子宮肌瘤病人接受傳統剖腹和腹腔鏡切除手術之醫療結果和費用比較：南部某一區域教學醫院為例

背景：全民健康保險之經營日益艱困，手術及住院費用之總額勢在必行，各醫院對常見的疾病如子宮肌瘤之治療，應盡量傾向微創手術處理以縮短住院天數以進行費用控制。目前在子宮肌瘤的診斷，可以超音波檢查出大小和位置再決定其手術方式。究竟傳統肌瘤切除手術和腹腔鏡肌瘤切除手術在手術過程、臨床效益、費用的差異性如何？本研究目的在進行此兩類手術之評估以作為醫療政策上醫療資源規劃與運用之參考。研究方法：依據目前文獻子宮肌瘤的之手術治療方式，主要分為傳統手術與腹腔鏡微創手術兩大類。本研究之研究對象為南部某區域教學醫院於2004年6月1日起至2007年10月31日止，此段期間進行內所進行此兩類手術之婦女的資料，並分析子宮肌瘤病人的治療方式與資源耗用，主要研究依變項包含手術時間、平均住院日、手術時出血量、手術醫療費用及合併症，藉此比較兩種治療方式之臨床效益。研究回收資料以SPSS for Windows 12.0統計套裝軟體作為分析的工具，驗證本研究假設採用統計方法有描述性統計分析、獨立樣本t檢定、單因子變異數分析、相關分析、線性複迴歸分析結果及邏輯式迴歸。研究結果：統計結果顯示腹腔鏡微創手術確實有較少失血量，因此也不需再進行輸血；術後白血球也顯示較無發炎現象，因手術較少失血量，術後血小板也無低下情形、Hct較高。在費用方面，腹腔鏡微創手術整體醫療費用雖較高，然而此乃牽涉到健保給付制度的因素，由費用細項統計來看則可發現腹腔鏡手術大大減少了診察費、血液血漿費及注射技術費，雖說病人之滿意度應著眼於手術本身，但可以較少花費達成手術結果，相信也有助減少病患心理壓力，儘速康復。結論：就高科技的引進與應用而言，子宮肌瘤是個具有指標性的疾病，由此分析可以知道未來健保經費之估算必需考慮將會有一大部份的增加是花費在住院天數過長上面，大部份的病人願意接受腹腔鏡微創肌瘤切除手術是因其可以有效減少傷口疼痛，讓民眾提早回到工作岡位以達到經濟又安全的現代化治療。根據本研究之結果可提供醫療政策制訂者擬定腹腔鏡微創子宮肌瘤切除手術之健保給付及申報，以及醫療服務提供者在提供病患選擇肌瘤切除手術方式之參考。

關鍵字

子宮肌剖腹肌瘤切除手術；腹腔鏡肌瘤切除手術；醫療費用

並列摘要

The management of Bureau of National Health Insurance has encountered a hard situation in the recent years. The policy of treatment for common disease tends to be more conservative in each hospital in order to control the cost of medical resources. The ultrasound has played a role in diagnosis the location for uterine myoma and helps us to decide the method of myomectomy. So far the application of laparoscopic technology has improved the treatment of uterine myomas. However, its clinical efficacy is still unknown. The aim of this study is to compare the medical cost and clinical outcomes between these methods of myomectomy. Methods：From June 2004 to October 2007, we studied 155 patients who under went myomectomy. We analyzed the difference of cost and clinical outcome in women undergoing abdominal myomectomy (AM) (n=74) and laparoscopic myomectomy (LM) (n=81) for symptomatic fibroid in a teaching hospital. Results：The results indicate that the patients underwent laparoscopic myomectomy had fewer blood loss, compared to the patients underwent abdominal myomectomy. Also, after the surgery, patient underwent laparoscopic myomectomy's WBC didn't appear to have Inflammation. In addition, Platelet did not appear to be low and hct appeared to be higher than the patients of abdominal myomectomy. Regarding the medical cost, patients of laparoscopic myomectomy had higher cost than the patients of abdominal myomectomy. Because of the paying systme in Bureau of National Health Insurance, some fees of detailed item for patients of laparoscopic myomectomy were fewer than patietns of abdominal myomectomy. However, the satisfaction of patients of laparoscopic myomectomy appeared to be higher. And their quality of life appeared to be higher than those of patient underwent abdominal myomectomy. Conclusion：It is evident that a large proportion of the budget of National Health Bureau will be spent in the advanced technology in the future. Facing this tendency, the government should start planning a new strategy in order to prevent social disorder due to the growth of advanced technology which will compromise the basic medical need of the general population.