腦瘤開顱手術與立體定位放射手術之成本效果分析

研究目的：腦瘤的治療方式，可分為開顱手術及立體定位放射手術，其中開顱手術為最傳統之治療方法，而立體定位放射手術自2003年12月開始納入健保給付範圍，然目前國內少見以立體定位放射手術與傳統開顱手術治療腦瘤之成本分析及相關醫療效果比較相關研究。因此，本研究目的為探討腦瘤開顱手術與立體定位放射手術之成本效果分析。研究方法：本研究為橫斷式(cross-sectional)研究，屬回溯性次級資料(secondary data)分析。資料來源為「全民健康保險學術研究資料庫」之2000年承保抽樣百萬歸人檔，「醫事機構基本資料檔（HOSB）」、「住院醫療費用清單明細檔(DD)」、「門診處方及治療明細檔(CD)」，研究對象以2003年12月~2010年12月，診斷為腦瘤的住院及門診病人，且接受「立體定位放射手術」或「開顱手術」治療方式者。為減少選樣偏差對研究結果解釋的干擾，利用傾向分數進行配對，作為最終之研究樣本。以SPSS for Windows 19.0版之套裝軟體進行資料處理及分析，根據研究架構及研究假設進行統計分析，採用雙尾檢定，其P值設為0.05；採用統計方法有：描述性統計、卡方檢定、獨立樣本t檢定、無母數分析以驗證本研究假設。研究結果：研究結果顯示，開顱手術與立體定位放射手術病人共有679人，經傾向分數配對調整後，研究樣本總人數為358人(立體定位放射手術及開顱手術各179人)，研究樣本年齡介於中壯年間，女性比例略高於男性；立體定位放射手術及開顱手術皆以醫學中心就診最多，腫瘤型態，皆以良性腫瘤最多、型態未明腫瘤最少，兩者未達顯著相關(P=.321)。再者成本部分，開顱手術之住院費用及醫療總費用顯著高於立體定位放射手術(住院費用分別為267,342±210,570元、131,729±80,464元；醫療總費用分別為267,342±210,570元、158,996±52,170元；皆P<.0005)，然而在門診費用部分則反之。另在效果方面，開顱手術之平均住院天數為23±20天，顯著高於立體定位放射手術之平均住院天數3±8天(P<.0005)，併發症及復發次數為開顱手術顯著高於立體定位放射手術(分別為P<.0005；P=0.014)；而在30日死亡率、門診追蹤次數及存活時間上沒有顯著差異(分別為P=0.100；P=0.553；P=0.069)。以ICER進行成本效果分析，發現立體定位放射手術在醫療總費用上較開顱手術費用便宜，且效果優於開顱手術。結論與建議：本研究比較開顱手術及立體定位放射手術之成本、效果之差異；發現兩者治療方式醫療總費用相差約11萬，然立體定位放射手術之平均住院天數、併發症及復發次數均低於開顱手術，且需恢復時間較短。進行成本效果分析結果顯示，腦瘤病人接受立體定位放射手術及開顱手術皆具成本效果；進一步探討發現立體定位放射手術在醫療總費用上較開顱手術費用便宜，且效果優於開顱手術，顯示立體定位放射手術是值得關注及投資的。本資料來源為全民健保資料庫，疾病特徵僅能考量腫瘤型態，無法考量腫瘤位置、大小、分期等，此為本研究之限制。腦瘤治療方式依據病人本身條件及意願，並加上專科醫師之評估及建議，然而經研究發現隨著治療方式不同，將產生治療成本及效果之差異，建議醫療服務機構及相關單位可運用本研究之結論，作為未來醫療資源分配之參考，以訂立合乎現實的醫療政策。

關鍵字

腦瘤；開顱手術；立體定位放射手術；成本效果分析

並列摘要

Objective：Treatment of brain tumors can be divided into craniotomy and stereotactic radiosurgery, which craniotomy is the most traditional methods of treatment. The stereotactic radiosurgery started since December 2003 include the scope of National Health Insurance (NHI). However, comparing the cost-effectiveness analysis and related medical research of stereotactic radiosurgery and craniotomy of brain tumors Cost is rare in the current domestic. Therefore, this study aims to evaluate the cost-effectiveness analysis of the treatment of brain tumors with craniotomy and stereotactic radiosurgery. Methods：This study was a cross-sectional study, be classified retrospective secondary data analysis.The source form the "National Health Insurance Research Database" in the 2000 underwriting normalized sampling million people file,including registry for contracted medical facilities (HOSB), inpatient expenditures by admissions(DD) and ambulatory care expenditures by visits(CD).Select the inpatient and outpatient’ diagnosis of brain tumors, and accept the "stereotactic radiosurgery" or "craniotomy" as sample of this study, between December 2003 and December 2010.Propensity score matching was used to adjust for selection bias. Using the software package of SPSS for Windows 19.0 version for data processing and analysis,based on the research framework and assumptions for statistical analysis,and using two-tailed test of its P value to 0.05.Using statistical methods:descriptive statistics, chi-square test, independent sample t test, non-parametric analysis to validate this assumptions. Results：The results show 679 people with brain tumors who underwent craniotomy and stereotactic radiosurgery, after propensity score matching adjustment, a total of 358 people (n=179 each). Study sample between the ages of middle age, the proportion of females slightly higher than the males; both of stereotactic radiosurgery and craniotomy treat at the medical center is highest, both of tumor types are benign tumors is the most , and tumor types unspecified is the least, both did not reach significant correlation(P=.321). In the cost part, craniotomy hospitalization costs and total health care costs were significantly higher than stereotactic radiosurgery (hospitalization costs was 267,342 ± 210,570 NTD and 131,729 ± 80,464 NTD, respectively；total health care costs was 267,342 ± 210,570 NTD and 158,996 ± 52,170 NTD, respectively；P <.0005), but in outpatient costs part is opposite. Also in the effectiveness part, the average length of hospital stay for craniotomy was 23±20 days, significantly higher than the average length of stereotactic radiosurgery 3±8 days (P <.0005). Complications and recurrence frequency of craniotomy was significantly higher than the stereotactic radiosurgery (P <.0005; P = 0.014, respectively). While in the mortality at 30 days, frequency of outpatient visits and survival time did not significantly differences (P = 0.100; P = 0.553; P = 0.069, respectively). Use of ICER for cost-effectiveness analysis, and found that stereotactic radiosurgery on the total of health costs was cheaper than craniotomy and effectiveness better than craniotomy. Conclusion and Suggestion：This study compared the craniotomy and stereotactic radiosurgery the difference of the cost and effectiveness. Found that both the total cost of treatment difference of about 11 million; however, stereotactic radiosurgery average length of hospital stay, complications and recurrence frequency were lower than the craniotomy, and the recovery time is shorter. A cost-effectiveness analysis showed that brain tumor patients receiving both of the stereotactic radiosurgery and craniotomy were cost-effectiveness; further explored found that stereotactic radiosurgery in total health care costs was the cheaper than craniotomy and more effectiveness, which means the stereotactic radiosurgery is worthy of our attention and investment. This data source from the National Health Insurance database, disease characteristics can only be considered tumor types, but can not consider the tumor location, size, stage etc, it is a limitations of this study. Brain tumors therapy according to the patient's own conditions and wishes , and specialist physicians's assessment and recommendations. The study found that treatment with the different ways will produce the difference costs and effectiveness of the treatment. Suggested Medical Service Organizations and related units can be applied conclusions of this study, as a reference for future allocation of medical resources, and establish a realistic medical policy.