手數量及麻醉方式對鼓室成形術醫療資源耗用及醫療療效的影響

Influence of Surgical Volume and Type of Anesthesia on Medical Utilization and Clinical Outcomes after Tympanoplasty

黃晟承(Cheng-Cheng Huang)

指導教授 ： 許弘毅

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2017年)

摘要

研究目的
本研究對象為慢性中耳炎病患接受鼓室成形術(Tympanoplasty Type 1,2)的患者，研究目的為分析醫院及醫師手術量及不同麻醉方式對於醫療療效及資源耗用的影響。
研究方法
本研究利用全民健康保險學術資料庫提供的資料，採回溯性橫斷性的研究，收集2001-2013年住院做鼓室成型術的成年患者(大於18歲)，扣除ICD-9主診斷碼非慢性中耳炎的個案，最後納入研究人數共2,206人。將資料依所屬醫院及醫師手術量多寡及不同麻醉方式來分別分成兩組，並追蹤其出院後一個月內的門診費用、住院天數及總醫療費用，分析對於醫療資源耗用及術後併發症的影響。
研究結果
在醫院服務量部分，高醫院服務量組相對於低醫院服務量組有顯著較長的住院天數以及顯著較高的總醫療費用(4.46 ± 2.07天vs. 3.79 ± 1.77天；44,871.9 ± 13,873元 vs. 41,243 ± 12,192元) (p <0.05)。醫師服務量部分，高醫師服務量組相對於低醫師服務量組同樣有顯著較長的住院天數以及顯著較高的總醫療費用(4.7天 vs. 3.8天；44,871.9元 vs. 41,243元) (p <0.05)。
局部麻醉比全身麻醉有較短住院天數及較低的住院醫療費用(3.60 ± 1.65天vs. 4.05 ± 1.92天；32,186.3 ± 7,645.9元 vs. 44,088.1 ± 12,677.9元) (p<0.05)。但在術後療效方面，本研究資料顯示，兩組再度手術的個案數均為零，均集中於門診手術病患，代表住院手術的病患有較好的預後。
醫院及醫師服務量對於大部分的併發症無明顯差異，在聽力受損方面，高醫院及高醫師服務量均較對照組有顯著減少的相關(p =0.02，0.01)。

結論與建議
本研究較之前其它類型手術的醫院及醫師服務量的探討，結果相異，探究其原因，一般複雜或困難手術有其醫師的學習曲線和醫院的團隊合作，造成醫院及醫師高服務量的組別多會降低住院天數及醫療費用，但本研究的手術術式可能較容易訓練，醫師較少手術量就可以熟練；醫療團隊人員的合作內容較單純，過程不易出錯，讓醫院及醫師服務量的重要性無法顯現。
在不同醫院層級可發現地區及區域醫院較醫學中心住院天數少。對於政策的制訂上可建議鼓室成形術可多往區域及地區醫院施行手術，降低醫學中心的服務量達到醫療分級的目的，也可節省醫療資源。
局部麻醉相較於全身麻醉，在住院天數及住院醫療費用均有顯著較少，而門診追蹤費用及再次手術機率無明顯差異。政策應鼓勵使用局部麻醉的方式來手術以降低醫療資源的使用。

關鍵字

鼓室成形術 ； 服務量 ； 麻醉方式 ； 醫療資源

並列摘要

Purpose：
The objects of this study were chronic otitis media patients receiving tympanoplasty (Type 1, 2). We purposed to analyze the effects of the hospital volume, surgeon volume, and type of anesthesia on the medical outcomes and medical resource utilization.
Methods：
Based on the data provided by the National Health Insurance Academic Database, a retrospective transection study was performed, including adult patients (> 18 years old) who were hospitalized for tympanoplasty from 2001 to 2013, and excluding cases whose main ICD-9 diagnostic code was not chronic otitis media, collecting a total of 2,206 people into the study. The subjects were divided into two groups according to the hospital volume, surgeon volume, and type of anesthesia methods. The effects of the outpatient cost within a month of discharge, hospital stay and total medical expenses on the medical resource utilization and postoperative complications were analyzed.
Results：
High hospital volume group had significantly longer hospital stay and higher total medical expense compared to the low hospital volume group (4.46 days ± 2.07 vs. 3.79 ± 1.77 days; $44,871.9 ± 13,873 vs. $41,243 ± 12,192) (p<0.05). There were also significantly longer hospital stay and higher total medical expense for the high surgeon volume group compared to the low surgeon volume group (4.7 days vs. 3.8 days; $44,871.9 vs. $41,243) (p<0.05).
The local anesthesia group had shorter hospital stay and lower total medical expense compared to the general anesthesia group. (3.60 days ± 1.65 vs. 4.05 days ± 1.92; $32,186.3 ± 7645.9 vs. $44,088.1 ± 12,677.9) (p<0.05). For the postoperative efficacy, the data showed that the number of cases in both groups which needed re-operation was zero. For most complications after discharge, there was no significant difference on the hospital and surgeon volume.
Conclusions and Suggestions：
Compared with previous studies on hospital volume and surgeon volume for different surgeries, the results are different. To examine the cause, most complex or difficult surgeries have learning curves for the surgeons and the factor of teamwork in the hospital, resulting in high hospital volume and surgeon volume groups have lower hospital stay and total medical expense. However, the surgical procedures for this study may be relatively easy to learn, surgeons need fewer operations to be skilled. The teamwork among the medical team staff is simpler, fewer mistakes can be made during the process, therefore, the importance of hospital volume and surgeon volume can not be revealed.
With respect to different hospital levels, district and regional hospitals have shorter hospital stay compared to medical centers. Concerning the formulation of government policy, tympanoplasty can be recommended to be performed in more district and regional hospitals, reducing the surgical volumes of medical centers, achieving the purpose of hierarchical medical classification, but also save medical resources.
Comparing local anesthesia with general anesthesia, the hospital stay and total medical expense were significantly less, but there was no significant difference in outpatient follow-up cost and re-operation rate. Local anesthesia for the surgery should be encouraged in order to reduce the use of medical resources.

並列關鍵字

tympanoplasty ； volume ； anesthesia ； utilizaation

參考文獻

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