退行性頸椎疾病的神經外科介入性處置與醫療資源耗用之關係研究

Degenerative Cervical Spondylosis:Neuro-surgical Interventions and Medical Cost

馮玉東(Yu-Tung Feng)

指導教授 ： 李金德

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)

https://doi.org/10.6832/KMU.2011.00135

摘要

研究目的
退行性頸椎疾病是成人脊柱病變最常見的原因，而這也是老化過程中的一部分。頸椎前開之椎間盤切除併人工骨塊融合術與頸椎後開之椎板切開術、椎間孔切開術和椎板切除併人工骨塊融合術是退行性頸椎疾病的外科手術治療選擇。可以預知的是隨著人口結構的老化，本類疾病治療的直接醫療成本將不斷增加。本研究具體的研究目的如下：〈一〉描述個案醫院退行性頸椎疾病病人接受不同神經外科手術術式之處置情形。〈二〉探討接受各術式退行性頸椎疾病的神經外科手術病人，其當次住院的醫療療效。〈三〉探討接受各術式退行性頸椎疾病的神經外科手術病人，其當次住院的醫療資源利用情形。〈四〉探討影響退行性頸椎疾病病患之醫療療效的關鍵因素。〈五〉探討影響退行性頸椎疾病病患之醫療資源利用的關鍵因素。

研究方法
本研究以回溯性病例審查方式收集前往高雄醫學大學附設中和紀念醫院外科部腦神經外科就診而經確認有退行性頸椎疾病且計畫接受手術治療的個案，摘錄病歷記載之退行性頸椎疾病個案的特性、過去的病史、危險因素、疾病嚴重度及個案當次的處置與臨床療效和醫療資源利用情形。主要的個案排除條件為：牽涉頸椎第1與2節之病患、由急診轉介之外傷病患、具退行性頸椎疾病，但合併腫瘤，以致無法正確評估該次住院期間的退行性頸椎疾病治療花費之病患與該次手術未植入任何人工植入物之病患。

研究結果
在2009年1月至2010年12月，145位退行性頸椎疾病患者於個案醫院接受手術治療，其中符合排除條件者，皆予以排除，最後實際納入105例個案進行分析。研究個案之基本特質的初步整理顯示人口學特質與病患接受手術方式並無關聯。研究個案之醫療療效的整理結果顯示住院中重大不良事件幾乎不曾發生，其中死亡或呼吸抑制等不良事件皆未發生，術後併發症僅出現1例〈0.9%；接受頸椎前開之椎間盤切除併人工骨塊融合術，並植入頸椎板作內固定之病患，因術後出血，緊急開刀處置〉。研究個案之醫療資源利用的整理結果顯示顯示接受手術治療的患者，其平均麻醉總時數為4.88 ?b1.78小時，平均手術總時數為3.87 ?b 1.67小時，平均ICU日數與時數分別為1.20 ?b 0.47天及24.21 ?b 11.32小時，ICU照護超過24小時的比率為21.0%〈22例〉，平均住院日數為8.94 ?b 4.70日，平均ICU花費為8,534 ?b 3,330元，平均住院花費為11,765 ?b 7,237元，平均健保花費為104,777 ?b 33,071元，平均病人部份負擔與雜支的總額則為17,299 ?b 13,878元，而接受頸椎前開或後開手術患者之平均病房日數(8.48 ?b 4.44 vs. 14.50 ?b 4.54, p<0.0001)、平均病房花費(11,004 ?b 6,655 vs. 20,984 ?b 8,100, p<0.0001)與平均健保花費(100161 ?b 27166 vs. 160744 ?b 47535, p=0.008)皆明顯少於接受頸椎前開合併頸椎後開之患者。複迴歸分析的結果，在控制其它變項下，手術方式是影響醫療資源利用的最關鍵因素，接受頸椎前開合併頸椎後開手術的患者，其醫療資源利用顯著的較高。

結論與建議
對於退行性頸椎疾病，神經外科介入性處置是非常安全的治療方式。在個案醫院裡，接受接受頸椎前開手術或頸椎後開手術與接受頸椎前開手術合併頸椎後開手術的病患，其住院中不良事件的發生機率沒有顯著差異，但醫療資源利用的情況有顯著差異，即接受頸椎前開手術合併頸椎後開手術的病患利用較高的醫療資源。本研究的結果建議思考評估以『門診手術』為基礎的脊椎前開手術之可行性，並著手規劃研究，以建立機制，制定明確的病人選擇準則與標準，安全的以『門診手術』的基礎，進行介入性處置，進而減少住院與ICU相關資源的利用。

關鍵字

退行性頸椎疾病 ； 頸椎前開 ； 頸椎後開 ； 醫療資源利用

並列摘要

OBJECTIVE. Actually part of aging process, degenerative cervical spondylosis (DCS) is the most common reason for degenerative changes with the spinal column. Operative intervention is considered when the severely pain is not relieved by non-operative treatment. Either with anterior or posterior approach, cervical discectomy and fusion is main option typically considered for operative management of DCS. It is predictable that resource utilization would be impacted with the aging population. The purposes of the research are: 1) to describe the distribution of a selective DCS patients receiving operative intervention of different surgical approaches at our institution, 2) to study the medical results of the above-mentioned patients’, 3) to study the resource utilization of the above-mentioned patients’, 4) to identify factors related to the medical results of the above-mentioned patients’, 5) to identify factors related to the resource utilization of the above-mentioned patients’.

METHODS. This is a retrospective chart review within a medical center of patients undergoing instrumented procedures using allografts. The sample included 145 patients who underwent anterior cervical discectomy and fusion and/or posterior laminectomy and fusion procedures from January 2009 to December 2011. Patients with degenerative changes involved cervical intervertebral levels of C1-C2, spinal injury traumatic in origin, spinal tumors, or previous cervical fusion were excluded. Information regarding age, gender, medical comorbidity (Charlson Comorbidity Index), history of smoking/alcohol consumption, body mass index (BMI), anesthesical details and surgical details were collected. Complications after surgery as well as immediate re-operation for any reason were defined as indicators to medical results, in addition, anesthesia duration, operation duration, hospital length of stay, hospital cost, and reimbursement of national health insurance were noted to define the resource utilization. All these parameters were used to evaluate the impact of surgical intervention on the outcomes. All tests were performed at the 0.05 level of significance.

RESULTS. Met with the inclusion criteria, one hundred and five patients (97 in the anterior or posterior group (AOP grop), 8 in the anterior and posterior group (AAP group)) were further reviewed to better characterize the sample. Only one of 105 (0.9%) patients developed acute complication, which was post-operative hemorrhage requiring immediate surgical intervention. It was resolved without any neurologic deficit or casualty. There were no hematomas, airway complications or deaths. Preliminary results of the resource utilization indicated that the average anesthesia duration for the patients receiving neurosurgical intervention for DSC was 4.88 ?b 1.78 hr, average operation duration, average ICU stay, average length of hospital stay, average ICU cost, average cost of hospital stay, and average reimbursement cost were 3.87 ?b 1.67 hr, 1.20 ?b 0.47 day, 8.94 ?b 4.70 day, 8,534 ?b 3,330 NTD, 11,765 ?b 7,237 NTD, and 104,777 ?b 33,071 NTD, respectively. The average length of hospital stay (8.48 ?b 4.44 vs. 14.50 ?b 4.54 day, p<0.0001), average cost of hospital stay (11,004 ?b 6,655 vs. 20,984 ?b 8,100 NTD, p<0.0001), and average reimbursement cost (100,161 ?b 27,166 vs. 160,744 ?b 47,535 NTD, p=0.008) for the patients in the AOP group were significantly higher than those who in the AAP group. The analyses of multiple regression demonstrated that surgical approach was the key factor to impact the outcomes of resource utilization, indicating patients in the AAP group significantly use more resource than patients in the AOP group.

CONCLUSION. Neurosurgical intervention is safe for patients with DSC. Postoperative complication rates associated with these procedures are low. Critical complications involving airway compromise occur very infrequently and in the early postoperative period. The results warrant a further study with much bigger scale to evaluate the feasibility of surgical procedures on an outpatient basis to reduce the hospital stay related resource utilization.

並列關鍵字

Degenerative cervical Spondylosis ； Anterior approach ； Posterior approach ； Resource utilization

參考文獻

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