Association of Provider Volume with Economic Outcome in Free Flap Operations for Oral Cancer Reconstruction
[[abstract]]隨著時代的進步，醫療資訊的揭露成為風潮，病患對醫療服務的選擇性增加。因服務量多寡往往被視為是品質的指標之一，醫院與醫師服務量又成為選擇的重要依據之一，服務量與治療成效之間的關連性便成為重要的研究課題。目前有許多範疇已被研究過，但鮮少於顯微手術中的口腔癌重建之自由皮瓣手術。就自由皮瓣重建手術而言，雖在早期的研究中，曾提及手術的成功率與醫師的經驗有關，然而，以高服務量代表醫師及醫院的經驗，花費或經濟性成效作為成功率的指標，則其中的關連性研究尚無實證的基礎。 本研究的目的即找出醫院與醫師服務量等因素，與該類手術經濟性成效之關聯性。研究對象為口腔癌患者，我們利用全民健保資料庫，找出二零零二年到二零零三年，二年期間接受切除手術及之後的自由皮瓣重建的病患。將執行重建手術的醫院及醫師，按照所執行手術的量分為四等分，並且訂為自變項；手術結果的經濟性成效--住院申報費用作為評估的依變項，其餘醫師、醫院、病患特性、疾病嚴重度等為控制變項；統計上使用變異數分析、以及階層回歸統計等，找出變項之間的相關性，來檢驗是否高手術量的醫院或醫師有較低的申報費用，即較佳的經濟性成效。 研究結果顯示，在變異數分析下，服務量的差異顯示申報費用不同。就迴歸分析結果：在醫師的服務量方面，手術量越高則申報費用越少，即經濟性成效較佳。醫院的服務量方面，費用由服務量漸增而申報費用漸減，到次高量的醫院群中，申報費用最低，到最高量時又略為升高。此略似經濟學上生產與成本的關係，起初生產成本隨產量增加而下降，但超過某一轉折點之後，平均成本反而會增加。此當值得作為主張將手術集中化的政策時的參考。然而，因最高量的醫院只有一間，若可作為特例，則服務量與經濟性成效仍可視為正相關。 Background: With the trend of medical information reporting, volume of performance was regarded as a measure of quality. The verification of volume-outcome association is therefore an important issue. Many fields were explored to check the relationship but scanty of studies was done in the field of microsurgery for oral cancer reconstruction. The success rate of free flap was related to experience of surgeon in previous study. However, choosing economical outcome, the cost, as context of success and provider volumes as measure of experience, the association has not been proved. Purpose: To verify the hypothesis that higher provider volume is associated with better economical outcome in the free flap operations for oral cancer reconstruction. Method: From 2002-2003, two year duration of population-based data were reviewed with the main diagnosis of ICD9 related to oral cancers and treated with free flap operations where 2,325 patients were recruited. The provider volumes, hospitals’ and surgeons’, were divided into quartiles from low, medium, high to very high, and to be independent variables. The claimed fees of admissions, defined as economic outcome, were regarded as dependent variables. Provider characteristics and patients’ characteristics including disease severities in Charlson co-morbidity index score were chosen as controlled variables. We used hierarchical linear regression model to examine the relation of the above factors. Result: The different volume groups, no matter in hospital or in surgeon, do present discrimination in mean cost of admission in the ANOVA analysis. In hierarchical regression analysis, the mean cost of “very high” surgeon volume group was NT＄315,602 and increase gradually to NT＄359,354 at “low” volume group( NT＄70,546 less with p<0.001). The mean cost in “low” volume group of hospital was NT＄360,777 and decreased to NT＄287,997 at “high” volume group( NT＄63,146 less with p<0.001) but raised to NT＄339,274 at the “very high” volume group. Although, a decrease in cost comparison to “low” volume group, there is no consistent relationship that higher volume groups are associated with lower cost. Conclusion: Volumes difference is associated with cost discrimination. The surgeons’ volume of free flap operations in oral cancer reconstruction is associated with better economic outcome. The differences of cost in hospital volume groups showed an interesting relationship resembling the cost-production relation in economics where a raised average cost after certain inflection point, as the cost in “very high” volume group, and worthy of attention in policy of centralization. However, since there is only one hospital in that group, if it is viewed as outlier, a positive volume-outcome relationship still exists.
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