中文摘要
背景目的：
十九世紀末，闌尾切除手術便成為急性闌尾炎手術治療的不二選擇；八十年代初期發展腹腔鏡式闌尾切除手術，歷經二十年的時間，然而，兩者之間的優缺點並沒能分出高下。因此，本研究目的是以2004-2007年中央健康保險局資料庫作回溯分析、從而比較兩者之優缺點及成本效益分析。

方法:
本研究採用國家衛生研究院全民健康保險學術資料庫（National Health Insurance Research Database），投保人口約2000萬之「住院醫療費用清單明細檔」，進行回溯性(Retrospective)次級資料的縱貫研究(Longitudinal Study)分析。針對接受腹腔鏡闌尾切除術與傳統闌尾切除術(ICD-9-CM手術碼分別為47.01以及47.09)之患者為研究對象。研究期間為2004年1月1日至2007年12月31日，共4年。並從中篩選出ICD-9-CM診斷碼編碼左三碼為540(急性闌尾炎)以及ICD-9-CM分別為540.0(急性闌尾炎併有腹膜炎)、540.1(急性闌尾炎併有腹內膿瘍)以及540.9(急性闌尾炎並未提及併有腹膜炎)之個案，排除部份非適合之樣本，剔除條件為（1）急性病床天數超出3個標準差（共1,262件）；（2）性別不詳（共243件），最後本研究分析醫療費用的個案，並針對其盛行率、住院天數以及醫療耗用等各方面進行比較分析。

結果：
本研究分析醫療費用的個案數四個年度腹腔鏡闌尾切除術共有11,118位，傳統闌尾切除術共有47,725位。腹腔鏡闌尾切除術之盛行率由2004年之每十萬人口佔6.97 人，逐年增加至2007年之每十萬人口佔21 人；傳統闌尾切除術之盛行率則由2004年之每十萬人口佔57.5人，逐年遞減 至2007年之每十萬人口佔44.86人。腹腔鏡闌尾切除患者平均住院天數(3.25±1.51天)低於傳統闌尾切除術患者(3.57±1.49天)(p<0.001)。腹腔鏡闌尾切除術總醫療費用有逐年增加之趨勢，而傳統闌尾切除術總醫療費用呈現相反之趨勢，整體而言腹腔鏡闌尾切除術患者總醫療花費仍顯著高於傳統闌尾切除術患者。影響腹腔鏡闌尾切除術與傳統闌尾切除術總醫療費用的相關因素方面，以腹腔鏡闌尾切除術之平均急性住院天數的預測能力最強，年度別次之；而傳統闌尾切除術，以急性住院天數的預測能力最強，醫院地區別次之。

結論：
腹腔鏡闌尾切除術是目前治療闌尾炎發展中的趨勢，腹腔鏡闌尾切除術可明顯減少患者平均住院天數與多項住院醫療費用，但手術費與總醫療費用較高；傳統闌尾切除術有利於減少手術費與總醫療費用支出，本結果對臺灣地區公共衛生與醫療體系而言具有代表性與重要性並可做為分配醫療費用之參考。

Abstract

Background and Objectives:
Since 1894, open appendectomy (OA) has been the treatment of choice for acute appendicitis. In 1981 Semm performed the first laparoscopic appendectomy (LA). More than 2 decades later, the benefits of LA are still controversial. The goal of the present investigation was to compare the effectiveness of LA and OA based on a large administrative (The Bureau of National Health Insurance, BNHI) Research Database. The source of data analyzed was the administrative claims data from the BNHI Research Database.

Methods:
The objective of this retrospective study was based on the ICD-9-CM procedure code of 4701 (Laparoscopic appendectomy, LA) and 4709 (Open appendectomy, OA) respectively from a database of 20 million insurance population, Separate analyses were performed for uncomplicated (ICD-9-CM, 540.9) and complicated (presence of appendiceal perforation or abscess; ICD-9-CM 540.0 and 540.1) appendicitis. Exclusive criteria were: (1) Average length of stay exceeds 3 S.D. (n=1,262). (2) Gender unmentioned (n=243). All these data will analyze in multiple dimensions including length of hospital stay, in-hospital complications, in-hospital mortality, and rate of routine discharge between laparoscopic (LA) and open appendectomy (OA) based on The Bureau of National Health Insurance (BNHI) database.

Results:
We enrolled 11,118 patients underwent LA and 47,725 patients underwent OA during 2004 to 2007. The prevalence of LA increases gradually from 6.97 per 100,000 populations in 2004 to 21 per 100,000 populations in 2007. The prevalence of OA decreases gradually from 57.5 per 100,000 populations in 2004 to 44.86 per 100,000 populations in 2007. Patients underwent LA (3.25±1.51day) have significant lower length of hospital stay than OA (3.57±1.49 day) (p<0.001). We also found the trend that the annual medical expenditure of LA increases gradually but OA decreases gradually. In general, LA spends higher medical expenditure than OA. With respect to medical expenditure, higher length of hospital stay and co-morbidity are associated with more medical expenditure significantly.

Conclusions:
LA is the current developing trend of surgical treatments for appendicitis. LA can reduce length of hospital stay significantly. OA can reduce the medical expenditure in Taiwan. In our opinion, the results represent the native data in Taiwan and are very important for a good administration of public resources distribution.

目錄
第一章 緒論.................................................. 1
第一節 背景和動機..................................... 1
第二節 研究目的....................................... 2
第三節 預期貢獻....................................... 3
第二章 文獻探討............................................... 4
第一節 闌尾炎之致病機轉、合併症、診斷與治療.............. 4
第二節 闌尾切除術流行病學之探討........................ 8
第三節 闌尾切除術之醫療耗用以及相關影響因素............ 11
第三章 研究方法.............................................. 13
第一節 研究架構....................................... 13
第二節 研究假說....................................... 14
第三節 研究設計與研究樣本............................. 15
第四節 研究操作型定義................................. 18
第五節 統計分析方法................................... 20
第四章 研究結果.............................................. 21
第一節 腹腔鏡闌尾切除術與傳統闌尾切除盛行率之描述性統計及其住院醫療費用之描述性統計.................
21
第二節 腹腔鏡闌尾切除術與傳統闌尾切除盛行率之分佈檢定..... 28
第三節 不同人口學特質、醫療機構特性、時間特性對接受腹腔鏡與傳統闌尾切除術之闌尾炎病患在醫療資源耗用之影響......
31
第五章 討論............................................... 45
第一節 研究目的、研究假說及討論........................ 45
第二節 研究限制以及未來研究方向....................... 56
第六章 結論與建議............................................ 58
第一節 研究結論....................................... 58
第二節 研究建議....................................... 59
參考文獻...................................................... 61








圖表目錄
圖一 研究架構............................................... 13
圖二 中央健康保險局全民資料庫處理流程圖..................... 1 16
圖三 腹腔鏡與傳統闌尾切除盛行率之趨勢....................... 22

表一之ㄧ 傳統式闌尾切除與腹腔鏡式闌尾切除優缺點比較..............
7
表一之二 共病症(Comorbidity)加權指數............................. 9
表一之三 疾病嚴重度與 ICD-9-CM之對照表.......................... 10
表二 重要文獻整理............................................ 12
表三之ㄧ 2004至2007年腹腔鏡闌尾切除術與傳統闌尾切除術之個案數.... 17
表三之二 2004至2007年消費者物價指數............................. 17
表四之一 腹腔鏡與傳統闌尾切除術之盛行率與改變率.................. 22
表四之二 腹腔鏡與傳統闌尾切除手術之描述性統計.................... 23
表四之三 腹腔鏡闌尾切除當次住院醫療費用.......................... 25
表四之四 傳統闌尾切除術當次住院醫療費用.......................... 26
表四之五 比較腹腔鏡闌尾切除術(4701)與傳統闌尾切除術(4709)在平均住院天數(ALOS)與各項醫療費用之差異......................
27
表四之六 各變項對腹腔鏡與傳統闌尾切除術盛行率的趨勢分析.......... 29
表四之七 2007年腹腔鏡與傳統闌尾切除術盛行率的各變項比較分析..... 30
表四之八 診察費複迴歸分析之係數值................................ 32
表四之九 病房費複迴歸分析之係數值................................ 34
表四之十 檢查費複迴歸分析之係數值................................ 36
表四之十一 手術費複迴歸分析之係數值................................ 38
表四之十二 麻醉費複迴歸分析之係數值................................ 40
表四之十三 藥費複迴歸分析之係數值.................................. 42
表四之十四 總醫療費用複迴歸分析之係數值............................ 44
表五 健保局預定96年1月增列胸、腹腔鏡診療項目.................. 49

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