不同的白内障手術之成本效果分析-以一所區域級教學醫院為例

Abstract

目的： 從醫院的觀點出發，執行傳統白內障囊外摘除手術（ECCE）、超音波晶體乳化手術合併摺疊式軟式人工水晶體植入（FoldSoftPhaco）、超音波晶體乳化手術合併注射式軟式人工水晶體植入（InjSoftPhaco）等三種不同白內障手術方式下的成本效果分析。 方法： 本研究採回溯性縱向研究，以某所區域教學醫院眼科白內障手術患者為分析準則。研究族群：1997年至2005年間門診白內障手術病患，患者平均追蹤時間：28.5+25.7(SD)月（範圍1至106個月），全部由同一位資深主治醫師執行，共845例。 病患特性：第一眼手術或第二眼手術、年齡、 性別、手術眼位、病人術前視力（裸視與矯正視力）、眼球眼軸、眼前房深度、眼壓、角膜散光、白內障嚴重程度分級。眼部合併症：青光眼、視神經病變、角膜混濁、虹彩炎、視網膜黃斑病變、眼外傷手術等病史。 評估方式之選擇：區分四組： A組：第一眼手術無眼部合併症，共389例。 B組：第一眼手術有眼部合併症，共146例。 C組：第二眼手術無眼部合併症，共221例。D組：第二眼手術有眼部合併症，共56例。蒐集不同之白內障手術相關成本與術後結果，採決策樹軟體進行成本效果分析（cost effectiveness analysis；CEA）。 結果： ［1］術後第三月手術屈光度誤差≦1D：不同白內障手術之比較， A組：無統計學上顯著差異P（X2m）=0.076。 B組：有統計學上顯著差異P（X2m）=0.001。 C組：有統計學上顯著差異P（X2m）=0.0045。 D組：無統計學上顯著差異P（X2m）=0.34。 ［2］第三月手術誘發散光≦ 1 D：不同白內障手術，A組與D組有統計學上顯著差異，A組：P（X2m）= 0.003、B組：P（X2m）=0.06、C組：P（X2m）=0.07、D組：P（X2m）= 0.04。 ［3］手術後矯正視力≧0.5：A組：ECCE：88.1% 、FoldSoftPhaco：94.6%、 InjSoftPhaco：92.2 %。無統計學上顯著差異P（X2m）=0.214。 B組：ECCE：63.9 % 、FoldSoftPhaco：87.1 %、 InjSoftPhaco ：66.7 %。有統計學上顯著差異P（X2）=0.013。 C組：ECCE：81.8 % 、FoldSoftPhaco：95.2 %、 InjSoftPhaco：97.6%。有統計學上顯著差異P（X2m）=0.011 。 D組：ECCE：62.5 % 。FoldSoftPhaco：88.9%。 InjSoftPhaco：66.7%。無統計學上顯著差異P（X2m）=0.67。 ［4］手術前後矯正視力改善LogMAR行數（≧一行）： A組：ECCE：96.8% 、FoldSoftPhaco：95.3%、InjSoftPhaco：97.3%。B組：ECCE：96.8% 、FoldSoftPhaco：94.8%、 InjSoftPhaco：90.9%。 C組：ECCE：95.2% 、FoldSoftPhaco：97.5%、 InjSoftPhaco：91.7%。 D組：ECCE：100%、FoldSoftPhaco：92.0%、 InjSoftPhaco：100%。 ［5］採決策樹進行成本效果分析（QALYs gain 依每年3%折現，折現5年，但成本不折現）：以一個月25臺刀計算，平均單項成本（不含回診費用）ECCE為18,098台幣。FoldSoftPhaco為22,965台幣。InjSoftPhaco為 23,395台幣。 成本效果分析： A組：ECCE為34,900台幣/QALY，FoldSoftPhaco為34,171台幣/QALY 、InjSoftPhaco為34,383台幣/QALY。 B組：ECCE為 37,080台幣/QALY，FoldSoftPhaco為36,896台幣/QALY、InjSoftPhaco為44,976台幣/QALY。 C組：ECCE為49,136台幣/QALY，FoldSoftPhaco為45,318台幣/QALY、InjSoftPhaco為40,275台幣/QALY。 D組：ECCE為33,925台幣/QALY，FoldSoftPhaco為41,724台幣/QALY、InjSoftPhaco為35,817台幣/QALY。 結論: 本研究結果以某醫院平均一個月25臺白內障手術計算，三種不同之白內障手術比較，超音波晶體乳化手術因須投入更多之手術相關之儀器設備，因此在平均成本上皆高於傳統白內障手術。但以醫院的觀點，未有其它眼科合併症的A 、 C 兩組，其臨床追蹤效果與成本效果分析，超音波晶體乳化手術皆優於傳統白內障手術。有眼科合併症的B 、 D 兩組，由於病例變異大，未來仍需進一步分析。

Purpose: To compare the cost-effectiveness of three cataract surgical techniques （conventional extracapsular cataract extraction （ECCE）,phacoemulsification with foldable three-piece hydrophobic acrylic soft intra-ocular lens（FoldSoftPhaco）, Phacoemulsification with injection single-piece hydrophobic acrylic soft intra-ocular lens （InjSoftPhaco） in a public regional teaching hospital ,Taiwan,ROC. Setting: The consecutive series comprised 845 eyes , mean age was 72.2± SD 8.9 Y/O（27 through 98 Y/O）, having ambulatory cataract surgery performed by one experienced extracapsular surgeon. The search was restricted to the years 1997 through 2005. Design: Computer-based decision analysis and Economic evaluation modeling of health care. These include cost-effectiveness analysis of cataract surgery in the first and second eyes. Methods: The patient's age, sex, axial length, anterior chamber depth, intraocular pressure, cornea astigmatism, pre-operative visual acuity, nuclear density, operation duration, per-operative complications, post-operative visual acuity and ocular comorbidity were documented. Average follow-up periods were 28.5±25.7(SD) months（1 through 106 months） All case-control comparisons were stratified into four subgroups： Group A：the first eye operation without ocular comorbidity, 389 cases。 Group B：the first eye operation with ocular comorbidity, 146 cases。 Group C：the second eye operation without ocular comorbidity , 221 cases。 Group D：the second eye operation with ocular comorbidity , 56 cases。 Data of the relevant cost and outcomes were collected. The compound data were connected with survival analysis ,time-trade-off （TTO）utility values, decision analysis, and econometric modeling to perform the cost effectiveness analysis（CEA）. Results： ［1］absolute value of the prediction error of Intraocular lens power calculation （3rd month）≦1D： comparison of three surgical techniques, Group A ：no statistical significance P（X2m）=0.076 , Group B：had statistical significance P（X2m）=0.001, Group C：had statistical significance P（X2m）=0.0045 , Group D：no statistical significance P（X2m）=0.34 ［2］absolute value of the surgical induced astigmatism （3rd month）≦1 D： comparison of three surgical techniques , Group A and Group D had statistical significance, Group A：P（X2m）= 0.003 ,Group B：P（X2m）=0.06 , Group C：P（X2m）=0.07 ,Group D：P（X2m）= 0.04 , ［3］ the post-operative visual acuity≧0.5 , comparison of three surgical techniques：Group A：ECCE：88.1% 、FoldSoftPhaco：94.6% , InjSoftPhaco：92.2 % ,no statistical significance P（X2m）=0.214 , Group B：ECCE：63.9 % , FoldSoftPhaco：87.1 %, InjSoftPhaco ：66.7 % , had statistical significance P（X2）=0.013。 Group C：ECCE：81.8 % 、FoldSoftPhaco：95.2 %、 InjSoftPhaco：97.6% ,had statistical significance P（X2m）=0.011 , Group D：ECCE：62.5 % ,FoldSoftPhaco：88.9% , InjSoftPhaco：66.7% ,no statistical significance P（X2m）=0.67 , ［4］the Log MAR line gained ≧one line： comparison of three surgical techniques： Group A：ECCE：96.8% ,FoldSoftPhaco：95.3% , InjSoftPhaco：97.3% ,Group B：ECCE：96.8% , FoldSoftPhaco：94.8% , InjSoftPhaco：90.9% , Group C：ECCE：95.2% , FoldSoftPhaco：97.5% , InjSoftPhaco：91.7% , Group D：ECCE：100%, FoldSoftPhaco：92.0%, InjSoftPhaco：100% , ［5］The average cost of a cataract surgery for the hospital（not include costs of care）ECCE：NT 18,098 ,FoldSoftPhaco NT22,965 ,InjSoftPhaco NT 23,395 , Cost-Effectiveness Ratio（A 3% annual discount rate was used to account for the QALYs gain over 5 years, costs without discount）： Group A： ECCE： NT34,900 $/QALY, FoldSoftPhaco： NT34,171 $ /QALY ,InjSoftPhaco： NT34,383 $ /QALY, Group B：ECCE： NT 37,080 $ /QALY, FoldSoftPhaco： NT36,896 $/QALY,InjSoftPhaco：NT 44,976 $/QALY, Group C：ECCE： NT 49,136$ /QALY, FoldSoftPhaco： NT 45,318 $/QALY,InjSoftPhaco： NT 40,275$ /QALY , Group D： ECCE：NT 33,925$ /QALY, FoldSoftPhaco： NT 41,724$ /QALY,InjSoftPhaco： NT 35,817 $/QALY Conclusions: Phacoemulsification needs additional cost for the machine (depreciation), replenishment of parts, and annual maintenance contract, and so phacoemulsification is more expensive than conventional extracapsular cataract extraction. However phacoemulsification had the advantages of effectiveness such as the lower prediction error of Intraocular lens power calculation , the lower surgical induced astigmatism , the more clear posterior capsule ,and the rapid visual recovery when compared to ECCE in the more than 3 months follow – up. In group A and C groups without ocular comorbidity, InjSoftPhaco and FoldSoftPhaco procedure were shown to be a highly cost-effective option compared with ECCE procedure. The cost-effectiveness of second-eye surgery （group C）diminished from first-eye cataract surgery（group A） , otherwise it needs further related factors analysis of effectiveness and costs in group B and D groups with ocular comorbidity due to wide variation in case-mix.