前開式單節頸椎椎間盤切除術後所進行之脊椎體間骨融合，不同融合術之成本效益分析

Cost-effectiveness Analysis of Different Fusion Procedures after One-level Anterior Cervical Discectomy

蔡明成(Ming-Cheng Tsai)

指導教授 ： 楊銘欽

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2005年)

https://doi.org/10.6342/NTU.2005.02634

摘要

目標
站在健保局或商業保險給付者的觀點，此篇論文希望能找出一個最符合成本效益分析的頸椎脊椎體間骨融合術。並期待能藉以建立一個分析的模式，提供日後對於特定疾病，不同治療方式的評估參考。

方法
此篇論文以回溯性的方式，分析從1995年4月至2004年4月共103個病患。這些病患因單節頸椎椎間盤突出導致頸神經根病變或脊髓病變而接受單節頸椎椎間盤切除術及椎體間骨融合手術。根據椎體間骨融合手術所用材料的不同，可將這些患者分為四組。第一組為單純使用自體骨進行骨融合手術，第二組為使用自體骨及鈦合金骨板進行骨融合手術，第三組為單純使用人工骨(BOP)進行骨融合手術，第四組為使用carbon fiber cage及鈦合金骨板進行骨融合手術。吾等使用ANOVA，multiple regression，及logistic regression進行成本與結果的分析。並收集影響結果的三變項，分別為術後住院天數、椎間盤高度的損失程度及椎體間骨融合率。為了便於多變項分析，吾等根據各組在術後椎間盤高度的保存率及骨融合率兩個結果變項的優劣表現，配合所花費的成本，將各組加以排序。再根據各組在兩變項排序的名次加總，獲得最符合成本效益的骨融合手術。

結果
對於包含手術費用、麻醉費用、及術後住院費用的總住院費用而言，第四組病患花費的成本最高，第二組次之，第三組為第三名，第一組最低。但是，若是以結果論之，第四組病患的術後住院天數最短，第一組病患的術後住院天數最長。第二組及第四組病患的術後頸椎椎間盤塌陷程度最輕微。而第三組的骨融合率最低。而因為產生術後合併症而必需接受第二次手術的病患則只出現於第一組及第三組中。所以根據術後椎間盤高度的保存率及骨融合率兩個結果變項排序的總合顯示只使用自體骨進行骨融合手術的第一組是四組中最符合成本效益的方法。

結論
雖然此篇論文是以健保局或商業保險給付者的觀點分析四種頸椎椎體間骨融合術的成本效益，但是若站在病患或手術醫師的立場，其結果可能迥然不同。故利用此多變項的分析模式對特定疾病不同的治療方式，可在決策分析上提供有利的參考。

關鍵字

頸椎前開手術 ； 頸椎骨板 ； 自體骨 ； 成本效益

並列摘要

Purpose
From a point of view of the third-party payers, this study hopes to look for the most acceptable intervertebral fusion procedure in terms of costs and effectiveness after anterior cervical discectomy. This fusion procedure should fit cost-effective analysis. Moreover, the other attempt is to establish an analytic model which could be applied to the comparison of different therapeutic strategies.
Methods
This investigation retrospectively analyzed one hundred and three consecutive cases who received one-level cervical discectomy and fusion procedures for radiculopathy and/or myelopathy between April 1995 and April 2004. According to the fusion materials and procedures, patients were classified into four groups, namely group I autograft only, group II autograft plus plate system, group III biocompatible osteoconductive polymer (BOP) only and group IV carbon fiber cage plus plate system. ANOVA (Analysis of Variance), multiple regression and logistic regression were used to analyse the estimated costs and outcomes. Three variables were used to evaluate the outcome. They were length of hospital stay (LOS), decrease of disc height (collapse of disc space) and bone fusion rate. In order to compute a multi-attribute index based on outcome variables, we first ranked the groups according to their performance in two variables, disc height preservation rate and bone fusion rate. Then, a summation of these two ranks was used to determine which fusion procedure was the best. The cost-effectiveness in fusion procedures also was evaluated.
Results
In terms of total hospitalization cost, including operative cost, anesthesia cost and post-operative hospitalization cost, group IV was the highest, followed by group II, group III, and group I was the lowest. As for outcomes, group IV had the shortest LOS and group I had the longest LOS (P < 0.01). Group II and group IV were the best two groups in maintenance of disc height after operations (P < 0.001). Group III’s bone fusion rate was the lowest (P < 0.001). Complications which needed to receive operation again during follow-up period only happened in cases of group I and group III. The summation of all the ranks in disc preservation rate and bone fusion rate revealed that group I autograft only was the best one to demonstrate the most cost-effectiveness option of the procedures in our study.
Conclusions
Besides choosing the most cost-effective fusion procedure, this model of multi-attribute cost-effectiveness analysis could be further used in other therapeutic protocols to provide a good decision making process for patients, doctors and the third-party payers.

並列關鍵字

anterior cervical fusion ； autograft ； cost effectiveness ； cervical plate

參考文獻

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