在腹腔鏡手術世代中，急性膽囊炎之發生率及醫療資源耗用

The prevalence and resource utilization of acute cholecystitis in the era of laparscopic surgery

蔡豐仰(Feng-Yang Tasi)

指導教授 ： 李金德

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2015年)

摘要

中文摘要
研究背景與目的
國人隨著飲食與生活型態愈趨西化的影響，膽結石盛行率有日漸攀升的趨勢，對於膽結石，腹腔鏡膽囊切除術已成為標準的術式，但對於膽結石合併急性膽囊炎外科手術之時機，時有爭議。因此本研究的目的在於探討在腹腔鏡手術世代中，膽結石合併急性膽囊炎之發生率，並探討膽結石合併急性膽囊炎手術病患之趨勢分析，另外分析膽結石合併急性膽囊炎手術病患之醫療資源耗用，最後依病患與疾病的特質、接受手術場所的地理分佈、醫院層級等特性，分析病患接受手術的影響因素。
研究方法
本研究係屬回溯性研究設計，由中央健保局釋出之「全民健康保險研究資料庫」中，取得2001至2010年間，各年度申報膽結石合併急性膽囊炎及膽結石未合併急性膽囊炎手術病患進行分析及趨勢的研究。統計分析採用SPSS 20.0統計軟體，以卡方檢定、單因子變異數分析、複迴歸分析及邏輯式分析進行資料分析及驗證假說。
研究結果
2001至2010年研究期間經資料處理後，以接受膽囊切除手術的病人為研究對象，共有69,813筆申報資料可供使用，其中52,381人接受腹腔鏡膽囊切除手術，隨著年代進展接受腹腔鏡膽囊切除手術病患逐年上升，這當中有36,150人合併急性膽囊炎，合併率為69.01%，然而膽石症合併急性膽囊炎的比例有逐年下降的趨勢。膽結石合併急性膽囊炎接受腹腔鏡膽囊切除術比例男性(75.00%)大於女性(64.00%)，且年齡大於65歲膽結石患者發生急性膽囊炎的比例會增加(76.00%＞64.00%)。
本研究採長期之縱貫性研究，共計10年，合併症嚴重度指數2分以上者及合併糖尿病的膽石症病患發生急性膽囊炎比例較高，且都將隨著年代進展而下降。在醫院層級別方面，醫學中心的病患，隨年代進展，膽結石合併急性膽囊炎的比例呈現下降趨勢，在手術場所區域不同之情況下，高屏區業務組的病患隨年代進展，膽結石合併急性膽囊炎的比例亦有下降趨勢。
在手術病患住院費用方面，隨著年代推演住院費用呈現下降趨勢，在住院天數方面，隨著年代推演住院天數亦呈現下降趨勢。
結論與建議
總體來講，由健保資料庫分析，膽結石合併急性膽囊炎還是具有高發生率(69.01%)，現在腹腔鏡膽囊切除術引進台灣後，國人對於此項創新醫療的接受度高，可早期診斷疾病後早期治療，已出現降低膽結石合併急性膽囊炎之發生率。雖然急性膽囊炎之各年度佔率有逐漸下降趨勢，但仍有進步空間，另外，對於急性膽囊炎的診斷，若申報時未能適當編碼，將造成急性膽囊炎手術比例與成果、年度趨勢的誤估。

關鍵字

膽石症 ； 急性膽囊炎 ； 腹腔鏡膽囊切除術

並列摘要

Abstract
Background and Purposes
There has been an upward trend in the prevalence of gallstones in Taiwan since the adoption of a Western diet and lifestyle among Taiwanese people. Laparoscopic cholecystectomy has become the standard surgical treatment for gallstones. However, the optimal timing of surgery in patients with both gallstones and acute cholecystitis is controversial. Therefore, the purposes of this study were to explore the incidence of gallstones combined with acute cholecystitis in the era of laparoscopic surgery, to assess the trend analysis and medical resource utilization of surgical patients with both gallstones and acute cholecystitis, and to analyze the affecting factors in terms of patients’ demographic and disease characteristics, the geographic distribution of the place where surgery was performed, and hospital level.
Methods
This is a retrospective study using data from the “National Health Insurance Research Database” released between 2001 and 2010 by the National Health Insurance Administration (NHIA) to assess the trend analysis of surgical patients who had gallstones combined with or without acute cholecystitis. Data were analyzed using SPSS 20.0. Data analysis and hypothesis testing approaches included chi-square tests, one-way analysis of variance, multiple regression analysis, and logical formula analysis.
Results
Based on available claims data during the period from 2001 to 2010, In patients undergoing cholecystectomy for the study,a total of 69,813 cases were undertaken,where 52,381 people underwent laparoscopic cholecystectomy. The patients who received laparoscopic cholecystectomy increased with years ,among these there are 36,150 people with acute cholecystitis merger,consolidation was 69.01%. However, the proportion of acute cholecystitis a declining trend.Have of the patients with both gallstones and acute cholecystitis, men (75.00%) had a higher proportion of undergoing laparoscopic cholecystectomy than women (64.00%); the patients aged 65 or older had an increased incidence of gallstones with acute cholecystitis than those younger than 65 (76.00% >64.00%).
This long-term longitudinal study collected a total of 10 years. The patients with Charlson comorbidity index (CCI) scores of ≥ 2 and diabetes had a higher incidence of gallstones with acute cholecystitis,and will decline as the years progress. In terms of hospital level, the proportion of patients with both gallstones and acute cholecystitis at medical centers showed a downward trend with years. In terms of the place where surgery occurred, the proportion of patients with both gallstones and acute cholecystitis from the NHIA Kaoping Division showed a downward trend with years.
The admission charges and length of stay also showed a downward trend with years.
Conclusions and Suggestions
Overall, the data based on the National Health Insurance Research Database have shown a high incidence of gallstones combined with acute cholecystitis(69.1%). After the introduction of laparoscopic cholecystectomy into Taiwan would increase Taiwanese people’s acceptance level and improve early detection and treatment, thereby facilitating the reduction of incidence of gallstones with acute cholecystitis. Although the incidence rate of acute cholecystitis has shown a downward trend with years, there is still room for improvement. Additionally, it should be noted that the incorrect diagnosis code for acute cholecystitis when submitting claims could lead to a misestimate of the proportion and outcomes of surgery for acute cholecystitis as well as the year-round trend analysis.

並列關鍵字

gallstones ； acute cholecystitis ； laparoscopic cholecystectomy

參考文獻

參考文獻

中文文獻

1.李大寬(2009).台灣腹腔鏡膽囊切除術之擴散與療效研究。高雄醫學大學醫務管理學研究所碩士在職專班碩士論文，高雄市。

2.徐和志(2000)，以腹腔鏡治療急性膽囊炎，Journal of Emergency Medicine,Taiwan.2(2)：29-33.

英文文獻