胸腔引流管提早拔除對胸腔鏡手術病人之成本及效果探討-系統性文獻回顧與統合分析

Cost and Effectiveness of Early Removal of the Chest Tube in Patients Undergoing Video-Assisted Thoracoscopic Surgery: Systematic Review and Meta Analysis

陳春香(Chun-Hsiang Chen)

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(2019年)

摘要

研究目的：
胸腔引流傳統上是在胸腔鏡楔形切除術後，預防胸膜腔術後可能的出血、空氣或淋巴滲漏。放置胸腔引流管可能會導致一些不良反應如疼痛和固定，增加傷口感染風險和癒合不良，並增加住院時間。根據研究背景與動機，本研究利用系統性文獻回顧及統合分析，探討胸腔引流管提早拔除對胸腔鏡手術病人成本及效果之差異。
研究方法：
本研究乃搜集自西元 2009年01月迄 2019年03月使用系統性文獻回顧與統合分析，利用關鍵字搜尋四個資料庫共搜尋27,187篇，再依據PRISMA四階段文獻篩選合乎納入標準的有10篇文獻，利用統合分析軟體(Comprehensive Meta-Analysis, CMA III)進行統合分析：森林圖(總效果量)、漏斗圖(成敗估計值Fail-safe N)、異質性檢定(固定或隨機效果模式)、Q-value、I-squared，進行提早拔除胸管和常規性拔除胸管兩者成本及效果分析之比較。
研究結果：
經統合分析結果發現：胸腔引流管提早拔除相對於常規拔除對胸腔鏡手術病人平均醫療費用顯著較低(Z Valve -3.830, P<.0001)。相對於常規拔除，胸腔引流管提早拔除對胸腔鏡手術病人平均住院天數顯著較短(Z Valve -5.211, P<.0001)；但是在引發感染情形(OR=0.527, p=.184)及漏氣情形皆無顯著性差異(OR 0.841, P=.637)，經敏感度分析後結果仍無顯著性差異。
結論與建議：
臨床照護品質得到改善，即併發症數量減少，住院和重新入院亦減少，降低醫療成本，提早拔除胸管可能透過控制術後疼痛，改善肺功能和降低肺切除術後肺部併發症的風險，提早切除胸管可能通過縮短住院時間來獲得一些經濟利益。

關鍵字

胸管 ； 胸腔鏡 ； 拔除 ； 系統性文獻回顧 ； 統合分析

並列摘要

Purpose:
Chest drainage is a preventive measure for the possible bleeding, air leakage or lymphatic leakage after the pleural cavity surgery after video-assisted thoracoscopic surgery (VATS) wedge resection. However, placing chest tube may lead to adverse effects such as feeling of pain, increased risk of wounds infection, poor healing, and prolonging lengths of stay. Based on the description of study background and motivation, we conducted a systematic review and meta-analysis study to explore the difference of costs and effectiveness between early removal and conservative removal of chest tubes for patients received VATS.
Methods:
Systematic review and meta-analysis were used by searching literatures from January 2009 to March 2019 with the keywords. There were 27,187 articles found in four databases. PRISMA four-stage checklists were adopted and finally qualified ten articles were selected. A Comprehensive Meta-Analysis (CMAIII) was employed to conduct forest plot (total quantity of effects), funnel plot (estimated values of Fail-Safe N to success or failure), heterogeneity test, Q-value, and I-squared. These statistics were used to describe and to compare cost and effectiveness of early removal and conventional removal of chest tube.
Results:
It indicates a significant lower average cost of early removal of the chest tube than conventional removal of the chest tube (Z Valve -3.830, P<.0001) for patients receiving VATS. In terms of medical effectiveness of patients receiving VATS, those having early removal of the chest tube have a significant shorter lengths of stay (Z Valve -5.211, P<.0001). There’s no significant difference in occurrence of infection (OR=0.527, P=.184) and air leakage (OR=0.841, P=.637). After sensitivity analysis, no significant difference is found as well.
Conclusion and Suggestion:
In order to improve the quality of medical care, the reduction of complications, lengths of stay, and frequency of readmission are necessary. Early removal of the chest tube could control postoperative pain, improve pulmonary functions, and reduce the risk of postoperative pulmonary complications from pneumonectomy, increasing efficiency and reducing medical cost. By shortening lengths of stay, early removal of the chest tube may bring some economic benefits.

並列關鍵字

chest tube ； video-assisted thoracoscopic surgery (VATS) ； removal ； systematic review ； meta analysis

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