探討軟式輸尿管鏡碎石手術與經皮腎造瘻腎臟碎石手術之醫療品質與健保資源耗用分析

Investigation and Analysis of Medical Quality and Health Insurance Consumption between Retrograde Intrarenal Surgery and Percutaneous Nephrolithotomy

目的
本研究旨在探討軟式輸尿管鏡碎石手術與經皮腎造瘻腎臟碎石手術的健保醫療資源耗用、手術後併發症及手術後滿意度成效。
方法
運用病歷回溯描述性研究，收集2019年1月至2022年8月，高雄某區域醫院資料庫接受腎臟結石碎石手術之住院病人病歷資料共60位。研究資料分為軟式輸尿管鏡碎石手術（RIRS）與經皮腎造瘻腎臟碎石手術（PNL），RIRS為利用可重複使用的軟式輸尿管鏡組，包含自費項目3-5萬元，至於PNL為健保手術，不含自費項目。我們對這兩種手術方式，進行健保醫療資源耗用、手術後併發症及手術後滿意度的分析。
結果
PNL手術醫療費用高於RIRS手術（p<0.001）；花費手術時間無差異（p=0.44）；RIRS手術在手術中出血量（p=0.002）、手術後Hb下降（p<0.001）低於PNL手術；PNL手術併發症發燒10％、敗血症3.3％，而RIRS則無發燒或敗血症；手術後第一次下床時間、手術後12小時的疼痛程度及平均住院日，RIRS手術都顯著低於PNL手術（p<0.001），醫療照護整體滿意度RIRS手術顯著高於PNL手術（p<0.001），在結石殘餘狀況，RIRS的Stone-free為86％，至於PNL為63％，但因為本研究沒有校正結石之大小、位置及數量，尤其PNL常常用在處理更為複雜的結石，所以難以比較優劣，還需其他研究設計來探討。
結論
RIRS手術自費項目會造成病人的負擔不論有否私人保險，但在平均住院日下降，手術後恢復快，維持病人醫療照護品質、節省健保支出及增加醫院收益等好處，本研究希望藉由這些指標數據，提升病人醫療品質與醫院效益，而達到雙贏的局面。

Purposes
This study is intended to investigate the differences in health insurance and medical resource consumption, postoperative complications, and postoperative satisfaction between retrograde intrarenal surgery and percutaneous nephrolithotomy.
Methods
A retrospective comparative study was conducted on the inpatient medical records of 60 patients who underwent nephrolithotripsy surgery in a Kaohsiung regional hospital between January 2019 and August 2022. The research data were categorized based on the surgical procedure: retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PNL). The RIRS group utilized reusable flexible ureteroscopy and included a patient self-funded component of NT$30,000 to NT$50,000, while PNL is fully covered by health insurance. The study analyzed the consumption of health insurance and medical resources, postoperative complications, and postoperative satisfaction for these two surgical methods.
Results
The medical cost of PNL was higher than that of RIRS (p<0.001). No significant difference was observed in the operation duration (p=0.44). RIRS had lower bleeding volume during surgery (p=0.002) and a lower decrease in Hb post-surgery (p<0.001). PNL surgery complications included fever (10%) and sepsis (3.3%), while RIRS had no postoperative complications. Time taken to get out of bed for the first time post-surgery, 12 hours post-surgical pain score, and average length of stay were significantly lower for RIRS than for PNL (p<0.001). Overall medical care satisfaction with RIRS was significantly higher than for PNL (p<0.001). In addition, RIRS was 86% stone-free, while PNL was 63% stone-free. However, due to the lack of adjustment for stone size, location, and number, further research is required to determine which procedure is superior.
Conclusions
The self-financing aspect of RIRS surgery might pose a burden on patients, regardless of insurance coverage, but it reduces the average length of stay, expedites post-surgery recovery, maintains the quality of care for patients, saves health insurance expenditure, and increases hospital revenue. This study is intended to achieve a win–win situation, by utilizing these findings to enhance patient care quality and healthcare institution efficiency. (