結直腸癌切除病患不同手術方式之成本效果評估

The Cost-Effectiveness By Different Operative Procedures In Patients with colorectal cancer

陳亦澐(Yi-Yun Chen)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士班/碩士(2015年)

摘要

研究背景與目的
結直腸癌(Colorectal Cancer，CRC)，在全球每年會影響到123萬人，導致60.8萬人死亡，是目前全球第三大癌症中最常見，2013年衛生福利部最新公告結直腸癌的排名及死因都在前三名，死亡人人數約占所有癌症死因的11.8%。其本研究利用病歷審查資料串連健保申報住院和門診醫療費用進行術後醫療資源利用情形的追蹤和利用結直腸癌病患生活品質分數的校正前後來看兩種手術方式的成效評估，並追蹤長期存活狀態和治療成效之影響，藉由本研究探討結直腸癌種不同手術方式、術後療效、醫療資源使用和成本效果評估，以提升照護品質療效照護。

研究方法
本研究採用縱貫性研究，以回溯性病歷審查的方式進行研究設計。收案對象為南部某醫學中心2007年01月01日至2010年12月31日為止，在個案醫院新診斷確診為結直腸癌(診斷碼為：153-154)並接受結直腸癌切除術(手術碼：45.7x、45.8、47.xx、48.4x~48.6x)的病患。資料來源主要由1.病歷審查資料、2.個案醫院門診和住院醫療費用申報檔案、3.行政院衛生署資料庫2012年的死亡檔案。4.健康相關生活品質(EROCT-QLQ C30)。其當次住院醫療費用有658人，術後一年內門診及住院醫療費用為313人。研究工具為SPSS21.0及Stata SE13，以卡方檢定、獨立樣本T檢定、變異數檢定、多變項對數迴歸分析、複迴歸分析、Kaplan-Meier存活分析、cox迴歸模型。

研究結果
本研究病患手術年齡為65.50±12.66歲，手術方式以傳統開腹式的病患居多占42.2%，平均住院天數17.8天±12.44天，醫療費用為160,888±114,541元。校正其他因子後，手術年齡、ASA分期、病理分化、腸阻塞輸血及腸造口和術前輔助性化療為為預測執行不同手術方式之影響因子；ASA分期、腸阻塞、AJCC分期和輸血為當次住院併發症影響因素；手術年齡、教育程度、ASA分期、CCI合併症指數、腸阻塞、輸血為術後住ICU影響因素。BMI指數、輸血、腸造口、手術方式和住院併發症為當次住院天數之影響因素。BMI指數、腸造口、住院併發症為當次住院醫療費用之影響因素。手術年齡、術後輔助性化療及手術方式對於術後一年的門診和住院費用皆為影響的重要因子。影響整體存活因素的有教育程度、ASA分期、血管侵犯及當次住院併發症和術後住ICU。

以成本效果的角度而言，執行Mini開腹式術後一年內總醫療費用比傳統開腹式節省37,794元，住院費用則節省31,482元，門診費用則節省6,312元。執行腹腔鏡手術後一年內總醫療費用比傳統開腹式節省8,528元、住院費用則多花3,424元，門診醫療費用則節省12,751元。以ICER分析發現，執行Mini開腹式術後一年總醫療費用per QALYs比執行傳統開腹式節省819,938元，住院費用則節省694,850元，門診費用則節省269,305元。執行腹腔鏡術後一年總醫療費用per QALYs比執行傳統開腹式多花850,351元，住院費用則節省551,065元，門診費用則多花495,998元。

結論與建議
本研究結果發現，手術年齡越大其增加住院天數及醫療費用的情形，且年紀越大選擇執行mini開腹式跟腹腔鏡的比率也是逐漸增加。在術後有併發症的情況也較不易產生。在成本效果而言，執行mini開腹式跟腹腔鏡有改善病患的生活品質及提升病患的存活年數，在醫療花費上也有節省。將QALYs考慮進去後，發現結直腸癌切除病患之不同手術方式其存活年數是有提升之餘，其執行mini開腹式在醫療費用有節省成本但在執行腹腔鏡手術則是略為上升趨勢，其可能不同術式花費上也將有所差異性，值得後續再進行研究。在復發情形與否則並未繼續追蹤與分析，建議未來能將後續能加入分析並加入輔助性治療等相關資訊列入資料庫進行分析，讓資料能更佳齊全使資料結果更加豐富化。
關鍵詞：結直腸癌、手術方式、療效、醫療資源利用、存活分析、成本效果

關鍵字

結直腸癌 ； 手術方式 ； 療效 ； 醫療資源利用 ； 存活分析 ； 成本效果

並列摘要

Background
Colorectal cancer (Colorectal Cancer, CRC) annually will globally affect 123 million people, causing 60.8 million deaths and ranking as the third among the most common cancers. In the Ministry of Health and Welfare Announcement up to 2013, cancer has topped the list of 10 most common death causes for 32 consecutive years. Among 44,791 deaths from cancer in 2013, colorectal cancer was the third leading cause, accounting for 11.8% (5,265 deaths) of all cancer death. Previous research on colorectal surgery across the world mostly explored cost-effectiveness of surgery alone, or medical utilization involved. Based on the combination of chart review and National Health Institute Databank (NHID), this research on three options of surgery covered inpatient and outpatient medical utilization, adjusted by postoperative quality of life, to assess the cost-effectiveness and the impact on long-term survival to improve the quality of care for patients with colorectal cancer..

Methods
This longitudinal and retrospective study employed chart review. Spanning January 1, 2007 to December 31, 2010, study subjects were sampled from a medical center in southern Taiwan, newly diagnosed with colorectal cancer (diagnosis code: 153-154) and undergoing resection of colorectal cancer ( Surgical code: 45.7x, 45.8,47.xx, 48.4x ~ 48.6x). The main sources of study subjects came firstly from the medical record review within six months postoperatively, secondly from claim data of outpatient and inpatient medical service of NHID and thirdly from death registry 2012 of Department of Health, Health-related quality of life (EROCT-QLQ C30). 658 subjects had complete claim data of admission for surgery, while 313 subjects had complete claim data of admission and outpatient service one year postoperatively. Based on SPSS21.0 and Stata SE13, Chi-square test, independent sample T test, variance test, multivariate logistic regression analysis, multiple regression analysis, Kaplan-Meier survival analysis and Cox regression model are used.
Results
Among 658 samples, patient age was 65.50 ± 12.66 years old. Traditional open laparotomy accounted for 42.2%, with average medical costs being 160,888 ± 114,541 NT$, average hospital stay being 17.8 days ± 12.44 days. After adjusting for confounding factors, age at surgery, ASA stage, histological differentiation, intestinal obstruction and intestinal stoma transfusion and preoperative adjuvant chemotherapy are significant predictors for choice of surgery mode. Age at surgery, ASA stage, intestinal obstruction, AJCC staging and blood transfusion are significant predictors for inpatient complications; age at surgery, education level, ASA stage, CCI comorbidity index, bowel obstruction, blood transfusion are significant predictors for postoperative ICU care. BMI index, blood transfusions, colostomy, surgical and hospital complications are significant predictors length of inpatient stay and hospital medical expenses. Age at surgery, postoperative adjuvant chemotherapy and surgery modes are significant predictors for costs of outpatient and inpatient service one year postoperatively. As for overall survival, ASA stage, vascular invasion, inpatient complications and postoperative transfer to ICU.In terms of cost-effectiveness and compared with traditional open laparotomy, mini-laparotomy save 37,794NT$ for total medical expenses, with 31,482 NT$ for admission cost and 6,312 NT$ for postoperative 1-year outpatient service. In terms of cost-effectiveness and compared with traditional open laparotomy, Laparacope surgery save 8.528NT$ for total medical expenses, with 3,432NT$ more for admission cost and 12,751 NT$ less for postoperative 1-year outpatient service. ICER analysis revealed that , compared with traditional open laparotomy, mini-laparotomy per QALYs saved 819,938NT$ for total medical expenses, with 694,850NT$ for admission cost and 269,305NT$ for postoperative 1-year outpatient service. ICER analysis revealed that , compared with traditional open laparotomy, laparoscopy surgery per QALYs spent 850,351NT$ more for total medical expenses, with 551,065NT$ less for admission cost and 495,998NT$ more for postoperative 1-year outpatient service.

Conclusion and recommendations
The results of the study revealed that of cost-effectiveness, mini laparotomy and laparoscopy surgery were associated with better quality of life of prolonged survival at less expense. QALYs revealed that non-traditional modes of surgery were associated with longer survival. However, laparoscopic surgery cost more than open laparotomy, which is worth further study. In this study, relapse of cancer and follow-up 1-year after surgery were not explored to provide solid data to complete the spectrum of care for patients with colorectal cancers.

Key words：Colorectal cancer, Operation Procedures, Outcome, Medical resource utilization, Survival analysis, Cost-effectiveness

並列關鍵字

Colorectal cancer ； Operation Procedures ； Outcome ； Medical resource utilization ； Survival analysis ； Cost-effectiveness

參考文獻

英文文獻

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