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研究生:朱家駿
研究生(外文):Chia-Chun Chu
論文名稱:針對首次復發之原發型自發性氣胸患者採用視訊輔助胸腔鏡手術的成本效果分析
論文名稱(外文):The Cost-effectiveness Analysis of Video-assisted Thoracoscopic Surgery (VATS) on First Recurrent Primary Spontaneous Pneumothorax
指導教授:馬作鏹馬作鏹引用關係
學位類別:碩士
校院名稱:中國醫藥大學
系所名稱:醫務管理學研究所碩士班
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
論文頁數:92
中文關鍵詞:原發型自發性氣胸視訊輔助胸腔鏡手術成本效果分析
外文關鍵詞:primary spontaneous pneumothoraxvideo-assisted thoracoscopic surgerycost-effectiveness analysis
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原發型自發性氣胸好發於健康年青之瘦高男性。接受傳統治療者致死率雖低,但再復發機率可高達20-60 %,對患者的生活品質甚至生命的威脅甚大。各國針對原發型自發性氣胸的治療建議並不一致;採用不同的治療方法,則存在著復發機率與醫療資源耗用的差異。目前國內醫療體系,對於原發型自發性氣胸首次發病的患者,大多採用胸管引流的方式治療。對於再復發個案,則傾向採用手術治療。而視訊輔助胸腔鏡手術為應用於原發型自發性氣胸的治療方法之一,此法能有效降低住院日數、減少術後復發及降低術後疼痛,但是耗用的醫療成本較高。在健保資源有限的情形下,對於單一疾病有不同治療方法時,選擇具成本效果之醫療服務,實為臨床醫療及醫務管理人員的重要課題。
本論文研究目的,將視訊輔助胸腔鏡手術應用於首次復發之原發型自發性氣胸,相較於僅採用傳統之胸管引流是否具有成本效果,並探討氣胸再復發之危險因素。篩選個案醫院1986年至2007年間,因原發型自發性氣胸首次復發入院治療之病歷資料與健保申報資料,透過配對分組,比較兩組費用與成效有無不同。進一步探討兩組差異之因素。
由結果顯示,施行視訊輔助胸腔鏡手術治療,相較於施行單純胸管引流之個案,可縮減2.3天之住院日數;因而減少之醫療費用共計3,018元。但是,單就手術費及麻醉費之健保給付,需多耗費約45,898元,最終增加之醫療費用(Incremental Cost)約為49,319元。選擇施行視訊輔助胸腔鏡手術治療,所增加之效果(Incremental Effectiveness)減少約21.23 %的復發率。即每減少1 %之復發率,需多耗費2,091元。將日後氣胸再復發所需之治療成本轉換為現值後,所需再支付之醫療費用現值為14,382元。相較於首次氣胸復發時,即以視訊輔助胸腔鏡手術治療,所需增加之費用49,319元為低。影響術後氣胸再復發的因素包括:性別、氣胸病側、吸煙狀態、本次治療方式及氣胸大小。經卡方檢定發現,僅吸煙狀態與本次治療方式達統計之顯著,Chi-Square value分別為4.2777(p=0.0386)及13.6674(p=0.0002)。至於連續變項包括:年齡、身高、體重及身體質量指數,以四分法轉變為類別變項後,再以卡方檢定後發現,僅身體質量指數一項達統計之顯著,Chi-Square value為10.2350(p=0.0167)。
首次復發之原發型自發性氣胸患者,影響其術後再復發的危險因素為有吸菸習慣者,僅採傳統胸管引流者以及身體質量指數偏低者。以視訊輔助胸腔鏡手術治療,相較於以胸管引流方式治療,就研究之結果評估,仍不具成本效果。
Primary spontaneous pneumothorax often occurs on tall and slim healthy young men. Although the morality of patients after receiving the traditional treatment is low, the chances of recurrence can be as high as 20-60%, thus posing a great threat to the quality of life and even the lives of the patients. Suggested treatments of primary spontaneous pneumothorax vary from country to country. The chances of reoccurrence and the consumption of medical resources differ by using different methods of treatment. Under the current health care system of Taiwan, most first time primary spontaneous pneumothorax patients are treated by the method of chest drains while surgery is used for patients with recurrence. The video-assisted thoracoscopic surgery is one of the methods of treatments for primary spontaneous pneumothorax patients. This method is able to effectively reduce the days of hospitalization, the chances of recurrence and postoperative pain of the patients. However, the medical costs of implementation of this method are relatively high. In the circumstances of limited health care resources, it is in fact an important issue for clinical care and medical management personnel to choose the medical service of cost-effectiveness from different treatment methods for a single disease.
This study compared the application of video-assisted thoracoscopic surgery in cases of first recurrent primary spontaneous pneumothorax patients with the traditional chest drains treatment in terms of cost-effectiveness, and discussed the risk factors of the recurrence of pneumothorax. Medical records and National Health Insurance data of patients of first recurrent primary spontaneous pneumothorax treated during 1986-2007 by the case hospital were selected to be compared with the matching group in terms of cost and effectiveness. Factors lead to the differences of the two groups were further discussed.
In comparison to the chest drains cases, the implementation of video-assisted thoracoscopic surgery can reduce hospitalization time by 2.3 days and reduce medical costs in a total of NT$3,018. However, the National Health Insurance payment of operation and anesthesia increases by about NT$45,898, leading to the final incremental cost of about NT$49,319. The incremental effectiveness of the video-assisted thoracoscopic surgery is reducing the recurrence by about 21.23%. Thus, it costs about NT$ 2091 to reduce recurrence rate by 1%. The treatment costs for recurrence in the future can be converted into the present day medical costs of NT$14,382. Compared with the first recurrence of pneumothorax, the incremental costs of NT$49319 for the video-assisted thoracoscopic surgery is relatively lower. Factors affecting the recurrence of pneumothorax include: sex, side of pneumothorax disease, smoking status, method of treatment, and the size of pneumothorax. Chi-Square test found that only smoking status and method of treatment were statistically significant with the Chi-Square values at 4.2777 (p=0.0386) and 13.6674 (p=0.0002) respectively. Meanwhile the continuous variables include: age, height, body weight and body mass index. After converting the variables into categorical variables by quartation, the Chi-Square test indicated that only body mass index was statistically significant with its Chi-Square value at 10.2350 (p=0.0167) .
Regarding primary spontaneous pneumothorax patients of first time recurrence, the affecting risk factors for recurrence include the habit of smoking, using only the traditional chest drains method and the low body mass index. The treatment of video-assisted thoracoscopic surgery in comparison to the chest drains treatment is not cost-effective as the assessment of research results suggests.
第一章 緒論 1
第一節 研究背景 1
第二節 研究動機 5
第三節 研究目的 6
第二章 文獻探討 8
第一節 疾病簡介 8
第一項 氣胸的定義 8
第二項 氣胸的特性與症狀 9
第三項 氣胸的診斷與分類 11
第四項 氣胸的治療與預後 13
第二節 原發型自發性氣胸 16
第三節 視訊輔助胸腔鏡手術 20
第四節 醫療經濟評估方法 33
第五節 結論 42
第三章 研究設計與方法 46
第一節 研究流程 46
第二節 研究架構 48
第三節 研究假設 48
第四節 研究變項 49
第五節 研究對象 51
第六節 測量方法 52
第七節 資料分析 53
第四章 研究結果 54
第一節 描述性統計 54
第二節 胸管引流與視訊輔助胸腔鏡手術之成本差異 65
第三節 成本效果分析 69
第四節 敏感度分析 71
第五章 討論 74
第六章 結論與建議 81
第一節 結論 81
第二節 建議 82
第七章 研究限制 85
參考文獻 86
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