chronic medication. The women that use chronic medication show an increase in pharmaceutical costs with an increase in physical activity. However, when investigating the GP cost of women who use chronic medication, there is only a small difference in GP cost in the different physical activity participation categories. The data shows that men have higher pharmaceutical costs than women in all the physical activity categories. The results also indicate that men who use chronic medication, participating in low levels of physical activity do show higher pharmacy and GP costs. Medical cost associated with hospitalisation of those men whose chronic medications show an average higher medical cost (R231.72 versus R672.71). The women who are on chronic medication show about two and a half times higher hospitalisation cost (R253.97 versus R650.82) and the men an almost four times higher cost (R189.34 versus R721.71). No practically significant difference was found between the groups. The women show an increased incidence of low physical activity participation (82.38%), whereas 68.80% of the men show low physical activity participation. Women who use chronic medication and participate in moderate physical activity show lower hospital costs. The women in this study group that use chronic medication and participate in high levels of physical activity show the highest hospital cost. The men’s profile indicates that medical cost due to hospital claims rise with the higher levels of physical activity. / Thesis (PhD (Human Movement Sciences))--North-West University, Potchefstroom Campus, 2013.

Physical activity has several advantages for health. The first objective of this research was to determine the relationship between physical activity and selected physical and psychological health components. The physical components include: diabetes risk, obesity, cholesterol and cardiovascular disease. The psychological health components include stress and depression. Secondly, this research aimed to determine the relationship between physical activity and medical costs. Medical costs were divided into pharmaceutical, general practitioners and hospital claims. A total of 9 860 employees of the same financial institution in South Africa, between the ages 18 and 64 (x̄ = 35.3 ± 18.6 years), participated in the study and participation was voluntary. No differentiation was made between race groups. The assessment of selected health risk factors and physical activity was done by using the Health Risk Assessment (HRA) methodology developed by the company, Monitored Health Risk (MHM). Assessment included a physical activity, diabetes risk and cardiovascular risk questionnaire, BMI and random blood glucose measurements, as well as stress and depression scores. The amount of days absent from work in the past six months was also determined by the questionnaire. Participants was categorised in three groups – low, moderate and high physical activity participation. Medical expenditure data was obtained from Monitored Health Risk Management Pty (Ltd). Hospital, pharmaceutical and general practitioners (GP) claims included all costs occurring during a six month period. The majority of the study group showed low physical activity participation (78.27%). The results also showed that both men and women showed an increased risk for diabetes, and high physical activity levels have a practically and statistically significant effect on the reduction of diabetes risk. In this study all the physical activity groups of both males and females showed an increased average body mass index (BMI) and therefore are considered to be an increased risk according to the classification as stipulated by the study perimeters. The average means for cholesterol in all groups are categorised as low risk. No significant differences are seen between the female groups as well as between the different male groups. The men in the study group showed higher cardiovascular risk than women. There are no statistically significant differences between the women’s groups. However, regarding the male groups, the low physically active male group showed significant differences to the high physical active male group. Thus, in this study it appears that the men participating in high levels of physical activity show the lowest risk for cardiovascular disease and therefore appear to be influenced by physical activity. The majority of the study group is shown to be in the high stress category (55.48%). It seems that work issues (82%), financial problems (74%) and family problems (69%) contribute most to the population’s high stress levels and depression experience. The Physical activity index (PAI) in relation to stress only shows practical significance in moderate and high physical women. The PAI and stress-related index reports statistically (p≤0.05; 0.001) significant and practice significant difference within the population. There was also a statistically significant (p≤0.05) relation between stress and physical activity in relation to days absent. Although high levels of stress and low levels of physical activity are present in the population, the relation become statistically significant in relation with depression. The study group was divided into two groups when the medical cost was examined. One group consisted of those individuals who do not use chronic medication and the other group, those individuals that use chronic medication. The majority of the study group (chronic and nonchronic medication use), show low physical activity participation (average of 78.80%). The results show statistically and practically significant differences between the groups that do not use chronic medication and the groups that use chronic medication. The women that use chronic medication show an increase in pharmaceutical costs with an increase in physical activity. However, when investigating the GP cost of women who use chronic medication, there is only a small difference in GP cost in the different physical activity participation categories. The data shows that men have higher pharmaceutical costs than women in all the physical activity categories. The results also indicate that men who use chronic medication, participating in low levels of physical activity do show higher pharmacy and GP costs. Medical cost associated with hospitalisation of those men whose chronic medications show an average higher medical cost (R231.72 versus R672.71). The women who are on chronic medication show about two and a half times higher hospitalisation cost (R253.97 versus R650.82) and the men an almost four times higher cost (R189.34 versus R721.71). No practically significant difference was found between the groups. The women show an increased incidence of low physical activity participation (82.38%), whereas 68.80% of the men show low physical activity participation. Women who use chronic medication and participate in moderate physical activity show lower hospital costs. The women in this study group that use chronic medication and participate in high levels of physical activity show the highest hospital cost. The men’s profile indicates that medical cost due to hospital claims rise with the higher levels of physical activity. / Thesis (PhD (Human Movement Sciences))--North-West University, Potchefstroom Campus, 2013.

本次研究使用全民健康保險研究資料庫2005承保抽樣歸人檔(LHID2005)，共40萬人的承保資料，針對肺癌患者的特徵進行分析，並與美國國家癌症研究所的肺癌資料作比較，罹患肺癌的人數都呈現男性多於女性，罹癌年齡的最高峰同樣落在65歲至74歲。 接著，將門診處方及治療明細檔和住院醫療費用清單明細檔進行彙整，整理出肺癌患者在2005年至2012年之間的門診費用以及住院費用，並比較不同項目的差距及特徵，門診費用以用藥明細點數最高，住院花費前五名的項目為葯費、病房費、放射線診療費、檢查費以及治療處置費。 最後，建構肺癌治療的多重型態模型，治療方式包含手術治療、放射線治療、化學治療，估計不同狀態之間的轉換力，進而算出五年定期躉繳肺癌保單之純保費。 / This study used Longitudinal Health Insurance Database 2005 (LHID2005) from Taiwan’s National Health Insurance Research Database (NHIRD). Screening the 400,000 insured of NHIRD to select the lung and bronchus cancer patients. This study analyzed and described their characteristics. Furthermore, it compared Taiwan’s lung and bronchus cancer data with the data in the United States derived from National Cancer Institute of the USA. The results revealed that the number of male patients is more than female patients and lung cancer is most frequently diagnosed among people aged 65-74 in both countries. Another aim was to sum up the lung cancer medical cost in 2005 to 2012 from NHIRD database, including ambulatory care expenditures by visits and inpatient expenditures by admissions. The highest cost of outpatients was medicine fee. The top five inpatient expenditures were medicine fee, ward fee, radiation therapy fee, inspection fee and therapeutic treatment fee. Finally, this study constructed a multiple state model of lung cancer treatment, including surgery, radiotherapy, chemotherapy. Estimating the transition intensities from multiple state model to calculate the pure premium of a five-year lung cancer policy.