醫師手術量與療效及資源耗用之關係--以腹腔鏡膽囊切除手術為例

The importance of surgeon’s volume for clinical and economic outcomes from laparoscopic cholecystectomy

李金德(King-Teh Lee)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/公共衛生學研究所碩士在職專班/碩士(2003年)

摘要

研究背景與目的：我國自古即有名訓曰熟能生巧，其用意在於勉勵世人，凡事勤於演練自然能把事情做得很好。於外科手術的過程亦有類似所謂的學習曲線，亦即外科手術經驗到達某種經驗水準之後，外科手術的成果會呈現有意義的改善。Luft等學者認為手術量多的外科醫師，病人死亡率有意義低於手術量少的醫師，亦即手術量多的醫師有較好的醫療成果。
近代的醫療照護在於強調降低成本，減少資源耗用，同時更要維持醫療品質及病人滿意度；我們進行該研究的目的在於：探討於其他條件相同下，醫療療效及醫療資源耗用應是否隨著提供者的經驗及提供量而改善。
研究方法與材料：我們逆行性回顧，以南部某醫學中心(本醫院)西元1998年1月至2000年4月，所有進行腹腔鏡膽囊切除手術的921病例為研究對象。我們以病歷審閱方式，逐例審閱記載病人的人口學特質(年齡、性別)、臨床表徵(疾病診斷、合併急性膽囊炎、胰臟炎、總膽管結石、共存疾病指標，Charlson comorbidity index)、醫療因素(入院狀況、手術狀況及等待日數)及每位醫師的手術量。並記載所發生的手術後併發症，每位病人的平均住院及醫療費用的耗用。我們以手術量的多寡，將醫師手術量分為4組；甲醫師量為521例；乙醫師量為192例；丙醫師量為147例；丁醫師量為75例。我們以術後併發症率、平均住院日數及醫療費用耗用總額當作成果來評估醫療療效及資源耗用情形；並以對數迴歸分析、複迴歸分析及STATA7.0來分析推論不同醫師手術量與療效及醫療資源耗用的關係，並且以干擾因素來調整其原發成果。
結果：本醫院的921例病人，其年齡由19 歲到86歲，平均為52.8±12.9歲；男性有555例，佔60.3%、女性326例佔39.7%。手術病例以膽囊結石症最多815例，佔88.5%；合併急性膽囊炎有180例，佔19.5%；急性胰臟炎33例，佔3.6%；總膽管結石19例，佔2.1%；共存疾病指標，平均為0-8分，平均1.35分。急診入院的病例有162人，佔17.6%；沒有急診手術的病人；入院至手術等待日數為0-9日，平均為1.95日。術後有11例發生併發症，發生率為1.2 %；全部例數的平均住院日數為4.7±2.5日；平均醫療費用為49581元。
我們以對數迴歸分析及STATA7.0的統計分析法，來推論醫師手術量與術後併發症的關係，各組的併發症在調整前的原發率各為甲0.59%、乙2.6%、丙0.68%及丁2.67%；調整後甲為0.24%，顯著低於乙的1.75%，Odds Ratio為7.306；統計學顯著邊緣地低於丁的1.3%，其Odds Ratio為5.432，表示丁的併發症發生率為甲的5.432倍，因此手術量高的醫師，其手術併發症有低於手術量少的醫師的傾向。
以複迴歸分析及STATA7.0的統計分析住院日數及醫療費用耗用，發現手術量高的甲醫師，其調整前的平均住院日數為4.3日，統計學上顯著地低於乙、丙、丁醫師；以干擾因素調整後、其平均日數為4.0日，統計學上依然顯著地低於乙、丙、丁醫師(調整之R2=0.7058)。醫療費用的耗用，手術量高的甲醫師，其調整前的醫療費用為46365元，統計學上顯著地低於手術量較低的乙、丙、丁醫師；以干擾因素調整後，其平均醫療費用為46815元，依然顯著低於乙、丙、丁醫師。(調整之R2=0.6779)
結論：由以上的結果引導我們的結論為手術量高的醫師有顯著較低的術後併發症發生率，顯著較短的住院日數及顯著耗用較少的醫療費用；亦即手術量高的醫師可得較好的醫療成果，及耗用較少的醫療資源。

關鍵字

醫師手術量 ； 住院日數 ； 醫療費用耗用 ； 腹腔鏡膽囊切除手術 ； 併發症

並列摘要

Background and Purpose: Since the first volume-outcome relationships in the provision of medical care were reported 2 decades ago, scores of studies has demonstrated that for a wide variety of surgical procedures and medical conditions, providers who treat higher volumes of patients have better patient outcome than their lower-volume counterparts. This study aims to determine whether individual surgeon volume is associated with improved short-term clinical and ecomonic outcomes for patients with gallbladder diseases who underwent laparoscopic cholecystectomy.
Methods: A retrospective study of all patients who underwent laparoscopic cholecystectomy in Division of Hepatobiliary Surgery, Department of Surgery of Kaohsiung Medical University Hospital between January, 1998 and April 2000, was conducted by reviewing medical charts. Surgeous were categorized by volume of laparoscopic cholecystectomy over the 4.3-year study period: A (521 cases), B (192cases), C (147 cases), D (75 cases). Logistic and multivariate regression was used to assess the relation between surgeon caseload and postoperative complications, length of stay, and total hospital charges, adjusting for demographics, clinical manifestation, age-adjusted Charlson comorbidity index and surgeon’s volume.
Results: In this study overall postoperative complication rate is 1.2%; the average length of stay is 4.7 days, and the averaged total hospital charge is NT$ 49581. After adjusting for confounding factors and sugeon volume, highest-volume surgeon had the shortest length of stay (4.0 days vs. 4.73 days for B, 4.28 days for C, and 4.48 days for D, adjusted R2= 0.7058) and lowest hospital charges (46815 yen vs. 51508 for B, 48677 for C, and 48879 for D; adjusted R2=0.6779). The highest-volume surgeon A also had the lowest complication rates. (0.24% vs. 1.75% for group B, OR=7.306; 0.26% for group C. OR=1.055; and 1.3% for group D, OR=5.432). Postoperative complications, length of stay and total hospital charges were more determined by surgeon volume.
Conclussions: Individual surgeon volume is significantly associated with complications rate, length of stay and hospital charges for laparoscopic cholecystectomy.

並列關鍵字

Surgeon's volume ； length of stay ； hospital charges ； laparoscopic cholecystecomy ； complications

參考文獻

中文文獻：

1. 歐陽 修： 賣油翁，歐陽文忠公文集，歸田錄，1067年。

英文文獻：

1.Birkmeyer JD, Siewers AE, Finlayson EV.A. et al. :Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346: 1128-37.

2. Brazier JE, Johnson AG: Economics of surgery. Lancet 2001; 358: 1077-81.