腹腔鏡子宮切除術與開腹子宮切除術用於治療子宮內膜癌患者之成本效果分析

Abstract

研究目的 本研究以衛生福利部中央健康保險署之觀點，藉由比較腹腔鏡子宮切除術與開腹子宮切除術兩手術相關的臨床結果指標(效果)與醫療資源耗用(成本)是否具有差異，以及進行兩手術模式之成本效果分析。 研究方法 本研究使用衛生福利資料科學中心之全民健康保險研究資料庫的2010年承保抽樣歸人檔，探討2003年至2010年間接受腹腔鏡子宮切除術與開腹子宮切除術之新發子宮內膜癌患者，比較兩組患者的手術當次住院天數、術後30天內發生併發症發生率、出院30天內再入院率、術後一年內復發率、三年整體存活、三年無復發存活、手術當次醫療費用、以及術後一年內醫療費用之差異。本研究以羅吉斯迴歸計算傾向分數(Propensity score) 對腹腔鏡子宮切除術與開腹子宮切除術患者進行1：2配對，臨床結果使用卡方檢定、無母數Wilcoxon rank-sum test、廣義估計方程式(GEE)、Cox比例風險迴歸模型、Kaplan-Meier存活曲線與對數等級Log-Rank test檢定分析兩組手術之差異，費用則利用廣義估計方程式(GEE)比較兩手術於手術當次醫療費用以及術後一年內相關醫療費用之差異。並將臨床結果與費用進行成本效果分析，計算兩手術模式之遞增成本效果比(ICER)，並進行單維敏感度分析以及使用無母數靴環法探討ICER值之分布。 研究結果 本研究經傾向分數配對後，腹腔鏡子宮切除術有59人，開腹子宮切除術則有100人，配對後兩組患者之基本特質無顯著差異。在臨床結果方面，手術當次住院天數，腹腔鏡子宮切除術較開腹子宮切除術短3.09天(p<0.0001)；手術後30日內併發症發生率，腹腔鏡子宮切除術有14人(23.73%)，開腹子宮切除術則有19人(19%)；出院後30日內再入院，腹腔鏡子宮切除術有1人(1.69%)，開腹子宮切除術有4人(4%)；術後一年內復發，腹腔鏡子宮切除術有2人(3.39%)，開腹子宮切除術有7人(7%)，但皆不具統計上顯著差異，此外，兩手術在三年整體存活與三年無復發存活皆相似。在相關醫療費用方面，手術當次醫療費用，腹腔鏡子宮切除術患者較開腹子宮切除術患者節省平均7,893元，術後一年內醫療費用可節省平均10,442元，其中與子宮內膜癌相關醫療費用則開腹子宮切除術患者節省7,916元，但皆未達到統計上顯著差異。而在成本效果分析方面，腹腔鏡子宮切除術相較於開腹子宮切除術為較具優勢之治療模式。 結論 整體而言，以衛生福利部中央健康保險署的觀點，患者接受腹腔鏡子宮切除術相較於開腹子宮切除術的臨床結果較佳，且醫療費用花費較低。因此，由本研究可得知，腹腔鏡子宮切除術相較開腹子宮切除術用於治療子宮內膜癌患者上為較具優勢之治療模式。

Aim: This study aimed to compare the difference in clinical outcomes (effectiveness), medical expenditures (cost) between laparoscopic and abdominal hysterectomy and to estimate the cost-effectiveness between these two surgeries from the perspective of National Health Insurance Administration in Taiwan. Methods: The study used the 2010 Longitudinal Health Insurance Database (LHID2010) of National Health Insurance Research Database (NHIRD). We selected only newly diagnosed endometrial cancer patients who received a laparoscopic or abdominal hysterectomy from 2003 to 2010 and compared the length of stay, the rateof complications cases within 30 days after surgery, the rate ofreadmission cases within 30 days after discharge, the rate of recurrence cases within 1 year after surgery, 3-year overall survival, 3-year progression free survival, and related medical expenditure and medical expenditure within 1 year after surgery. We conducted logistic regression to calculate propensity score for 1:2 matching (PSM) between laparoscopic and abdominal hysterectomy. Chi-square test, Wilcoxon rank-sum test, generalized estimating equation (GEE), Cox proportional hazards regression, Kaplan-Meier survival curve and Log-rank test to analysis the difference of clinical outcomes and medical expenditure between two surgical approaches. Finally, this study used clinical outcomes and medical expenditure to estimate the incremental cost-effectiveness ratio (ICER) in cost-effectiveness analysis and also conducted one-way sensitivity and non-parametric bootstrap to discuss the distribution of ICER. Results: There were 59 patients in laparoscopic hysterectomy and 100 patients in abdominal hysterectomy after matching and no differences were found in baseline characteristics of patients between two groups. In clinical outcomes, the lengths of stay were significantly 3.09 days shorter for laparoscopic surgery in comparison with abdominal surgery (p<0.0001). In laparoscopy versus laparotomy, the number of complications cases within 30 days after surgery were 14 (23.73%) and 19 (19%), the number of readmission cases within 30 days after discharge were 1 (1.69%) and 4 (4%), and the number of recurrence cases within 1 year after surgery were 2 (3.39%) and 7 (7%), respectively. However, the differences were not significant for these two groups. Besides, 3-year overall survival and 3-year progression free survival are similar for the two groups. In terms of medical expenditure, although laparoscopy patients saved an average of NT$7,893 for surgical medical expenditure, NT$10,442 for medical expenditure within one year and NT$ 7,916 for endometrial cancer related medical expenses in comparison with abdominal surgery but there were no significant differences for two groups. In cost-effectiveness analysis, compared to abdominal hysterectomy, laparoscopic hysterectomy was the dominant treatment option. Conclusions: On the whole, laparoscopic hysterectomy had better clinical outcomes and also lower medical expenditure comparing to abdominal hysterectomy. Therefore, laparoscopic hysterectomy was the dominant treatment option for endometrial cancer patients from the perspective of National Health Insurance Administration.