「傳統式」與「內視鏡輔助」甲狀腺切除術之成效分析

Comparisons of the Outcomes between the Conventional and Video-assisted Thyroidectomy

陳富滿(Fu-Man Chen)

指導教授 ： 陳宏一

共同指導教授 ： 陳秀珠(Hsiu-Chu Chen)

長榮大學/健康科學學院/醫學研究所/碩士(2010年)

摘要

甲狀腺切除術在傳統的手術方式至少須要5至6公分的切口，甚至更長。有時會造成明顯易見的疤痕。而醫療技術的發展及患者對於醫療結果的要求，逐步發展內視鏡補助甲狀腺切除手術，對於單側小於3公分的甲狀腺腫瘤，只須在頸部作一個1.5公分至2公分的切口，經由內視鏡的幫忙，即可成功且安全的將腫瘤切除，傷口只有傳統手術的三分之一，不僅美觀上獲得重大的突破，病人在術後的疼痛方面也減輕很多，手術完後第二天或第三天即可出院。但健保對於「內視鏡輔助」甲狀腺切除手術費用支付標準，與「傳統式」技術並未區分。本研究期望藉由比較「傳統式」甲狀腺切除手術以及「內視鏡輔助」於臨床成效及醫療資源耗用差異，作為醫療資源規劃與運用，以及支付標準調整之參考。
本研究以回溯性分析法從中部某醫學中心自2001年1年至2008年12月之健保醫令清單，加以連結該院醫療費用清單檔案以及病歷資料，共1434例，其中採「傳統式」手術者1065例(74.3%)，採「內視鏡輔助」手術者369例(25.7%)。
經初步分析採全民健康保險醫療費用支付標準中甲狀腺有關的切除術之個案病人特性發現，執行「內視鏡輔助」甲狀腺切除手術的個案與「傳統式」甲狀腺切除手術的個案，在年齡及腫瘤重量於統計上有顯著差異；經參考研究文獻以及訪談資深專科主治醫師意見，以主診斷(以ICD-9-CM編碼)再進行分類，並進行腫瘤重量勝算比檢定；最後，選擇以單純或非毐性甲狀腺腫(ICD-9-CM 240-241)，腫瘤重量小於20gm的個案，進行兩種不同術式的臨床成效及醫療資源耗用分析，個案數總共406例，其中接受「傳統式」手術技術共198例(48.8%)，接受「內視鏡輔助」手術技術共208例(51.2%)。臨床成效於兩種不同手術技術於統計上並無顯著差異，醫療資源耗用方面「內視鏡輔助」技術的開刀時間、手術費、麻醉費、藥費、總醫療費用點數及健保申請點數均較「傳統式」技術為低，但在統計僅有「健保平均申請點數」具顯著的差異。
「內視鏡輔助」甲狀腺切除手術，且因其切口小，不影響術後手術成效、美觀及生活品質，對民眾而言是一大福音；但在健保給付上卻較低於「傳統式」技術，然而發展新技術需要投資設備及耗材成本，可惜的是未反應在健保給付點數中，建議後續應進行兩項手術技術成本分析比較，以確認實際的成本狀況，給予合理給付方式。

關鍵字

甲狀腺切除術 ； 成效分析 ； 醫療資源耗用

並列摘要

The conventional thyroidectomy would to inflict 5 to 6 cm or even longer incision wound, thus leaving prominent scar is fairly common. As medical technology advances and patients are equipped with more medical knowledge, video-assisted thyroidectomy became more demanding.
For thyroid tumors less than 3cm in diameter; video-assisted surgery only requires a 1.5cm to 2cm incision which is one third of the size of the conventional method produces. This major breakthrough not only generates lesser pain, patients can also reduce the length of stay to 2 to 3 days of hospitalization. However, the Bureau of National Health Insurance does not recognize video-assisted surgery as a better option for both medical institutions and patients.
This study compares the conventional thyroidectomy and video-assisted thyroidectomy, and intends to prove advance video-assisted thyroidectomy is not a dependent consumable, which is less invasive and creating lesser complications comparing to conventional method. Since video-assisted thyroidectomy is both more patient and resources friendly, it deserves better and fairer financial attention from Health Insurance Payment System.
Methods: A retrospective analytical comparison from a Medical Center located in the center of Taiwan collected data from 2001 to 2008. Total 1434 cases, 1065 cases (74.3%) used conventional thyroidectomy and 369 (25.7%) video-assisted methods were adopted respectively.
Results : according a preliminary analysis based on National Health Insurance and medical fee schedule, patients’ age and size of tumor reveal obvious statistical differences.
After researches and interviews with senior attending physicians, classified major diagnosis was suggested first (by using the ICD-9-CM coding method), then Odds ratio test on tumor weight. Finally, we choose simple or non-toxic goiter (ICD-9-CM 240-241) tumor, which weights less than 20gm, was opted and studied with clinical effectiveness and health resource consumption.
Out of 406 cases, 198 (48.8%) patients had selected the conventional surgical technique while 208 patients (51.2%) chose video-assisted surgery.
There is no significant differences in terms of clinical outcome. However the medical resources consumption of video-assisted thyroidectomy, such as operation time, operation fee, anesthesia fee, drug fee, total medical fee and Health Insurance payment decreased. Obvious statistical differences of average Health Insurance payment can be seen.
Conclusion: Due to the smaller wound, same clinical outcome, pleasing appearance and higher quality of life, Video-assisted thyroidectomy is much more beneficial to patient. Although, hospitals are unable to claim as much payment for the video-assisted thyroidectomy than for the conventional method. Video-assisted thyroidectomy requires much more investment in medical equipments and other overhead, thus it should obtain more financial reimbursement support from the National Health Insurance. We suggest the analysis of the cost between these operation methods are necessary, therefore the Bureau of National Health Insurance can have a better estimation of the real cost of operation and offers a reasonable payment.

並列關鍵字

Video-assisted thyroidectomy ； thyroidectomy ； comparison outcome

參考文獻

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