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研究生:洪世明
研究生(外文):Shih-Ming Hung
論文名稱:全民健保對施行亞曼式青光眼引流瓣膜手術適應症規範之探討
論文名稱(外文):An Investigation of Changing Indications of Ahmed Glaucoma Valve Implantation by the National Health Insurance
指導教授:錢慶文錢慶文引用關係
指導教授(外文):Ching-Wen Chien
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:醫務管理研究所
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:81
中文關鍵詞:青光眼亞曼式青光眼引流瓣膜手術適應症
外文關鍵詞:GlaucomaAhmed glaucoma valve implantationIndication
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研究目的
過去健保局為避免「亞曼式青光眼引流瓣膜手術」浮濫使用,規定頑強性青光眼經二次以上傳統青光眼濾孔手術失敗後,甚至加抗癌藥物仍無法控制者,經事前專案申請同意後才可以使用。但這項規定近來放寬修訂為「頑強性青光眼」經「傳統青光眼濾孔手術」失敗一次後,經事前專案申請同意後即可以使用。這樣放寬使用規定是否適當而應該有所依據?本研究先比較一次及二次傳統青光眼濾孔手術失敗率後,再以醫療費用之差異評估健保局對亞曼式青光眼引流瓣膜手術之適應症限制條件放寬之合理性。
研究材料及方法
本研究之資料來源有二:一是2003-2006年全民健保學術研究資料庫,用以計算因頑強性青光眼進行傳統青光眼濾孔手術一次及二次手術失敗率及相關之醫療費用。二為北部某醫學中心於2005年至2007年期間,接受亞曼式青光眼引流瓣膜手術的青光眼患者之眼部資料,共59人病人,60隻眼睛的資料為分析單位。其分別為只接受一次傳統青光眼濾孔手術組(n=30)及接受過二次組(n=30),估計亞曼式青光眼引流瓣膜手術失敗率。控制變項包括年齡、性別、眼別、青光眼診斷種類、術前眼壓、術前使用降眼壓藥物數量、接受傳統青光眼濾孔手術到亞曼式青光眼引流瓣膜手術間隔天數。以Cox regression探討控制其他自變項後,評估各個變項對手術失敗與否的影響。
研究結果
分析全民健保資料庫結果顯示接受一次及二次傳統青光眼濾孔手術後失敗率分別為6.96%及14.07%。若以此進行推估,則所有第一次傳統青光眼濾孔手術失敗個案都接受亞曼式青光眼引流瓣膜手術所產生的費用,會比假設所有第一次傳統青光眼濾孔手術失敗後都先接受第二次傳統青光眼濾孔手術,失敗後才再進行亞曼式青光眼引流瓣膜手術,平均每人節省6,267~15,426元。其次接受第一次傳統青光眼濾孔手術後即直接做亞曼式青光眼引流瓣膜手術,在視力狀況、眼壓減少程度、使用降眼壓藥物減少的數量及手術的成功率等方面皆優於接受第二次傳統青光眼濾孔手術後再接受亞曼式青光眼引流瓣膜手術。只有接受一次傳統青光眼濾孔手術組之亞曼式青光眼引流瓣膜手術失敗率為10.0%,接受二次傳統青光眼濾孔手術組則為13.3%。Cox regression分析顯示,相較於只接受過一次傳統青光眼濾孔手術組,接受過二次傳統青光眼濾孔手術組發生手術失敗的機會較高,其OR值為4.024,但未達統計上之顯著差異(p=0.247)。
討論及建議
針對本研究之結果顯示健保局的新規定是合理的,放寬限制讓「頑強性青光眼」接受一次傳統青光眼濾孔手術失敗後,就進行亞曼式青光眼引流瓣膜手術,可以提升病患照護品質並減少醫療支出。對於昂貴的醫療技術及藥品衛材,健保局都訂定有事前審查的規範,建議醫院管理者必須要求醫師確實遵守相關規定,以避免健保資源的浪費及增加醫院的營運成本。另外建議健保局,依據本研究之結果,不僅對亞曼式青光眼引流瓣膜手術應有類似的研究,對其他類似貴重材料也應有類似的評估,以減少對病人的醫療傷害及健保醫療資源的浪費。

關鍵字:青光眼、亞曼式青光眼引流瓣膜手術、適應症
Purpose
In the past, in order to keep off “the Ahmed glaucoma valve implantation” was the indiscriminate use of floating, the health insurance bureau stipulated that the Ahmed glaucoma valve implantation should only be used after previous failured trabeculectomy with the anti-metabolite drug twice. In addition, it could be only used after the special case application was permitted by the health insurance bureau. But recently, this stipulation was amended to relax, and the revision is as follow: “the Ahmed glaucoma valve implantation” can be used when the “refractory glaucoma” cannot be controlled by one time traditional trabeculectomy. Is there any basis to relax the regulation? In this present study, we plan to compare the failure rate of previous once and twice trabeculectomy to evaluate the reasonability of relaxed indications of the Ahmed glaucoma valve implantation.

Materials and methods
There are two data sources in this study. One is from national health insurance data base in academic research during 2003 to 2006, the computation the refractory glaucoma carries on the traditional trabeculectomy case one time and two times traditional trabeculectomy failure rate and the medical expense. The other is from a medicine center in north, during 2005 to 2007, the Ahmed valve implantation eye of material a glaucoma patient, the altogether 59 patients, 60 eye materials are the analysis units, respectively be only accepts one time traditional trabeculectomy group (n=30) and has accepted two groups (n=30). The dependent variable is the failure rate of Ahmed glaucoma valve implantation. The control variables are age, sex, which eye, type of the glaucoma, the intraocular pressure before the operation, drugs before the operation, duration between the traditional trabeculectomy and the Ahmed glaucoma valve implantation. Analyzed by Cox regression to recognize each variable to surgery defeat or not influence.
Results
The data form the national health insurance data base in academic research showed that, the failure rate of one time and second traditional trabeculectomy respectively are 6.96% and 14.07%. Carries on by this pushes estimates, if all first traditional trabeculectomy defeat cases all to accept the Ahmed glaucoma valve implantation , compared to the supposition all first traditional trabeculectomy defeat cases all first to accept the second traditional trabeculectomy the loser to carry on the Ahmed glaucoma valve implantation again, average each person saves 6,267~15,426 nt. After the first traditional trabeculectomy then to perform the Ahmed glaucoma valve implantation, the vision prognosis, the intraocular pressure control, the use falls the intraocular pressure medicine quantity and the surgery success ratio aspect all surpass accept the second traditional trabeculectomy to perform the Ahmed glaucoma valve implantation again. Only one time traditional trabeculectomy defeat cases accept the Ahmed glaucoma valve implantation group failure rate is 10.0%, the failure rate of two times traditional trabeculectomy group is 13.3%. The analysis of the Cox regression, compares traditional trabeculectomy group and two times traditional trabeculectomy group to have the surgery defeat opportunity to be high, its OR value is 4.024, but has not reached the statistically significant difference (p=0.247).

Discussions and suggestions
Results of this study demonstrate, the new stipulation of the health insurance bureau is reasonable. The relaxation of the limitation makes it possible that the refractory glaucoma would be treated with Ahmed valve implantation after previous failured trabeculectomy once. The new stipulation may not only promote the quality of health care in these patients but also reduce the medical disbursement. Regarding the expensive medical technology, the drugs, and medical material, the health insurance bureau all subscribed anticipations clearly. We suggested the hospital superintendent had to request doctors to follow the related stipulation truly and avoid to waste the medical expense to increase the hospital cost. Moreover, we suggested that the health insurance bureau should study not only the Ahmed glaucoma valve implantation but also other expensive medical materials. In this way, we can not only reduce patient's medical injury but also decrease the waste of the health insurance resources.

Key words: Glaucoma, Ahmed glaucoma valve implantation, Indication
中文摘要..................................................1
英文摘要..................................................4
第一章 緒論
第一節 研究緣起.........................................6
第二節 研究目的.........................................9
第二章 文獻探討
第一節 青光眼疾病的探討................................11
第二節 青光眼醫療資源耗用之探討......................17
第三節 影響亞曼式青光眼引流瓣膜手術成功因素的探討....19
第三章 研究設計與方法
第一節 探討影響亞曼式青光眼引流瓣膜手術成功率的因素....21
第二節 比較頑強性青光眼患者接受一次及二次傳統青光眼濾孔手術資源耗用上的差異.......................................28
第四章 研究結果
第一節 探討影響亞曼式青光眼引流瓣膜手術成功率的因素....30
第二節 比較頑強性青光眼患者接受一次及二次傳統青光眼濾孔手術資源耗用上的差異.......................................46
第五章 研究討論
第一節 研究樣本之討論................................52
第二節 研究假設之討論..................................56
第三節 和健保管理有關之討論............................64
第六章 結論與建議
第一節 結論............................................69
第二節 建議............................................72
第三節 研究限制........................................75
參考文獻.................................................77
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