台灣地區透析患者接受副甲狀腺切除手術之住院醫療服務利用分析
-以全民健保研究資料庫為例(2000-2004)

摘要本研究主要目的為探討台灣地區透析患者接受副甲狀腺切除手術之人口學特質和疾病型態、手術率的趨勢和副甲狀腺切除手術的高危險群，並探討透析患者接受副甲狀腺切除手術住院醫療服務利用之影響因子。本研究設計是回溯性之次級資料分析，主要資料來源是從西元2000年到2004年共五年，登錄於國家衛生研究院發行之全民健康保險研究資料庫。使用的檔案包括醫事機構基本資料檔、重大傷病證明申請檔、專科醫師證書主檔和住院醫療費用清單明細檔等。經資料處理後，取得全國透析患者接受副甲狀腺切除手術共1,326人進入本研究。醫療資源利用包括住院天數和費用。以病人之年齡、性別、透析方式、接受手術方式、接受透析時間、合併症個數、手術醫院之層級別、權屬別、分局別、醫院手術量、醫師年資和醫師手術量分析副甲狀腺切除手術率、住院天數和醫療費用。資料採用統計套裝軟體SPSS® for windows 12.0版進行描述性統計及推論性統計分析。研究結果發現：(一)在手術率方面，從西元2000年到2004年逐年增加，年發生率由每一千人年5.11次，逐年上升到9.42次。手術率男性多於女性，年齡小多於年齡大，腹膜透析多於血液透析，非糖尿病多於糖尿病患者。(二)在住院天數方面，全副甲狀腺切除手術高於部分副甲狀腺切除手術，血液透析高於腹膜透析，合併症個數越多，住院天數越久，醫學中心高於區域及地區醫院，醫院分局別以台北分局最多，高手術量醫院和低年資、低手術量醫師，住院天數較多。(三)在醫療費用方面，血液透析高於腹膜透析，接受透析時間越久，合併症個數越多，醫療費用越高，公立醫院高於私立醫院，醫院分局別以南區分局最多，低年資和低手術量醫師，醫療費用較高。本研究結果顯示男性、年齡小、腹膜透析和非糖尿病患者副甲狀腺切除手術率較高，為高危險群，臨床醫師應特別注意鈣和磷的控制和維生素D的使用。公立醫院的醫療費用較高，管理者應特別注意。醫學中心和高手術量醫院，平均天數較多，低年資和低手術量醫師，醫療費用較高，建議實施臨床路徑以降低平均住院天數和醫療費用。本研究未能取得生化值、臨床症狀和併發症等數據，建議未來研究者能直接採用醫院病歷的資料，搜集詳細之數據，增加預測變項；也建議中央衛生機關整合台灣腎臟醫學會相關指標，進行全國性研究，增加學術研究價值。關鍵詞：次發性副甲狀腺功能亢進、副甲狀腺切除手術、住院天數、醫療費用

關鍵字

次發性副甲狀腺功能亢進；副甲狀腺切除手術；住院天數；醫療費用

並列摘要

Abstract The major purpose of this study was to investigate patient demographics, trend of parathyroidectomy rate, high risk groups and clinical factors of dialysis patients who underwent parathyroidectomy in Taiwan. The study design was a retrospective secondary data analysis. The study used hospitalization data covering the periods from 2000 to 2004, taken from Taiwan’s National Health Insurance Research Database (NHIRD), published by the National Health Research Institute, including files of registry for contracted medical facilities (HOSB), registry for catastrophic illness patients(HV), registry for board-certified specialists(DOC) and inpatient expenditures by admissions (DD).The study papulation consisted of a total number of 1,326 dialysis patients of secondary hyperparathyroidism (ICD-9-CM code 588.8) who underwent parathyroidectomy (ICD-9-CM code 068.1 and 068.9). In-patient service utilizations included length of stay (LOS) and cost per discharge. Moreover, the service utilization differences in parathyroidectomy was compared by type of dialysis, parathyroidectomy, number of co-morbidities, hospital characteristics and provider volumes. The computer software SPSS® 12.0 for Windows was used to conduct descriptive and theoretical comparison and analysis. According to planned statistical analyses, the results indicated that: (1)By trend analysis, the incidence of parathyroidectomy rate in 2000 was 5.11 per 1000 person-years. By 2004, the incidence rose to 9.42 per 1000 person-years. Male, younger age group, peritoneal dialysis and non-diabetic dialysis patients had higher incidence of parathyroidectomy. (2)The mean LOS was longer in the dialysis patients with toal parathyroidectomy, hemodialysis, more co-morbidities, and hospitals of medical center, north location (Taipei) , high volume hospitals and low volume surgeons. (3) The patient costs was higher in the dialysis patients of hemodialysis, longer duration, more co-morbidities, and hospitals of public, south location and low volume surgeons. In conclusion, male, younger, peritoneal dialysis and non-diabetic dialysis patients was particularly high risk groups for parathyroidectomy. Phosphate binder and Vit.D were administered especially. Public hospitals had longer and more stastistically significant costs. Medical center and high volume hospitals had longer LOS. Low voume surgeons had higher patient’s cost. It was then suggested that hospitals practiced “clinical pathway ” to decrease LOS and patient costs. However, the research databases was from NHRID secondary data. The major limitation of the research was lack of : (1)clinical data, (2)clinical symptoms and (3)complications. For further research, the clinical registry database may conduct by Taiwan Nephrology Society and integrate NHIRD and increase values of clinical research. Keywords: Secondary hyperparathyroidism、Parathyroidecotmy、Length of stay、Cost