探討甲狀腺全切除術術中使用喉返神經偵測系統與否之醫療成效與醫療資源耗用分析

研究目的目的一：比較喉返神經偵測系統術中使用與否於甲狀腺全切除手術在臨床醫療成效上差異。目的二：比較喉返神經偵測系統術中使用與否於甲狀腺全切除手術臨床醫療資源耗用上的差異。研究方法以回溯性分析研究方法，收集南部某醫學中心於2010年1月至2012年6月接受甲狀腺全切除手術術中有使用喉返神經偵測系統之病人122例；術中無使用喉返神經偵測系統之病人107例，比較兩組病人在住院天數、手術時間、麻醉時間、醫療費用、併發症、傷口疼痛之間的差異性，進而討論醫療資源耗用效益的評估。研究結果一、醫療成效： 1、雙側甲狀腺全切除術發生併發症機率是單側甲狀腺全切除術的2.27倍，且若病理組織重量越重，發生併發症的機率也增加。術中使用喉返神經監測系統聲音沙啞機率明顯較低(P=0.004) 2、傷口疼痛程度：發現術中沒有使用喉返神經監測系統組在平均疼痛指數(4.11±2.35)高於術中有使用喉返神經監測系統組(3.05±2.23)，具顯著性差異（P=0.039）。二、醫療資源耗用：(1)住院天數：術中有使用喉返神經監測系統組的平均住院天數為5.11±1.01天，術中沒有使用喉返神經監測系統組為4.36±0.97天(P=0.001），且術後產生血腫、傷口感染等併發症會影響住院天數。(2)手術及麻醉時間：術中有使用喉返神經監測系統組的平均手術時間為144.18±49.13分鐘，平均麻醉時間為165.40±51.95分鐘；術中沒有使用喉返神經監測系統組為113.18±33.11分鐘，平均麻醉時間為136.64±35.99分鐘，二組相差時間約30分鐘(P=0.001)。(3)醫療費用：術中有使用喉返神經監測系統在總醫療費用為67208±17035元，術中無使用喉返神經監測系統總醫療費用為47353±23791元；若手術方式為單側甲狀腺全切除術醫療費用53384±19459，雙側甲狀腺全切除術醫療費用61519±24461元，具顯著性差異(P=0.001）。結論與建議一、術中使用喉返神經偵測系統對於避免喉返神經受損具有明顯成效，可避免因併發症發生而增加額外醫療花費。而使用喉返神經偵測系統對於低血鈣、血腫、傷口感染方面則無顯著相關。二、雙側甲狀腺全切除術發生低血鈣機率高於單側甲狀腺切除術，且病理組織重量越重，持續仍有低血鈣機率高，需補充鈣劑的時間也較久，藥品費用支出增加。三、術中有使用喉返神經監測系統的醫療費用較高，可能與手術時間、麻醉時間、住院天數較長有關，而增加醫療資源利用。四、使用喉返神經偵測系統需自費，對病人而言需多花費一筆費用，因此對於整體醫療資源耗用而言是增加的。隨著手術技術和經驗的改善，暫時性喉返神經麻痺和副甲狀腺功能低下，是需特別注意的主要併發症，而神經監測系統主要是避免喉返神經受損，造成嚴重的併發症，因而增加醫療資源利用，負擔額外的醫療花費，因此喉返神經監測系統建議於手術中使用。

關鍵字

甲狀腺全切除術；喉返神經監測系統；醫療資源耗用；醫療成效

並列摘要

Purpose Objective one: To compare the differences, on clinical medical result, of whether or not using the neuro monitoring of recurrent laryngeal nerve in total thyroidectomy. Objective two: To compare the differences, on clinical medical resource utilization, of whether or not using the neuro monitoring of recurrent laryngeal nerve in total thyroidectomy. Method With a retrospective analysis of research methods, I have collected 229 cases from a southern medical center during January 2010 to June 2012, in which, 122 cases were proceeded using the neuro monitoring of recurrent laryngeal nerve while 107 cases were not. Next, analyzing the differences in two groups of patients of hospital stay, operative time, anesthesia time, medical expenses, complications, and wound pain. Eventually, the medical resource utilization efficiency was evaluated. The results 1. Medical results: A. The complications probability in bilateral total thyroidectomy is 2.27 times to unilateral total thyroidectomy, and, if the weight of the pathology is heavier, the chances of complications would be higher. The probability of hoarseness is significantly lower with the use of recurrent laryngeal nerve monitoring system(P=0.004) B. Wound pain: The average pain score (4.11±2.376) is higher in case wither using recurrent laryngeal nerve monitoring system group than that average pain score (3.05± 2.226) of case using of recurrent laryngeal nerve monitoring systems group. This result has a significant difference (P=0.039). 2. Medical resource utilization: A. Hospital stay :the average hospital stay of cases receiving recurrent laryngeal nerve monitoring system is 5.11± 1.011 days while cases without using it only stay 4.36±0.974 day (P=0.001 ). Besides, the postoperative hematoma, wound infection and other complications will affect the day of hospital stay. B. Operation and anesthesia time: For the group using recurrent laryngeal nerve monitoring system, the average operation time is 144.18 ± 49.130 minutes, and the average anesthesia time is 165.40 ± 51.949 minutes. For the group without using it ,the average operation time is 113.18± 33.105 minutes and the average anesthesia time is 136.64±35.989minutes. These two groups differ in 30 minutes (P=0.001). C. Medical expenses: The total expense of operation with recurrent laryngeal nerve monitoring system is 67,208±17,035 dollars, while the operation without using it is 47,353 ±23,791 dollars. On the other hand, the unilateral thyroidectomy surgery cost 53,384±19,459 dollars. while the bilateral thyroidectomycost 61,519±24,461 dollars. This make a significant difference (P = 0.001). Conclusion and recommendation 1. The use of intraoperative recurrent laryngeal nerve monitoring systems to avoid recurrent laryngeal nerve damage has been significant. It can help avoid complications due to the increase health care costs. While monitoring system for the use of the recurrent laryngeal nerve hypocalcemia, hematoma, and wound infections had no significant correlation. 2. Bilateral total thyroidectomy hypocalcemia probability higher than unilateral thyroidectomy. And, if the weight of pathological was heavier, the hypocalcemia probability would be higher, the patient need to add more calcium, which led the drug expenses increased. 3. The medical cost will be higher if the recurrent laryngeal nerve monitoring system was used during the operation. This may be associated with operative time, anesthesia time, and hospital stays were longer, which increased the use of medical resources. 4. Using the recurrent laryngeal nerve monitoring system would not be paid by National Health Insurance. This means the patient need to spend more money to get that service, so the overall medical resource utilization was increased. Even though the surgical experiences have been improved, the temporary paralysis of the recurrent laryngeal nerve and low parathyroid function are still the complications requiring special care. The nerve monitoring system is mainly used to avoid the intraoperative recurrent laryngeal nerve damage .Those complications may increase the use of medical resources. Therefore, the usage of this system are suggested.