- 學位論文
腦下垂體瘤行顯微鏡經蝶竇手術及經鼻內視鏡手術之成本效果分析：以南部某醫學中心為例
The cost-effectiveness analysis of microscopic transsphenoidal surgery and endoscopic transnasal pituitary surgery in patients with pituitary tumor: Example of a medical center in southern Taiwan.
摘要
研究目的 腦下垂體瘤為緩慢生長且多為良性腫瘤，佔所有顱內腫瘤約10-15％。其治療方式包含藥物、放射線治療及手術治療，依照腫瘤的大小功能性侵犯的程度而有所不同，現在主要的治療方式為手術為優先選擇方法。在腦下垂體瘤常採用的切除手術方法中，使用顯微鏡經蝶竇手術為傳統手術方法，經鼻內視鏡手術為近十年所逐漸推行的手術方法，也被稱為腦下垂體瘤的新式微創手術。 本研究將探討腦下垂體瘤行顯微鏡經蝶竇手術及經鼻內視鏡手術治療成本及效果分析，主要研究目的為: 一、 比較腦下垂體瘤患者行顯微鏡經蝶竇手術及經鼻內視鏡手術之人口學及疾病特質之差異 二、 比較腦下垂體瘤患者行腦下垂體瘤行顯微鏡經蝶竇手術及經鼻內視鏡手術治療成本之差異。 三、 比較腦下垂體瘤患者行腦下垂體瘤行顯微鏡經蝶竇手術及經鼻內視鏡手術效果之差異。 四、 比較腦下垂體瘤患者行腦下垂體瘤行顯微鏡經蝶竇手術及經鼻內視鏡手術成本效果分析之差異。 研究方法 本研究以回溯性研究，採次級資料分析，資料來源取自於台灣南部某醫學中心住院與門診醫療資料庫與醫院批價資料檔及病歷查閱的方式獲得研究樣本，收集2009年至2016年進行腦下垂體瘤切除手術的患者資料進行分析。以研究醫院所有腦下垂體瘤(診斷碼ICD-9-CM227.3 pituitary tumor benign、ICD-9-CM 237.0 pituitary adenoma、ICD-9-CM 239.7 pituitary tumor unspecified之患者。接受經由蝶竇腦下垂體切除術(手術處置碼83057B)之住院患者，回溯期間由2009年4月1日至至2016年12月31日，共個93個月。採用統計套裝軟體中文版SPSS 20.0進行資料的處理及分析，利用卡方檢定(Chi-square)及獨立樣本t檢定(Indepenent t-test)等統計方式描述各變項及分析兩種手術方式的差異。並藉由傾向分數配對法，將接受腦下垂體手術治療的兩組患者人口學特質與疾病特質變項依照傾向分數進行1:1配對，以平衡兩組干擾因子分佈的差異，兩組各取104人，最後以成本效果評估指標，針對兩種手術方式進行成本效果分析。 研究結果 經過傾向分數配對後之成本分析，經鼻內視鏡手術之醫療總費用高於顯微鏡經蝶竇手術，檢定達顯著差異(p<.0005)。效果分析中顯微鏡經蝶竇手術與經鼻內視鏡手術中住院天數(8.36±3.017天與8.63±5.744天，p=.673)，三個月內門診次數(4.22次與4.44次，p=.470)手術後併發症、再開刀次數與再入院次數皆顯示無顯著差異(p>.05)，但手術時間(197±44分鐘與247±59分鐘)，結果顯示經鼻內視鏡手術之手術時間較長，達顯著差異(p<.0005)，兩種開刀方式之增量成本效果比值(ICER)皆小於三倍國民生產毛額(GDP)1,851,234元，皆具有成本效益。 結論與建議 腦下垂體瘤患者接受經鼻內視鏡手術醫療總成本較高，平均總醫療費用相差61,810元，兩種手術方式成本達顯著差異，在效果指標中，兩種手術方式效果無顯著差異(p>.05)，成本效果分析中顯示選擇顯微鏡經蝶竇手術具成本效果。此研究結果可提供醫療管理者作決策參考，但本研究只收集單一家醫院研究樣本，研究數量不足以推論至全國腦下垂體瘤患者的資料，未來研究方向可朝收集多家全國不同層級與屬性的醫院的研究樣本，作為研究資料的來源。並建議未來研究可增加此兩種手術術後的生活品質量表問卷調查，長期的追蹤術後症狀有無緩解，期望未來的相關研究可加以探討。
並列摘要
The purpose of this study was to investigate the cost effectiveness analysis of the two surgical treatments for the pituitary tumors, microscopic transsphenoidal pituitary surgery and endoscopic transsphenoidal pituitary surgery. The aim was to find out the following differences between them: (1) the difference of demographic and disease characteristics (2) the cost of the surgical treatments (3) the outcome of the surgical treatments (4) the cost effectiveness analysis. The study examined the medical records of a southern medical center from 2009 to 2016. The chi-square test and independent t-test were used to describe the variables and analysis of the difference between the two surgeries. The demographic characteristics and clinical characterization of the two groups of patients undergoing pituitary surgery were matched by 1: 1 in accordance with the propensity score to balance the differences in the distribution of the interference factors in the two groups. Two groups each take 104 people. Then cost effectiveness evaluation index was used to analyze the cost effectiveness of the two surgical methods. The results of the study were that the total cost of medical surgery for endoscopic sinus surgery was significantly higher than that of microscopic transsphenoidal surgery (p <.0005), average hospital stay being days (8.36days ± 3.017 days and 8.63days ± 5.744 days, p = .673), the number of outpatients (4.22times and 4.44 times) in the three months were examined by the transsphenoidal surgery and transnasal endoscopic sinus surgery. (P> .05), but the operative time (197 ± 44 minutes and 247 ± 59 minutes) was significantly higher than that of the endoscopic sinus surgery (P <.0005). The incremental cost-effectiveness ratio (ICER) of the two modes of operation is less than three times the gross national product (GDP) NT 1,851,234 Yuan, cost-effectives respective fields. It was found that patients with pituitary tumors underwent endoscopic surgery, the total cost of medical is higher, the average total medical expenses difference of NT61, 810 Yuan, the cost of the two surgical methods significant difference in the effect of indicators, the two surgical methods no significant difference (p> .05), the cost-effectiveness analysis showed the choice of microscopic transsphenoidal surgery with cost effective. The results of this study can be used as a reference for medical managers. However, this study only collected the number of samples from a single hospital. The number of studies was not enough to deduce the data of patients with pituitary tumor in Taiwan. We will collect different levels of hospital sample of the study as a source of research data. And suggested that future studies can increase the quality of life of these two postoperative questionnaire survey and long-term follow-up symptoms of remission in the future.
參考文獻
延伸閱讀
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