醫院及醫師手術量對甲狀腺手術醫療療效的影響

Influence of Hospital and Surgeon Volume on Thyroidectomy Outcomes

梁宗榮(Tsung-Jung Liang)

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(2014年)

摘要

研究目的
本研究採用全民健保資料庫，篩選出因甲狀腺良惡性疾病而施行甲狀腺手術(thyroidectomy)的患者為研究對象，探討醫院及醫師服務量對此類患者醫療資源耗用及術後存活的影響

研究方法
本研究為回溯性橫斷性之研究，以1996-2010年間的全民健保學術資料庫為研究主體，收集所有因良性或惡性甲狀腺疾病而住院接受甲狀腺切除手術之成年患者(大於18歲)，總共為125,037人納入研究。依照研究對象所屬之醫院及醫師手術量分為高低兩組，分析醫院及醫師手術量對於醫療資源耗用(住院天數、醫療費用)及術後存活之影響。為減少選擇偏誤對研究結果解釋之干擾。將兩組病患之人口學特徵、合併症嚴重度、機構特質、醫師科別、手術方式、疾病診斷等特質以傾向分數配對方法進行配對。

研究結果
經傾向分數配對之後，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同樣有顯著較短的住院天數以及較低的總醫療費用(3.2天 vs 3.4天；1,101.6美元 vs 1,141.2美元)。但在術後療效方面，兩組在術後5年的死亡率則無顯著差異。(1.8% vs 1.7%)，而以整體存活期來看，兩組也無顯著差異(p=0.328)，併發症的部分兩組同樣沒有差異(p=0.442)。而在醫師服務量部分，高醫師服務量組相對於低醫院服務量組同樣有顯著較短的住院天數以及較低的總醫療費用(3.2天 vs 3.4天；1,124.3美元 vs 1,141.9美元)。而在術後療效方面，高醫師服務量組有較低的的死亡率(1.5% vs 1.9%)，呈邊際顯著性(p=0.051)，以整體存活期來看，高醫師服務量組有明顯較佳的整體存活率(p=0.029)。併發症的部分兩組則無顯著差異(p=0.557)

結論與建議
本研究發現高服務量醫院或高服務量醫師在進行甲狀腺手術時有顯著較低的醫療資源耗用，包括較短的住院天數以及較低的醫療費用。本研究亦發現，高醫院服務量對甲狀腺手術後的存活情形沒有影響，但高醫師服務量有明顯較長的整體存活期。
依據本研究結果，有需要進行甲狀腺切除手術的病患及家屬在選擇就醫時，可以將醫院及醫師服務量列入參考。而醫療提供者則可以考慮是否鼓勵醫師將精力集中，發展專長手術(專開甲狀腺)。以及是否成立(甲狀腺)專科醫院，將醫院提供的服務差異化，以達到更佳的治療結果。

關鍵字

甲狀腺切除手術 ； 醫院服務量 ； 醫師服務量 ； 醫療資源耗用 ； 傾向分數配對

並列摘要

Purpose:
This study analyzed administrative claims data obtained from the Taiwan Bureau of National Health Insurance (BNHI). We explored the effect of hospital and surgeon volume on thyroidectomy outcomes in terms of length of stay (LOS), hospital charges, and survival rate.

Methods:
This cohort study retrospectively analyzed 125,037 thyroidectomies performed from 1996 to 2010. Relationships between hospital/surgeon volume and patient outcomes were analyzed. To eliminate selection bias, propensity score matching (PSM) method was applied to adjust patient characteristics and hospital characteristics (age, gender, Charlson/Deyo co-morbidity index, disease diagnosis, principal procedure type, surgeon specialty, and hospital level).

Results:
After PSM method, both high-volume hospitals and high-volume surgeons were associated with significantly shorter LOS and lower hospital charges than their low-volume counterparts (p < 0.001). Overall survival was significantly better in high-volume surgeon groups (p = 0.029), but there was no significant difference between the high- and low-volume hospital groups. The complications rates were similar between different volume groups.

Conclusions and Suggestion:
This nationwide study showed less medical resource utilization in high-volume hospitals and surgeons. Moreover, overall survival rate is better in patients treated by high-volume surgeon. For those who seek surgical consultation for thyroidecetomy, hospital and surgeon volumes are significant factors that should not be ignored. For medical providers, regionalization of thyroidectomy to high-volume hospitals and surgeons also should be considered.

並列關鍵字

thyroidectomy ； hospital volume ； surgeon volume ； propensity score matching ； medical resource utilization ； mortality

參考文獻

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