輸尿管下段結石兩種治療方式成本和治療效果的分析

Cost and Outcome Analysis of Two Treatment Strategies for Patients with Distal Ureteral stone

莊光達(Guang-Dar Juang)

指導教授 ： 湯澡薰

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2006年)

摘要

本研究的目的以採用醫療資源耗用的方式，計算兩種治療方式的直接醫療成本和客觀的治療效果參數。再從醫院的觀點比較那一種治療方式比較符合經濟效益。 從2002至2004年於北區某醫學中心的回溯性研究，在結石< 1公分的849位病患中，接受輸尿管鏡碎石術治療有639位，接受體外電震波碎石術治療有210位的病患，體外電震波碎石術是使用Siemens公司Lithostar II震波碎石機碎石。在結石? 1公分的185位病患中接受體外電震波碎石術治療有74位，接受輸尿管鏡碎石術治療有111位。在治療成功率方面，不論結石< 1公分或結石? 1公分這二組接受輸尿管鏡碎石術治療的成功率遠比接受體外電震波碎石術的高，有統計學上的意義（94.5% vs. 81.9%, 86.5% vs. 62.2%, P < 0.001）。但是輸尿管鏡碎石術治療的750位病患中，有29位（3.86%）於治療後有併發症發生。 成本的計算是從醫院的觀點、以資源耗用的方式計算直接醫療成本。單位成本是根據健保醫令清單和各醫療單位的成本收費比計算。單次治療的成本當結石< 1公分，體外電震波碎石術平均醫療成本為22884元而輸尿管鏡碎石術治療為30309元。當結石? 1公分，接受體外碎石治療的平均醫療成本為22494元而輸尿管鏡碎石術為30911元。而全部治療費用是利用決策分析模式計算，結果無論結石的大小，採用體外震波碎石術治療的預期成本耗費比較少（36672元vs. 37621元, 30315元vs. 32155元）而醫院的盈餘比較高（p < 0.001）。 結論︰從醫院的觀點，採用醫療資源耗用的方式計算體外電震波碎石術與輸尿管鏡碎石術兩種方式在治療輸尿管下段結石時的直接治療成本以體外電震波碎石術的成本耗費較少，醫院的盈餘較高。但是在臨床的效果方面，輸尿管鏡碎石術有較高的結石擴清率，碎石排清所耗費的時間也較短。

關鍵字

成本分析 ； 治療效果分析 ； 碎石機 ； 治療費 ； 擴清率 ； 統計學 ； 輸尿管 ； 輸尿管下段結石 ； 輸尿管鏡碎石術 ； 體外電震波碎石術

並列摘要

The aim of the study is to estimate the direct medical cost, based on resources utilization and objective outcomes of these two treatment modalities for distal ureteral stone. Economic analysis was done from the point of view of health providers. From Jan. 2002 through Dec. 2004, 1034 distal ureteral calculi were treated using either ESWL (Siemens Lithostar II electromagnetic ESWL in 284 patients) or ureteroscopy (750 patients). Patient age and stone size were similar among the groups. All ESWL treatments were performed with the patient under intravenous sedation and on outpatient basis. Stone free rate were 62.2% for stone size larger than 1 cm, and 81.9% for stone size less than 1 cm. Retreatment was required in 9 cases (19.6%) and 12 cases (7.0%) respectively. The ureteroscopy treatments were performed under spinal or general anesthesia and on inpatient basis. Stone free rate were 86.5% for larger stone and 94.5% for smaller one. Retreatment was also required in 5 cases (5.2%) and 6 cases (1.49%) respectively. The direct medical cost of treatment was estimated by resources utilization from the viewpoint of health provider and derived by adjusting for department-specific cost-to-charge ratios. The decision analysis model was constructed to estimate the expected treatment costs of each strategy. The successful rates of each treatment modality were determined from outcomes in this series. Overall ESWL was less costly than ureteroscopy in single treatment cost and expected treatment cost for any stone size. A cost difference between the 2 modalities for smaller stone and larger was 7425 NTD and 7417 NTD for single treatment cost, respectively. For smaller stone, the expected cost of ESWL and ureteroscopy were 30315 NTD and 32155 NTD, respectively. For larger stone, the expected cost of ESWL and ureteroscopy were 36672 NTD and 37621 NTD, respectively. The high inpatient cost and professional fee is responsible for the high treatment cost associated with ureteroscopy. From the benefit standpoint, ESWL was a few thousand dollars more than ureteroscopy for hospital. Conclusions: From the viewpoint of hospital, ESWL is less cost expense and more benefit treatment strategy for distal ureteral stones by resources utilization. However, ureteroscopy is more cost effective in stone clearance.

並列關鍵字

cost analysis ； cost benefit analysis ； treatment outcome ； distal ureteral stone ； ureteroscopy ； extracorporeal shock wave lithotripsy (ESWL)

參考文獻

張心湜、邱文祥、陳明村等(1991)。台灣地區碎石機評估。行政院衛生署80年計畫。 李瀛輝、張心湜、陳明村、黃榮慶(1994)。台灣南部地區尿路結石流行病學之研究。中華泌尿醫誌，5，1-7。

Lee Y.H., Chang L.S., Chen M.T., & Huang J.K. (1994). The epidemiology of urolithiasis in southern Taiwan. J Urol ROC. 5,1-7.

Chang S.C., Hsu T., & Kuo H.C. (1993). Treatment options for upper ureteral calculi: a Comparison between ureteroscopy and extracorporeal shock wave lithotripsy. J Urol ROC 4, 112-1130.

健保局(1998)。上尿路結石台灣地區各醫療院所申報之統計資料。 劉國銘(2001)。「經尿道前列腺切除術(TURP)」臨床路徑實施對患者生活品質量表、臨床療效及醫療耗用之影響。台北:長庚大學醫務管理學研究所碩士論文。 吳榮州(2003)。某區域醫院冠狀動脈疾病以經皮冠狀動脈氣球擴張術治療與支架治療之成本效果分析。高雄:高雄醫學大學公共衛生學研究所碩士論文。 張世忠(1993)。上段輸尿管結石之治療選擇:輸尿管鏡和体外電震波碎石術之比較。慈濟醫學，3，15-21。

林秀玲(2002)。子宮頸癌篩檢之成本效性分析。臺北:臺北醫學大學醫務管理學研究所碩士論文。 林芳樹、王旭翔、馬永漢、陳淳(1994)。宜蘭縣內尿路結石症之臨床統計分析。台灣醫誌，93，142-147。