| 摘要: | 背景及動機
膽石症乃國人常見疾病，其盛行率為5%。膽結石病患10%~15%合併患有總膽管結石。總膽管結石為可能導致死亡之危險疾病，加上健保資源緊縮，因此值得對總膽管結石不同治療方式之成本效益作進一步研究。
研究目的
本研究欲分析台灣地區總膽管結石治療趨勢，提供一階段與二階段治療成本效益分析，以找出最具效益之治療方式，此結果將可提供衛生主管機關訂定合理醫療給付和治療指引之參考。
研究方法
以2002-2009健保資料庫百萬抽樣歸人檔進行回溯性世代分析。研究對象為總膽管結石（ICD9-CM：574-576）患者，總樣本數499人，分為接受一階段治療（腹腔鏡膽囊摘除及總膽管探查，76人）及二階段治療（內視鏡膽管取石及腹腔鏡膽囊摘除，423人）兩組，以SAS 9.2分析兩組間醫療品質及各項醫療費用之差異。
以卡方檢定分析一階段及二階段治療之病患特性分佈差異；以GLM、線性迴歸及複迴歸探討兩組間各項醫療費用的差異及影響醫療費用相關因素；以羅吉斯迴歸分析影響再住院相關因子。
研究結果
因膽石症而就診之病患數佔全人口之0.78%，男女性別分佈比例分別為44%、56%。一階段治療於2008-2009年呈明顯上升趨勢，年老及無共病者傾向以一階段治療。一階段和二階段平均住院日11.2、10.6(天)，未達顯著差異。多變項GLM顯示，在醫療費用上，病房費，手術費，麻醉費，特殊耗材費為一階段顯著較二階段高；處置費，放射線檢查費則二階段較一階段高；而總醫療費用為一階段顯著較二階段高(100,739元、86,020元)。一階段和二階段之再住院率(5.26%、2.13%)未達顯著差異；二階段治療僅一個病患死亡(0.24%)；此外醫師年齡及醫師執業年資則和病患治療結果及總醫療費用沒有相關。
結論
如預期不論何種治療方式，共病是影響費用最重要的因子，雖然國外的研究大多指出一階段治療總膽管結石對整體效益較有優勢，但台灣一階段治療醫療耗用較二階段高之結果與國外研究相反。造成此差異的最可能原因為，本研究是以全國平均治療水準和西方國家頂尖的醫學中心作比較。我們相信，待台灣的外科醫師LCBDE的技術更為熟練，將會凸顯出一階段治療的優勢。此外，政府或可調整腹腔鏡醫療給付，以激勵醫師朝一階段治療發展。
Background
Cholelithiasis is a common disease in Taiwan with a prevalence of 5%. Among these patients, the incidence of having concomitant CBD stones (Choledocholithiasis) has been reported to be 10%-15%. Carrying a high risk of mortality if not treated properly, it is of much importance to investigate the optimal management strategy for this disease.
Purpose
The purpose of this study is to analyze the current trend of treating CBD stones in Taiwan and provides a detailed cost-effectiveness analysis for its optimal management. We assume that our results will be useful for the authorities to determine a reasonable insurance reimbursement and set up treatment guidelines.
Methods
The data source of this study was a database that contains records of medical expenditure of one-million Taiwanese population during 2002-2009. There were 499 patients been identified within this dataset (ICD9-CM:574-576) and were divided into two groups according to the type of treatments. Seventy-six patients were treated by LC+LCBDE (one-stage treatment, group 1, n=76) and the others were treated by ERCP/S+ LC (two-stage treatment, group 2, n=423).
Patient demographics were compared between the groups by using Chi-square tests. GLM analysis was used to compare the medical costs between the groups. In addition, GLM analysis as well as simple linear and multiple regression analysis were also used to analyze the association of the variables with each category of medical costs. Multiple logistic regression analysis was used to analyze the association of readmission rate with the variables.
Results
The calculated prevalence of cholelithiasis that required a cholecystectomy was 0.78% with a male: female ratio of 44: 56. Group1 patients were significant older but with less comorbidities compared to that of group 2.
The mean length of hospital stay was 11.2 and 10.6 days for group1 and 2, respectively without statistical difference. The ward fee and the fee for operation, anesthesia and special material were significant higher in group 1. In contrast, the fee for treatment and radiology examination were significant higher in group 2. However, the overall hospital cost was significantly higher in group 1 than in group 2 (NT $100,739 vs. $86,020). Nonetheless, comorbiditity is the most important factor that determine the medical costs regardless the types of treatment. The readmission rates (5.26% vs, 2.13%) and mortality rates (0% vs. 0.24%) were similar between the groups.
Couclusion
Unlike most published reports that favored LC+LCBDE, our results indicated that ERCP/S+ LC was more cost-effective treatment modality in Taiwan. A possible explaination for this contradiction is that the overall standard of care in Taiwan is still inferior to that of elite medical centers of western countries. We believe that after surgeons in Taiwan gradually become familiar with the technique of LCBDE the advantages of one-stage operation will show. However, the government should encourage surgeons to perform LCBDE by providing better reimbursement to this procedure. |
