加馬刀治療腦膜瘤病人的資源使用及臨床效果：與傳統開顱手術比較

The utilization of medical resources and the clinical effectiveness in Meningiomas patients Received Gamma Knife Stereotactic Radiosurgery Compared with Open surgery

陳雅婷(Ya-Ting Chen)

指導教授 ： 邱亨嘉

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(2017年)

摘要

目的
腦膜瘤開刀治療方式有傳統開顱手術及加馬刀立體定位術，台灣加馬機立體定位放射手術自2003年12月開始納入全民健康保險給付範圍，本研究預進行全國醫院、南部某區域醫院腦膜瘤接受加馬刀立體定位術與開顱手術的臨床效果及醫療資源利用進行相關探討並比較兩者是否有其差異。
研究方法
本研究採回溯性研究，使用2004年至2012年全民健康保險資料庫百萬歸人檔及南部某區域醫院2005至2015年申報資料，主診斷為腦膜瘤(ICD-9-CM碼：225.2) 腫瘤小於(含)3公分以下，接受加馬刀立體定位術(ICD-9-CM碼：92.32及93.59)或開顱手術(ICD-9-CM碼：01.51~01.59)住院病人，對當次臨床效果、當次醫療資源利用及短中期醫療效果，使用SPSS 20.0進行統計分析。
研究結果
全國病人，線性回歸結果，開顱手術和加馬刀相比較，當次住院天數多9.68天，(P<0.001)；當次住院醫療費用低33,711元，(P=0.003)。描述性統計發現，開顱手術11.54%有併發症，加馬刀則無；加馬刀發生出院後三十天內有再急診3.85%，開顱手術7.69%；加馬刀發生出院後三年有再入院3.85%，開顱手術則沒有。
南部某區域醫院病人，線性回歸結果，開顱手術和加馬刀相比較，當次住院天數多8.49天，(P<0.001)；當次住院醫療費用低103,341元，(P<0.001)。開顱手術6.35%有併發症，加馬刀則無；開顱手術發生出院後三十天內有再急診3.17%，加馬刀沒有；術後腫瘤復發加馬刀37.50%，開顱手術62.50%。
結論與建議
從全國病人或是南部某區域醫院資料，本研究結果發現，加馬刀當次住院醫療費用及手術費用高於開顱手術，但開顱手術平均住院天數是加馬刀的5.16倍~5.93倍，加馬刀治療特性傷口小，不需麻醉，術後恢復時間較短，對於腦膜瘤腫瘤小於(含)3公分以下的病人，加馬刀是較佳的選擇。未來全面導入Tw-DRGs支付制度時，可提供健保署訂定標準住院天數與定額給付的評估以及醫院成本考量與評估預期效益的參考。

關鍵字

加馬刀立體定位術 ； 開顱手術 ； 醫療資源利用 ； 臨床效果

並列摘要

Background and Aim
Craniotomy and gamma knife stereotactic radiosurgery have proven for meningioma of surgical treatment. Plus three-dimensional positioning of radiation surgery was reported to the universal health insurance payments in Taiwan since December 2003. The clinical effects and utilization of the medical resources of the gamma knife stereotactic radiosurgery and open surgery for meningioma were discussed and compared with the difference between the pre-national hospitals and a southern regional hospital in this study.
Method
The diagnosed the ≤ 3 cm meningioma (ICD-9-CM: 225.2) inpatients to received the gamma knife stereotactic radiosurgery (ICD-9-CM code: 92.32, 93.59) or open surgery (ICD-9-CM code: 01.51~01.59) in the south regional hospital from 2005 to 2015 were enrolled in our retrospective study and conducted the National Health Insurance Database from 2004 to 2012.All statistical evaluations were performed using SPSS version 20.0 software.
Results
The open surgery group revealed lower cost of hospitalization as NT33,711 (P= 0.003) and higher number of hospitalizations as9.68 days (P<0.001). Descriptive statistics showed that 11.54% of open surgery complications and no complication of gamma knife stereotactic radiosurgery; gamma knife stereotactic radiosurgery occurred within 30 days after discharge there are emergency 3.85%, open surgery was 7.69%; gamma knife stereotactic radiosurgery occurred three years after discharge were readmission3.85%, open surgery is not. The cost of hospitalization was NT103,341 (P <0.001), and the number of hospitalizations was 8.49 days (P <0.001). Complications of open surgery showed 6.35% without the patient of gamma knife stereotactic radiosurgery. Open surgery occurred within 30 days after emergency and then emergency showed 3.17% without the patient of gamma knife stereotactic radiosurgery. Recurrent postoperative tumor showed gamma knife stereotactic radiosurgery 37.50% and open surgery 62.50%.
Conclusion and Suggestion
From the data of national patient and south regional hospital, the results of this study demonstrated the medical expenses of gamma knife stereotactic radiosurgery higher than open surgery. However, the average of hospitalizations for open surgery was 5.16 to 5.93 folds than gamma knife stereotactic radiosurgery. The characteristics of gamma knife stereotactic radiosurgery showed small wound, no anesthesia and shorter recovery time of postoperative for the ≤ 3 cm meningioma patients as the better option. In the future, the introduction of the Tw-DRGs payment system will provide a reference for the health insurance department to set the standard hospital stay and the assessment of the quota and the cost of the hospital and the expected benefits of the assessment.

並列關鍵字

gamma knife stereotactic radiosurgery ； open surgery ； medical resource utilization ； clinical effect

參考文獻

Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis, 40(5), 373-383.

英文參考文獻

Bir, S. C., Ambekar, S., Ward, T., & Nanda, A. (2014). Outcomes and complications of gamma knife radiosurgery for skull base meningiomas. Journal of neurological surgery. Part B, Skull base, 75(6), 397-401. doi:10.1055/s-0034-1376422

Bir, S. C., Murray, R. D., Ambekar, S., Bollam, P., & Nanda, A. (2015). Clinical and Radiologic Outcome of Gamma Knife Radiosurgery on Nonfunctioning Pituitary Adenomas. Journal of neurological surgery. Part B, Skull base, 76(5), 351-357. doi:10.1055/s-0035-1549309

Caruso, J. P., Moosa, S., Fezeu, F., Ramesh, A., & Sheehan, J. P. (2015). A cost comparative study of Gamma Knife radiosurgery versus open surgery for intracranial pathology. Journal of Clinical Neuroscience, 22(1), 184-188. doi:10.1016/j.jocn.2014.08.012