臺灣博碩士論文加值系統

研究目的
目前膽石症仍是腹部常見的疾病之一。本研究將針對膽囊切除術做一系統性、全面性之探討，並比較腹腔鏡膽囊切除術（LC）及剖腹式膽囊切除術（OC）之成本效益分析。
研究方法與材料
本研究樣本醫院採前瞻性縱貫性之研究設計，從 2007年05月至 2008年03月間，接受OC與LC之患者為研究樣本，其蒐集之個案數共259例。醫療直接成本的部分，LC樣本數共223例，OC樣本數共36例；間接成本的部分，亦各為96例及36例。分析不同治療模式、人口特質、臨床特質等變項，是否影響醫療費用分布及病患術後自覺健康狀態的SF-36 分數，並以經濟評估計算兩種治療模式之成本效用比值，且對成本效益面進行單變量敏感度分析；另使用1996年01月至2004年12月之全民健康保險研究資料庫中之「住院醫療費用清單明細檔」與「醫事機構基本資料檔」，為與樣本醫院進行比較之全國資料，其研究樣本OC個案共 32535位、LC個案共 80335位。。
研究結果
檢測結果顯示樣本醫院之病患屬性與全國健保資料庫並無顯著差異性，因此樣本醫院足以代表母群體來做為OC與LC病患醫療資源耗用風險因子之探討。本研究之結果呈現選擇OC病患平均年齡為60.88 ± 15.30歲、LC病患平均年齡為53.49 ± 14.19歲，其中OC vs LC於性別、ASA分類、合併症指數、年齡、手術時間、麻醉時間與平均住院天數對選擇手術切除方式上有顯著差異（P＜0.05）。
以線性複迴歸分析的統計方式，探討不同術式對平均住院天數及醫療費用耗用之因素，發現在住院天數方面影響OC之預測因子為「入院形式」、「手術時間」（Adjusted R2=0.461）；但影響LC之預測因子卻為「入院形式」、「合併症指數」（Adjusted R2=0.334）。醫療費用之耗用方面，結果顯示影響OC之預測因子為「平均住院天數」（Adjusted R2=0.769）；而影響LC之重要因子為「平均住院天數」，其它影響變項依重要程度依序為入院形式、年齡、手術時間（Adjusted R2=0.808）。
在成本效益分析方面直接成本部分：將直接成本與間接成本加總後之醫療總成本分別為OC：89598.23元（N=36）、LC：53947.07元（N=223）。
成本效用方面OC與LC分別可提供19.49 QALY、30.91 QALY；以社會學及病患觀點進行成本效益探討，因此除了醫療直接成本外還納入間接成本考量，所得結果顯示相較於OC病患平均住院天數（10.31 ± 4.75天）與復原時間（13.81 ± 8.36天），選擇LC之病患完全復原所需的住院天數與時間明顯下降（平均住院天數：4.05 ± 3.28天、復原時間：6.34 ± 3.05天），由此可知OC比LC具有較高的增加成本效益比，亦即每增加1年品質調整後存活人年（QALY）的成本費用為3121.27元。經過單變量敏感度分析（One-way sensitivity Analysis）發現不同年齡層與性別，是影響成本效益之重要因素。
結論與建議
1、 剖腹式膽囊切除術之病患年齡偏高且男性多於女性；反之，腹腔鏡膽囊切術之病患則是年齡較輕且女性多於男性。
2、 年齡、入院形式、合併症指數、手術時間與平均住院天數皆為影響醫療資源耗用之風險因子，其中以平均住院天數為最重要因素為，其次為入院形式（門診/急診），而影響平均住院天數卻是入院形式。
3、 本研究是以社會學及病患觀點進行成本效益探討，所得結果顯示LC病患比OC病患術後具有較佳的生活品質，且OC比LC病患每增加1年品質調整後存活人年的成本費用為3121.27元，故LC比OC是較具成本效益的。
4、 腹腔鏡膽囊切除術是較具成本效益的，建議政府與醫療提供者應該為病患規劃出完善的醫療資訊與健康照護療程。

Purpose
Cholelithiasis is still the most common abdominal disease among Taiwanese people. The aims of this study were characterized by a systemic and organized research in comparing outcome cost-effectiveness of both laparoscopic and conventional open cholecystectomy through new statistic method.
Methods
This prospective survey started from May 2007 to March 2008, we collected 259 cases which underwent conventional open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) from the sampling hospital. In the study of direct medical cost/expense, we collected 223 cases for LC and 36 cases for OC; in the study of indirect medical cost/expense we collect 96 cases and 36 cases respectively. We compared the therapeutic model, demographic and clinical variables to identify whether they can affect medical expenditure or the scoring system of SF-36; nevertheless, we also used The Bureau of National Health Insurance, (BNHI) data for January 1, 1996 to December 31, 2004 (n=32535 for OC and n=80335 for LC).
Results
The result showed that data collected from sampling hospital had no difference while comparing with the data collected from BNHI. In the characteristics of age between OC and LC. LC patients were younger than OC. After controlling for age, comorbidity, ASA status, operation time, anesthetic time, length of stay and sex, we had significant result (p< 0.05).
We use linear regression to evaluate the association between length of hospital stay and medical expenditures. We found that the predicting factors which affected the length of hospital stay in OC patients were mode of admission and operation time (Adjusted R2=0.461). While the predicting factors which affected the length of hospital stay in LC patients were mode of admission and comorbidity, CCI (Adjusted R2=0.334). In the study of medical expenditures, the results showed the predicting factors which affected the medical expenditures in OC patients was Average Length Of Stay, ALOS (Adjusted R2=0.769), where affecting the LC group were the Average Length Of Stay, ALOS; and the others factors including mode of admission, age and operation time (Adjusted R2=0.808).
In the study of cost effectiveness, the QALY for OC and LC were 19.49 and 30.91 respectively. In comparing the length of hospital stay and recovery time, OC group patient had a longer length of stay and recovery time while comparing with LC group (ALOS =10.31±4.75 days, recovery= 13.81±8.36 days for OC and ALOS=4.05±3.28 days, recovery= 6.34±3.05 days for LC).We concluded that OC had higher cost expenditure than LC, that is, in increasing per QALY cost $3,121.27 and after One-way sensitivity Analysis we found that the most important factors affecting cost effectiveness were age and sex.
Conclusions
1. There is a prevalence of higher proportion of older male patients in the OC group; while in the LC group had a higher proportion of younger female.
2. Age, mode of admission, comorbidity, operation time and ALOS were the risk factors affecting medical expenditures, and especially in the ALOS.
3. This study was based on sociology and patients point of view on discussing cost effectiveness. Our results showed that LC group had a better post operative quality of life (QOL) than that of OC patients. We also found that every increasing QALY would raise the cost of $3,121.27 in each patient. Thus we can conclude that LC had higher cost effectiveness than OC.
4. There is a higher cost effectiveness in the LC group in our study, so we suggest the government and other medical provider planned for a perfect scheme of medical information medical management programs for their patients.

目 錄

中文摘要........................................................................................................................I
Abstract........................................................................................................................III
誌 謝……………………………………………………………………………......Ⅵ
目 錄........................................................................................................................VII
表目錄........................................................................................................................ IX
圖目錄........................................................................................................................ XI
附 錄……………………………………………………………………………....XII
第一章 緒論..................................................................................................................1
第一節 研究背景與動機......................................................................................1
第二節 研究目的..................................................................................................5
第三節 預期貢獻..................................................................................................6
第四節 名詞解釋..................................................................................................8
第五節 各章節之安排…………………………………………………………11
第二章 文獻探討........................................................................................................12
第一節 膽結石流行病學之描述........................................................................12
第二節 膽囊結石手術治療與其它相關治療…………………………………16
第三節 經濟學評估............................................................................................20
第四節 健康相關生活品質與效用....................................................................28
第五節 膽囊結石之醫療利用與成本效益……………………………………34
第三章 研究方法........................................................................................................46
第一節 研究概念架構及研究假說....................................................................46
第二節 研究設計和研究樣本............................................................................49
第三節 研究材料................................................................................................54
第四節 研究變項................................................................................................55
第五節 分析計畫................................................................................................61
第四章 研究結果........................................................................................................66
第一節 樣本醫院與全國健保資料庫之分析結果............................................66
第二節 樣本醫院剖腹式膽囊切除術與腹腔鏡膽囊切除術之成本效益分析.............................................................................................................80
第三節 樣本醫院膽囊切除術成本效益之單變量敏感度分析結果................84
第五章 討論與結論....................................................................................................86
第一節 研究目的和研究假說討論....................................................................86
第二節 結論與建議............................................................................................93
第三節 研究限制及未來研究方向....................................................................96
參考文獻......................................................................................................................98
中文文獻………………………………………………………………………..98
英文文獻…………………………………………………………...………….100













表目錄

表2-3-1 健康照護經濟分析模式..............................................................................23
表2-4-1 SF-36偏好導向運算法則的彙總................................................................33
表2-5-1 膽囊切除手術方式選擇、醫療資源耗用、間接成本之文獻彙整.........39
表2-5-1 膽囊切除手術方式選擇、醫療資源耗用、間接成本之文獻彙整（續）...40
表2-5-2 成本效益相關之文獻彙整.........................................................................43
表2-5-2 成本效益相關之文獻彙整（續）.............................................................44
表3-4-1 樣本醫院風險因子屬性及資料來源.........................................................56
表3-4-2 樣本醫院風險因子屬性及資料來源（續）.............................................57
表3-4-3 樣本醫院醫療資源耗用變項屬性及資料來源.........................................58
表3-4-4 樣本醫院醫療資源耗用與效用變項屬性及資料來源.............................59
表3-4-5 NHIRD 風險因子屬性及資料來源..........................................................60
表3-5-1 流行病學變項與實用性數值間對應的轉移機率.....................................63
表4-1-1 比較兩個資料庫剖腹式膽囊切除術及腹腔鏡式膽囊切除術病患屬性之差異..............................................................................................................................67
表4-1-2 比較樣本醫院剖腹式膽囊切除術及腹腔鏡膽囊切除術病患之屬性結果（一）..........................................................................................................................68
表4-1-3 比較樣本醫院剖腹式膽囊切除術及腹腔鏡膽囊切除術病患之屬性結果（二）...........................................................................................................................69
表4-1-4 影響樣本醫院剖腹式膽囊切除術及腹腔鏡膽囊切除術平均住院天數之
相關因素---單變量變異數分析（一）.......................................................................70
表4-1-5 影響樣本醫院剖腹式膽囊切除術及腹腔鏡膽囊切除術平均住院天數之
相關因素---單變量變異數分析（二）.......................................................................71

表4-1-6 比較樣本醫院剖腹式膽囊切除術及腹腔鏡膽囊切除術平均住院天數之
影響因---複迴歸分析..................................................................................................74
表4-1-7 影響樣本醫院剖腹式膽囊切除術及腹腔鏡膽囊切除術醫療總費用之相關因素---單變量變異數分析（ㄧ）..........................................................................75
表4-1-8 影響樣本醫院剖腹式膽囊切除術及腹腔鏡膽囊切除術醫療總費用之相關因素---單變量變異數分析（二）..........................................................................76
表4-1-9 比較樣本醫院剖腹式膽囊切除術及腹腔鏡膽囊切除術醫療總費用之影響因素---複迴歸分析..................................................................................................79
表4-2-1 兩種手術治療模式之ICUR計算.............................................................81
表4-2-2 比較剖腹式膽囊切除術及腹腔鏡膽囊切除術術後六個月SF-36構面分數
……………………………………………………………………………..82
表4-3-1 兩種手術治療模式在不同年齡ICUR計算之單變量敏感度分析............84
表4-3-2 兩種手術治療模式在不同性別ICUR計算之單變量敏感度分析............85













圖目錄

圖2-1-1 說明並比較可能事件處置之決策樹.........................................................15
圖3-1-1 研究概念架構圖.........................................................................................47
圖3-2-1 樣本醫院資料處理流程圖.........................................................................52
圖3-2-2 全國健保資料庫處理流程圖.....................................................................53
圖3-5-1 國外之決策樹模型.....................................................................................62
圖4-2-1 樣本醫院決策樹模型.................................................................................80
圖4-2-2 兩種治療模式SF-36之構面分數……………..…………………………..83
















附 錄


附錄一 中文版SF-36 健康量表問卷......................................................................110
附錄二 膽結石病患病歷審查資料表......................................................................113
附錄三 成本估算問卷..............................................................................................115
附錄四 合併症ICD-9-CM診斷碼定義表................................................................116

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