比較三種常見腰椎手術之盛行率與住院醫療資源耗用及其影響因素之研究

The comparison of prevalence, medical expenditure and related factors among the three common lumbar surgery

王重元(Chung-Yuan Wang)

指導教授 ： 許弘毅

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2011年)

摘要

研究目的
台灣全面實施 DRG 制度在即，若要避免醫療水平的降低、醫病關係的惡
化、醫療糾紛的增加、醫療資源的浪費、醫療供需的失衡，脊椎手術之臨床醫療
資源耗用的相關研究確實有迫切的需要。但是，國內外有關脊椎手術在臨床醫療
資源耗用的相關研究卻是少之又少。因此，本研究利用國家衛生研究院全民健康
保險研究資料庫，針對三種常見腰椎手術進行研究，以探討(1)腰椎手術之長期
趨勢及其影響因素，(2)腰椎手術在人口學、醫療機構特性與住院天數及醫療費
用之差異性，(3)腰椎手術醫療資源耗用之重要因子，(4)醫院與醫師手術服務量
與病人術後療效之相關性，以及(5)腰椎手術醫療資源耗用之國際間比較。
研究方法
本研究採回溯性研究設計，研究期間為 1996 年至2007 年(共12 年)，針對
腰椎脊骨融合術、腰部椎間盤切除術、腰部椎弓切除術病人為研究對象，排除年
齡小於18 歲之個案(2662 位)，最後的研究對象分別為腰椎脊骨融合術91,249 人，
腰部椎間盤切除術118,094 人，與腰部椎弓切除術41,491 人。本研究首先將年度
分成前(1996-1999)、中(2000-2003)、後(2004-2007)等三個時期，探討常見三種腰
椎手術患者之盛行率及長期趨勢，並利用Odds Ratio(OR)來分析影響盛行率的相
關因子。其次，探討三種常見腰椎手術在人口學特質、醫療機構特性、住院天數
及醫療費用之差異性；接著，探討醫院及醫師手術服務量與住院天數及醫療費用
之相關性。最後，以複迴歸模式(Multiple Linear Regression)分析帶入年齡、性別、
共病症數目、醫院與醫師服務量、醫院層級、手術術式及時間等變項，探討影響
腰椎手術住院天數與各項醫療費用之相關因素。
VI
研究結果
腰部脊骨融合術盛行率自 1996 年的19.48/105 上升至2007 年的56.95/105，
腰部椎弓切除術介於11.08/105~19.77/105，腰部椎間盤切除術則介於38.26/105~
49.79/105，二者皆呈現相對穩定趨勢。在三種術式的差異性部分：病患年齡方面，
接受脊骨融合術或椎弓切除術以老年人較多，接受椎間盤切除術則以「非老年」
族群較多。在病患性別方面，接受脊骨融合術以女性較多，接受椎間盤切除術或
椎弓切除術則以男性較多。在共病症數目方面，接受脊骨融合術以兩個共病症為
最多，接受椎間盤切除術或椎弓切除術則以單一共病症最多。在就醫科別方面，
骨科醫師明顯有較高比例的脊骨融合術，椎間盤切除術或椎弓切除術則大多由神
經外科醫師執行。在醫院層級別方面，病患接受脊骨融合術的地點，區域醫院略
多於醫學中心; 病患接受椎間盤切除術的地點，醫學中心略多於區域醫院; 病患
接受單純椎弓切除術的地點，半數以上比例在醫學中心。在住院天數方面，椎間
盤切除術的平均住院天數最短，為9.98 天，脊骨融合術與椎弓切除術相近，平
均住院天數分別為13.49 天與13.61 天。在平均住院總費用方面，脊骨融合術最
多，為141,161.00 元，椎間盤切除術為73,325.88 元，椎弓切除術為82,869.10
元。在手術服務量與術後療效之相關性部分：高服務量醫師之病患的住院天數皆
為最短，住院總費用皆為同時期的最低值。以複迴歸模式分析影響腰椎手術「住
院天數」之相關因素中，「共病症數目」的預測能力最強; 影響腰椎手術「手術
總費用」之相關因素中，「術式」的預測能力最強。
結論與建議
本研究為國內第一篇針對非外傷性脊椎疾患之腰椎手術進行醫療資源耗用
的論文，研究結果，有助於即將逐步全面實施TW-DRG 的政策制定與後續專家
的研究。台灣常見腰椎手術的盛行率與世界各國有一致趨勢，脊骨融合術的成長
曲線極為明顯，因此，雖然平均住院天數大幅下降，但平均住院總費用卻無法同
VII
步減少。相較於其他國家，台灣的平均住院天數明顯較高，醫療總費用明顯較低。
醫療總費用的上升是否與術後療效及生活品質的改善一致，不同科別醫師對手術
術式是否有不同見解，以及傳統手術術式與內試鏡術式是否應該享有相同健保給
付價格，都是值得思考的議題，也值得後續深入研究討論。

關鍵字

腰椎手術 ； 盛行率住院天數醫療總費用

並列摘要

Background
Low back pain is the common disorder at musculoskeletal system. Its prevalence
at developed country ranged from 11% to 84%. Conservative treatment does help part
of the patients with low back pain syndrome, but surgical treatment is also another
choice. Most of the literatures studying on lumbar spinal surgery were cases study or
subjects from the single hospital. And the studies with national data were limited in
Asia. Therefore, the aim of our work was to investigate the prevalence, medical
expenditure and related factors among the three common lumbar surgeries in Taiwan.
Methods
In Taiwan, the National Health Insurance (NHI) Plan has accumulated 23 million
administrative and claims data. For the purpose of research, the National Health
Research Institute (NHRI) has established a NHI research database (NHIRD).
From this database, we selected 295,319 patients with lumbar surgery between
1996 and 2007. The inclusive criteria were the following surgical procedure codes
from the International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) items: (1) Fusion (81.00、81.04、81.05、81.09) , (2)
Discectomy (80.5、80.50、80.51、80.52、80.59) and (3) Laminectomy (03.0、03.09).
The patients were classified in one of the three lumbar surgical types. We excluded
the patients whose age is younger than 18, due to most of them might have their
lumbar surgery for congenital spinal diseases. Therefore, there were 91249 cases with
lumbar spinal fusion, 118094 cases with lumbar discectomy and 41491 cases with
lumbar laminectomy.
IX
Results
Over the years 1996-2007, the rate of lumbar spinal fusion increased obviously
from 19.48 per 100,000 in 1996 to 56.95 per 100,000 in 2007, a triple increase.
During these years, the rate of lumbar discectomy and laminectomy were 43.09-49.79
per 100,000 and 11.08-19.77 per 100,000, respectively. Compared with lumbar spinal
fusion, both lumbar discectomy and laminectomy had a relative flat surgery rates. Due
to severe acute respiratory syndrome (SARS) broke out, the tendancy curves of the
three surgeries dropped in 2003. Lumbar fusion had more increasing tendency among
older group than younger one (odds ratio 2.83 V.S. 2.27). Lumbar discectomy had
more increasing tendency among younger group than older one (odds ratio 1.31
V.S.1.12). The odds ratio between older and younger groups in lumbar laminectomy
was close. Lumbar discectomy and laminectomy had more increasing tendency at
medical center hospital level, while fusion had more increasing tendency at region
hospital level. When considering surgeon’s operation volume, lumbar discectomy and
laminectomy had more increasing tendency at surgeons with lower surgical volume,
while fusion had more increasing tendency at surgeons with higher surgical volume.
Orthopedic surgeon carried out most of the lumbar fusion, while neurosurgeon
performed most of the lumbar discectomy and laminectomy. No matter which type of
these three surgeries, surgeons with higher surgical volume carried out most of the
operations. Compared with the short length of stay (9.98 days) in discectomy, lumbar
fusion and laminectomy were longer, 13.49 days and 13.61 days, respectively. The
average in-patient total charges were largely influenced by differing surgical
operation (USD$4628.23 in fusion, USD$2404.13 in discectomy, USD$2717.02 in
laminectomy). We used multivariate linear regression to analyze the related factors of
length of hospitalization. The number of comorbility was the most important
X
predicted factor. In analyzing related factors of total charges, the surgery type was the
most important predicted factor, instead of the comorbility number.
Conclusion
Our work was the first article using Taiwan's National Health Insurance Data
studying on the prevalence and medical expenditure of the lumbar surgeries. We
found that lumbar spinal fusion increased rapidly in Taiwan as other countries did.
The most important predictive factor of the length of days in the lumbar surgeries was
the numbers of comorbidity. The most important related factor of total direct cost in
the lumbar surgeries was the surgery type. Compared with other developmental
countries, the length of stay in lumbar surgeries hospitalization in Taiwan was longer
and the cost was less. Further studies on the outcomes of comparing different surgeon
types (Orthopedic surgeon V.S. Neurosurgeon), different surgery type (Traditional V.S.
Endoscopic) and geographic area might be needed.

並列關鍵字

Lumbar surgery ； average length of stay ； medical expenditure

參考文獻

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