不同科別執行脊椎手術之效益探討一 以骨科及神經外科為例

Analysis the efficiency of the spinal surgery between orthopedic and neurosurgery departments

蔡美真(Mei-Chen Tsai)

指導教授 ： 邱亨嘉

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

中文摘要
研究背景
脊椎手術部分健保局將預於100年7月起列入Tw-DRG給付，本研究期盼瞭解不同科別執行脊椎手術，是否有不同臨床效益可循，期以統計數據瞭解不同科別執行同一手術，其醫療資源耗用之差異程度，以達到有效控制成本、提昇資源利用的效能，更進一步提昇醫療品質，作為成果管理的工具，期望為醫院管理及改善病人照護品質與療效之參考。
研究方法
利用1998-2009年健保局高屏業務組住院費用資料庫，醫療機構申報(1)融合手術(2)椎間盤切除術(3)減壓術等3種手術，共263,667位脊椎手術住院病患為樣本，其人口學特質、疾病差異、地區差異、醫院特質、手術方式等變項，探討不同科別執行脊椎手術其醫療品質與醫療資源利用情形。
研究結果
「科別」在執行脊椎手術方面，於醫療品質與醫療資源利用確有其差異存在。整體脊椎手術醫療品質比較，併發症minor兩科無差異；major P＜0.001神經外科發生機率是骨科2.76倍，當次住院死亡率P＜0.019；神經外科發生機率多骨科1.317倍，3日內再急診及14日再入院二科無差異。醫療資源住院天數比較上，P＜0.001神經外科較骨科多0.9天，醫療費用使用上，P＜0.001神經外科較骨科少40,140元。但如細分脊椎手術類別，又有不同結果。如後側方式融合術在醫療品質及醫療資源比較，神經外科較骨科佳。前側方式融合術醫療品質及醫療資源比較，神經外科較骨科佳。椎間盤切除術術後及減壓術在醫療品質及醫療資源比較，骨科較神經外科佳。

結論和建議
「科別」在執行脊椎手術方面，於醫療品質與醫療資源利用確有其差異存在。目前在本國脊椎手術，絕大多數脊椎手術病患，不是選擇骨科專科，就是選擇神經外科專科。而術業有專攻，每一專業都有其養成領域，在講求專業的時代，相信很多技術，都是持續不斷求新求進步，尤其醫療體系是為廣大民眾服務，每位專業人士，無不戰戰兢兢於自己職場，為民眾健康把關，謀民眾最有效益情勢。期盼透過骨科及神經外科，兩專科領域同儕相互學習，精緻執行脊椎外科技巧，降低二大科別間之差異性，以提升醫療品質及減少不必要之醫療資源使用。而衛生主管機構醫療政策訂定，亦應有科別專科化之思考前瞻，才是真正握有替病患把守健康大門之鎖鑰。
健保局DRG給付已陸續啟動，而脊椎手術部分預定於100年7月實施。本研究資料可為脊椎手術部分DRG端倪參考。不同科別執行脊椎手術有其在醫療品質與醫療資源上之差異。目前在本國醫療體系制度下，尚未規範詳細專業科別執行範圍，尤其健保支付標準仍少有專業科別之規範，致不分專業科別，僅一醫師執照，即可看診各科別，造成忽略專業科別其背後素養，希冀隨著醫療水平的提高，因有專業科別之限制，以有助於降低死亡率、併發症等不當醫療發生率與降低醫療資源之利用。

關鍵字

融合手術(Fusion) ； 椎間盤切除術(discectomy) ； 減壓術(decompression) ； 醫療品質 ； 醫療資源

並列摘要

Background
Orthopedic and neurosurgery departments play an important role in performing of spinal operations. The purpose of this study is to analyze the utilizing of medical resources between the two departments. According to the diagnoses of spine, types of surgery intervention, complication or not, age, gender, the status of discharge, their differences were analyzed between local, region and medical center hospitals. Secondary, Bureau of national health insurance are planning to conduct Tw-DRG into the spinal surgery in July, 2011, and with understanding the differences between the department in the cost efficiency, the results can provide for management tool and expect to be the references of hospital manage and improvement of quality of patient care.
Materials and Methods
Using the data bank from the Bureau of national health insurance between 1998-2009, there were 26,3667 patients reported to have spinal surgical intervention with three types (1) bone fusion, (2) discectomy, (3) laminectomy. Patient’s demography, diseases, regions, hospital characters, surgical interventions were used to analyze the medical resource and quality. Using the average of medical cost(length of stay days；hospital charges), rates of complication, rates of inpatient mortality, rates of returning to emergency department (ED) within three days and readmission within fourteen days as indicators, we explored the aspects of future monitor and inspection.
Results
Orthopedic department get better medical quality, neurosurgery department use less medical resources in the overall comparison about spinal surgery.. There was a significant difference of medical quality including complication of major(P＜0.001), neurosurgery department is 2.76 fold higher than orthopedic department . neurosurgery department is 1.317 fold higher than orthopedic department in the mortality. Both of rates of returning to emergency department (ED) within three days and readmission within fourteen days made no difference. The statistic average orthopedic department inpatient days were lower than neurosurgery department(0.9day；P＜0.001). Medical cost orthopedic department were lower $40,140 NT.The detail statistic results demonstrate that neurosurgery department have better medical quality and use less medical resources in the interventions of anterior and posterior bone fusion. Orthopedic department have better medical quality and use less medical resources in the intervention of laminectomy and discectomy.
Conclusions and recommendations
Differences of outcomes about medical quality and medical resources utilization of the spinal surgery exist between orthopedic and neurosurgery departments. Every specialist has its own skills and talents. In order to provide most satisfied medical services for patients and best interest for public society, every physician are work hard and do their best. Through the competition of the different departments, specialty surgeon can upgrade their physician skill, and provide most satisfied services for patients.
DRG has been active continually. This thesis provide convenience statistic data of spinal surgery. Taiwan’s health system has no restriction on practice of medical services between different department. Specialists of different department can practice every kind of medical services and ignore the technique difference. Government should be set up the restriction of the practice, as soon as possible, It can be help to decrease the mortality, morbidity, inappropriate medical rate and reduce medical expenditure.

並列關鍵字

fusion ； discectomy ； decompression ； medical quality ； medical resource

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