目的：本研究旨在比較傳統式闌尾切除術與腹腔鏡闌尾切除術住院醫療費用的差異，並評估台灣版診斷關聯群實施後對闌尾切除病人住院醫療費用的影響，同時也探討醫療支付制度對醫院申報費用差額的影響性。
方法：本研究採用橫斷性研究設計，透過病歷回顧並收集高雄某區域教學醫院在2008年1月1日至2011年12月31日所有急性闌尾炎病人接受闌尾切除手術的住院醫療費用資料，定義2008年至2009年為論病例計酬施行年度，2010年至2011年為台灣版診斷關聯群施行年度，初步篩選出的1100人，排除掉53筆資料不完整或重複計算個案，實際納入統計分析樣本共計1047人。使用合適的統計方法分析病人臨床資料、住院醫療費用以及醫院申報費用差額。
結果：總體樣本1047人中，男性555人(53.0%)、女性492人(47.0%)，平均年齡為41.4歲（標準差17.3歲），樣本採取的手術方式，共有431人採用腹腔鏡闌尾切除術，而有616人採用傳統式闌尾切除術。腹腔鏡組平均住院天數顯著較傳統式組來的短（腹腔鏡3.37天+/-1.60天 vs 傳統式5.18天+/-3.88天；p<0.001），腹腔鏡手術病人為3.37天(標準差1.60天)、傳統式手術病人為5.18天(標準差3.88天)，兩組間有顯著差異，但兩組病人的術後14天內合併症發生比情形(腹腔鏡4人，0.9% vs 傳統式8人，1.3%)、術後30天內死亡情形(兩組均無個案發生)皆無顯著差異，初步住院醫療費用分析的結果，腹腔鏡組平均35347.3元(標準差8544.7元)、傳統式組平均39042.4元(19716.3元)，有顯著差異。全體樣本的平均申報費用差額為886.5元(標準差15769.6元)，但在不同手術方式間有顯著差異(腹腔鏡組平均3674.1元，標準差5703.6元 vs 傳統式組平均-1064.0元，標準差19772.6元；p<0.001)。多變項迴歸分析在各別控制了可能影響病人住院醫療費用、醫院申報費用差額、申報案件有利潤情形的因素後發現，腹腔鏡手術的住院醫療費用反而要比傳統式手術來的昂貴，平均約高出3574.2元（增加12.1%），直接比較腹腔鏡手術個案相較於傳統式手術個案的住院醫療費用效果量指標，顯示出ES值約在0.23-0.24左右。台灣版診斷關聯群支付制度相較於論病例計酬支付制度並未顯著減少住院醫療費用，但在腹腔鏡組病人的平均住院醫療費用可顯著減少2,987.1元（減少7.6%），而在傳統式組病人平均住院醫療費用可顯著減少2,493.3元（減少4.5%）。醫院申報費用差額以2008年為比較基準，2009年減少177.2元、2010年增加9,082.8元、2011年增加10,880.9元。多變項迴歸分析結果顯示，腹腔鏡手術案件相較於傳統式手術案件，醫院申報費用差額卻是減少了1,142.4元，但並不具顯著意義，而就案件申報費用差額有無利潤的多變項對數迴歸分析模式呈現的結果來看，腹腔鏡手術案件相較於傳統式手術案件，就申報費用差額有利潤的OR值，由調整前OR=0.505下降至調整後OR=0.019。
結論：台灣版診斷關聯群支付制度實施後對於醫療機構的獲利會正向增加醫院的利潤，而選擇腹腔鏡闌尾切除術相較於傳統式闌尾切除術，可能會增加病人住院醫療費用的支出，外科醫師針對急性闌尾炎病人的治療，選擇腹腔鏡或傳統式闌尾切除術，對於醫院申報費用差額並無顯著影響。

Objectives: The aim of this study is to compare the difference of hospitalized costs between open appendectomy (OA) and laparoscopic appendectomy (LA). We will evaluated the influence of hospitalized costs among the patients who had received appendectomy after Tw-DRGs was apply. We were also exploring the impact of medical payment system on declaration of expense differences in our study at the same time.
Methods: This is a cross-sectional study design. The patient’s data was retrospectives collection by chart review from a general teaching hospital in the Kaohsiung city. Between January 1, 2008 and December 31, 2011, 1100 patients were received with appendectomy. We defined the year of case payment from 2008 to 2009, and the Tw-DRGs from 2010 to 2011. After exclude 53 patients who had uncompleted data or repeated cases. Of these, 1047 patients met the inclusion criteria and we analyzed the patient’s clinical data, hospitalized costs, and hospital declaration of expense differences.
Results: All of the 1047 patients, there were 555 male (53.0%) and 492 female (47.0) and with a mean age of 41.4 (17.3) years. Of these, 431 patients had LA and the remaining 616 had OA. The mean length of stay was relatively shorter for LA (3.37+/-1.60 days) compare to OA (5.18+/-3.88 days; p<0.001). But the complication within 14 days (LA 0.9% vs. OA 1.3%) and death within 30 days (no case occur in LA or OA) after surgery was no significant differences between LA and OA. The mean of hospitalized costs was significant lower for LA (35347.3+/-8544.7 dollars) compare to OA (39042.4+/-19716.3 dollars; p<0.001). The total patient’s mean hospital declaration of expense differences was 886.5+/15769.6 dollars, but divided into 2 types of appendectomy were different (LA 3674.1+/- 7503.6 dollars vs. OA -1064.0+/-19772.6 dollars; p<0.001). When we used the multiple regression models that were control other factors which were associated with hospitalized costs, hospital declaration of expense differences, and case profit. The mean hospitalized costs on LA 3574.2 dollars were more expensive than OA (increase 12.1%). The effect size of LA compare to OA was lower degree level (0.23 to 0.24). We founded that years of Tw-DRGs compare to case payment was not significant decreased the patient’s hospitalized costs. But in each type of appendectomy groups, the patient’s hospitalized costs were both decreased (LA was -2987.1 dollars, decreased 7.6% and OA was -2493.3 dollars, decreased 4.5%) after Tw-DRGs system was apply in Taiwan. Based on year of 2008, the hospital declaration of expense differences were decreased 177.2 dollars in year of 2009, and both increased 9082.8 dollars and 10880.9 dollars in year of 2010 and 2011. In the multiple linear regression model, the hospital declaration of expense differences was decreased 1142.4 dollars when LA compare to OA, but no statistically significant (p=0.184). In the multiple logistical regression model, compare the OR of case profit between LA and OA was decrease (crude OR was 0.505 and adjusted OR was 0.019).
Conclusion: In our study shows that the Tw-DRGs system compared with case payment system will be increases the hospital profit when treatment patients who received appendectomy. But we suggested that choice LA compare to OA will increase patient’s hospitalized cost. Surgeons selective LA or OA to treatment acute appendicitis will no significant influences on hospital declaration of expense differences.

論文審定書---------------------------------------------------------------------------- i
誌謝-------------------------------------------------------------------------------------- ii
中文摘要-------------------------------------------------------------------------------- iii
英文摘要-------------------------------------------------------------------------------- v
內文目錄-------------------------------------------------------------------------------- vii
表次-------------------------------------------------------------------------------------- viii
圖次-------------------------------------------------------------------------------------- ix
第一章 緒論-------------------------------------------------------------------------- 1
第一節 研究背景及動機-------------------------------------------------------- 1
第二節 研究目的----------------------------------------------------------------- 5
第二章 文獻探討-------------------------------------------------------------------- 6
第一節 闌尾炎及其治療方法概述-------------------------------------------- 6
第二節 台灣闌尾炎流行概況與闌尾切除術的施行趨勢----------------- 16
第三節 台灣醫療支付制度沿革與台灣版診斷關聯群(Tw-DRGs)------ 22
第四節 新醫療支付制度施行後的潛在影響-------------------------------- 38
第三章 材料與方法----------------------------------------------------------------- 53
第一節 研究設計與研究架構-------------------------------------------------- 53
第二節 研究對象與資料來源-------------------------------------------------- 54
第三節 研究變項操作型定義-------------------------------------------------- 56
第四節 資料處理及統計分析-------------------------------------------------- 61
第四章 研究結果-------------------------------------------------------------------- 63
第一節 基本特徵分析----------------------------------------------------------- 63
第二節 住院醫療費用單因子相關因素分析-------------------------------- 73
第三節 多變量分析-------------------------------------------------------------- 92
第四節 住院醫療費用&申報費用差額相關因子效果量分析------------ 114
第五章 討論與建議----------------------------------------------------------------- 126
第一節 腹腔鏡與傳統闌尾切除術病人的特徵與成本效益分析-------- 126
第二節 Tw-DRGs實施前後對闌尾切除術病人醫療費用的影響------- 130
第三節 Tw-DRGs實施前後對醫院申報費用差額的影響---------------- 134
第四節 結論與建議-------------------------------------------------------------- 139
參考文獻-------------------------------------------------------------------------------- 142
附錄一 本研究病例回顧登錄表------------------------------------------------- 158
附錄二 阮綜合醫院人體試驗委員會 核准同意函------------------------- 160

一、中文部分
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二、英文部分
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