開顱手術或血管內栓塞治療顱內動脈瘤破裂之醫療耗用比較

Medical utilization of endovascular versus neurosurgical treatment for ruptured intracranial aneurysms in Taiwan

黃炳生(Bing-Sang Wong)

指導教授 ： 張永源

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(2010年)

摘要

研究目的
腦中風高居台灣地區十大死因的第二位。「顱內動脈瘤」破裂出血則是「出血性腦中風」的主要因素之一。動脈瘤可用外科手術經由外部治療或使用微創介入性治療由血管內部來著手。國外相關文獻研究指出以新的顱內動脈瘤栓塞手術治療，患者恢復期較短，治療效果較佳，但所使用之特殊材料白金纖維環比傳統開顱術所使用的動脈夾較為昂貴。目前健保對白金纖維環之使用訂有適應症及使用之規範。本研究目的在進行此兩類手術、之評估以作為醫療政策上醫療資源規劃與運用之參考。
研究方法
依據目前文獻顱內動脈瘤的手術治療方式，主要分為傳統開顱手術夾手術與血管內栓塞手術兩大類。本研究為橫斷性研究，回溯性的次級資料分析。研究對象為全國醫學中心自2004年1月1日至2007年12月31日止，在健保所申報此兩類手術之民眾的資料，並分析其治療方式與醫療耗用，主要研究依變項包含手術費用、總醫療費用、平均住院天日、併發症及死亡率等。利用SPSS14.0中文版統計套裝軟體進行統計分析，驗證本研究假說採用統計方法有描述性統計分析、獨立樣本 t 檢定、卡方檢定、one-way ANOVA、相關分析、線性及對數迴歸分析。
研究結果
統計結果顯示在手術併發症上，以血管內栓塞來治療腦動脈瘤破裂比以傳統開顱手術少，發生機率約為傳統手術的50％（OR＝0.515，p＝0.038）。而在住院天數方面，以血管內栓塞治療可平均縮短病患住院7.8天。但在死亡率上兩者並無明顯差異（p＝0.785）。在費用方面，年齡每增加一歲，總醫療費用增加4,052元（p＜0.0005），而在合併症嚴重度方面，每增加一分，總醫療費用增加34,359元（p＜0.0005）。在手術方式方面，因未達顯著差異而被淘汰，但在個別區域上仍有顯著差異，在台北及南區接受開顱手術病患之總醫療費用，分別比其他地區多111,337元及110,605元（p＜0.0005）。而在中區治療腦動脈瘤破裂比其他分局在總醫療費用多出57,542元（p＝0.005）。
結論與建議
以血管內栓塞來治療顱內動脈瘤破裂不論在住院天數及併發症的發生上，都較傳統的開顱血管夾手術為低，而在死亡率上兩者並無差異，表示以血管內栓塞來治療顱內動脈瘤破裂有較佳之醫療效果。而在醫療耗用方面，血管內栓塞並沒有比傳統的開顱血管夾手術費用更高，反觀在一些特定區域，傳統的開顱血管夾手術還消耗更多的醫療資源。故就本研究的結果顯示，不論在疾病的治療或醫療耗用上，以血管內栓塞來治療顱內動脈瘤破裂的一項值得發展的醫療技術。
腦動脈瘤是一種複雜的疾病，其治療會因發生的位置、腦瘤的大小及病患的嚴重度而有所不同。血管內栓塞是一種新的治療方式，其治療成效仍須長期研究追蹤。目前各國初步研究的結論是讓人振奮的，特別是發生在一些開顱手術困難的位置。國外的研究也指出如病患同時適合作栓塞或開顱手術，用栓塞治療在治療成效上優於傳統的開顱手術，但所需的費用因特殊材料的使用而較高。隨著醫療科技的發展，相信費用的差距會日益減少。根據本研究之結果可提供醫療政策制訂者在擬定血管內栓塞手術之健保給付及規範方向，以及醫療服務提供者在腦動脈瘤病患選擇手術方式之參考。

關鍵字

顱內動脈瘤 ； 開顱手術夾手術 ； 血管內栓塞 ； 白金纖維環 ； 醫療耗用

並列摘要

Objectives
Stroke ranks the second leading cause of death in Taiwan. Ruptured intracranial aneurysm is one of the main factors of hemorrhagic stroke. Aneurysm surgery can be done by traditional craniotomy with external clipping of the aneurysm. Recently, study of relevant literature review that a new surgical treatment of intracranial aneurysm by using minimally invasive intravascular embolization may provide patients with better outcome and shorter recovery time. However, the used of platinum coils for embolization is more expensive than the aneurysm clips. The National Health Insurance restricted the use of these platinum coils clinically. The purpose of this study is to compare these two types of procedures in their clinical outcomes and medical utilizations. And to provide information for the medical resource planning while making the health care policy.

Methods
According to the current literature of intracranial aneurysms treatment, we divided the traditional craniotomy surgery and endovascular surgery into two categories. This study was a cross-sectional, retrospective secondary data analysis. We obtained data from the National Health Insurance Database. Patients were eligible for the study if they harbored a ruptured intracranial aneurysm that received either technique (surgical or endovascular) in medical centers from January 1, 2004 to December 31, 2007. The following data were obtained from the Database: age, sex, surgical costs, total medical utilization, length of stay, complications and mortality. By using SPSS14.0 Chinese statistical software for statistical analysis, we validated of this hypothesis through statistical methods of descriptive statistics, independent sample t test, chi square test, one-way ANOVA, correlation analysis, linear and multiple regression analysis.

Results
The results showed that complications of embolization group in the treatment of ruptured intracranial aneurysms was less than the traditional craniotomy group, the incidence is about half than the traditional surgery (OR = 0.515, p = 0.038). The length of stay in the embolization group had a reduction of 7.8 hospital days to an average. However, no significant difference was found in mortality (p = 0.785). In terms of costs, the total medical consumption cost 4,052NT (p <0.0005) in each additional year-old age. Each additional point of comorbility increased in total medical costs 34,359NT (p <0.0005). In the surgical procedure, although the results showed no significant difference amount the two categories, there was still significant differences between individual regions, the total medical costs of patients who received craniotomy in Taipei District and Southern District were higher in about 111,337NT 110,605 (p <0.0005) respectively when compared with other regions. The costs of treatment of ruptured intracranial aneurysm in Central District was higher than any other branches in an average of 57,542 NT (p = 0.005).

Conclusion and suggestion
Cerebral aneurysm is a complex disease, the severity of patients varies from each another, greatly depends on the aneurysm size and location. Endovascular embolization is a new treatment technique, the effectiveness of this treatment still needs long-term follow-up. Current national preliminary study is encouraged, especially in some difficult aneurysm location where performing craniotomy is highly risky. Some study at the same time shows that, if the aneurysm is suitable for either technique, embolization will have a better outcome, but the cost of materials used will be higher. With the development of medical technology, I believe that the gap between the costs will become narrower. The results of this study can provide health care policy makers some specifications and direction in the formulation of endovascular surgery, and to the health care providers, the treatment of choices while facing ruptured intracranial aneurysm.

並列關鍵字

intracranial aneurysm ； craniotomy surgery ； endovascular embolization ； Platinum coil ； medical utilization

參考文獻

中文部份

中央健保局資料（2007）

台灣地區2010年衛生白皮書（94年版）

台灣腦中風學會

施慧娟（2007）．雌二醇減緩大鼠實驗性蜘蛛膜下腔出血引發腦血管痙攣的角色•未發表的博士論文，高雄：高雄醫學大學