鼓室成形術及修正式鼓室成形術病人盛行率與醫療資源耗用分佈趨勢及影響因素之探討

背景目的：慢性中耳炎是耳鼻喉科常見的疾病，鼓室成形術是治療慢性中耳炎最有效的方式，而且是耳科住院手術之最大宗，然而臺灣地區並無大規模探討其盛行率與醫療資源耗用之分析。因此，本研究目的是以1996~2007 年中央健保局資料庫作回溯性分析，探討鼓室成形術及修正式鼓室成形術病人盛行率與醫療資源耗用之長期分佈趨勢及影響因素，並比較此兩種手術在醫療資源耗用上有無差異。研究方法：本研究採用國家衛生研究院全民健康保險學術資料庫 (National Health Insurance Research Database )的次級資料來進行回溯性的縱貫分析，研究對象為接受鼓室成形術 (ICD-9-CM 手術碼為19.4 或19.5) 或接受修正式鼓室成形術 (ICD-9-CM 手術碼為19.6)的病患，研究時間為西元1996 年1 月1 日至2007 年 12 月31 日，共計12 年，並且從中篩選出ICD-9-CM 診斷碼為381.2、382.1、382.2、 382.3、382.4、382.9、384.2、385.1 及385.2 之慢性中耳炎個案，總計59,521 例，排除性別不詳之個案(530 例)，最後研究分析58,038 例鼓室成形術和953 例修正式鼓室成形術。首先，將年度分成前(1996~1999 年)、中(2000~2003 年)、後 (2004~2007 年) 等三個時期，針對盛行率、住院天數及醫療費用等方面，來探討長期趨勢；接著，利用Odds Ratio (OR)探討影響兩種手術盛行率之相關因子；最後，以複迴歸分析帶入年齡、性別、共病數、醫院層級、醫療機構服務量、醫師服務量及時間特性等變項，探討影響住院天數與各項醫療費用之相關因素。研究結果：分析在 12 個年度之間接受鼓室成形術或修正式鼓室成形術共58,991 例的慢性中耳炎患者，鼓室成形術有58,038 例，盛行率由1996 年之每十萬人口佔22.97 人，逐年增加至2001 年之每十萬人口佔26.7 人為最高點，然後又逐年遞減至2007 III 年之每十萬人口佔 16.61 人；而修正式鼓室成形術每年僅有數十例，最多為2000 年的102 例，所以其盛行率每年大約為每十萬人口佔0.4 人左右，變化不太大。兩種手術的住院天數均有縮短趨勢，而醫療總費用則均為增加趨勢，但兩種手術在醫療資源耗用上彼此間並無顯著差異。在鼓室成形術醫療費用方面，增加費用最大幅度為麻醉費，而減少費用最大幅度為藥費；在修正式鼓室成形術醫療費用方面，增加費用最大幅度為檢查費，而減少費用最大幅度為藥費。至於複迴歸分析模式影響因子分析方面，在兩種手術的住院天數上，以醫師服務量的預測能力最強；在診察費、病房費、手術費、藥費及總醫療費用上，兩種手術都是以住院天數的預測能力最強；在檢查費上，鼓室成形術以住院天數的預測能力最強，修正式鼓室成形術則為時間特性的預測能力最強；而在麻醉費上，鼓室成形術以時間特性的預測能力最強，修正式鼓室成形術則為病患疾病嚴重度的預測能力最強。結論和建議：以往臺灣未曾有過針對鼓室成形術或修正式鼓室成形術的大型流行病學調查，本研究的結果，對於臺灣地區公共衛生與醫療體系而言，具有代表性及重要性。我們可以藉此研究結果，對慢性中耳炎的盛行率有更多的認識與研究，有助於公共衛生政策的制定，減少相關醫療費用的支出。鼓室成形術及修正式鼓室成形術的住院天數均有減少的趨勢，但是其總醫療費用卻都逐年攀升，可見醫療技術是有在進步，但醫療費用的上升是否和醫療效果及生活品質的改善有同步，這是值得思考的議題，中央健保局應依此來調整論病計酬權值，以避免病人權利受損及醫療資源浪費。另外，各層級醫療機構間的各項醫療費用有所差異，可以藉本研究的分析並參考他院的做法，來修訂鼓室成形術及修正式鼓室成形術的臨床路徑，以最少的醫療費用來獲得最大的醫療效益。

關鍵字

鼓室成形術；修正式鼓室成形術；盛行率；住院天數醫療費用

並列摘要

Background and Objectives Chronic otitis media (COM) is one of the most common diseases in otolaryngology. The best eradicated treatment of COM is tympanoplasty, the most common surgical procedure received in hospitalization for the patients with otologic diseases. So far, few larger sample size investigation of the prevalence and hospital resource utilization of tympanoplasty were analyzed. The goal of the present study was to compare prevalence and hospital resource utilization between tympanoplasty and revision tympanoplasty on a large administration database of the Bureau of National Health Insurance in Taiwan. Materials and Methods A retrospective longitudinal study was based on the ICD-9-CM procedure codes of 19.4 or 19.5 (tympanoplasty) and 19.6 (revision tympanoplasty) combined with the ICD-9-CM diagnosis codes of 381.2, 382.1, 382.2, 382.3, 382.4,382.9,384.2,385.1 or 385.2 (COM). Five hundred and thirty cases were excluded due to unmentioned gender. Totally, 58,038 cases of tympanoplasty and 953 cases of revision tympanoplasty were enrolled from January 1996 to December 2007. The period was divided into three equal time intervals (T1: 1996-1999, T2: 2000-2003, T3: 2004-2007). All these cases were analyzed in four dimensions: patients’ demographic characteristics, clinical characteristics, surgical volume of hospitals or surgeons, and hospital resource utilization. Results The prevalence of tympanoplasty in Taiwan was 22.97 per 100,000 persons in 1996 and gradually increased to 26.7 in 2001, then gradually decreased to 16.61 in 2007. The prevalence of revision tympanoplasty was around 0.29-0.48 per 100,000 V persons in these twelve years. The data showed a decreased trend of average length of stay and an increased trend of hospital cost, either in tympanoplasty or revision tympanoplasty. Between two procedures, there was no significant difference in hospital resource utilization. In multiple regression models, the strongest predictor for average length of stay was the surgical volume of the surgeons. The strongest predictor for total hospital cost was average length of stay, either in tympanoplasty or revision tympanoplasty. Discussion Based on the database from the Bureau of National Health Insurance, this was the first population-based survey about prevalence and hospital resource utilization of tympanoplasty and revision tympanoplasty in Taiwan. We should increase our knowledge about the COM in Taiwan as it could help the evaluation of public health policy and hospital resource utilization of the related diseases. Although medical cost increased year by year, we should do more studies in quality improvement and cost-utility analysis. Due to impact of the Tw-DRGs (Taiwan version of Diagnosis Related Groups) payment system under the global budget of health insurance, renew or modification of the clinical pathways in tympanoplasty and revision tympanoplasty is a very important issue for all hospitals in Taiwan.