棘突间融合撑开固定术在治疗腰椎退行性疾病中的卫生经济学评价

Hygienic economic evaluation of inter-spinal distraction fusion and fixation for lumbar disc herniation

目的分析棘突间融合撑开固定术与腰椎后路减压椎弓根螺钉固定融合术在治疗腰椎间盘突出伴狭窄症的临床疗效,同时评价2种术式卫生经济学。方法采用回顾性研究方法,选取2015年1月-2019年1月首都医科大学附属北京友谊医院收治的400例腰椎间盘突出伴狭窄症患者,其中男190例,女210例,年龄50~87岁,平均年龄67.97岁。按照手术方式不同,分为使用棘突间融合撑开固定术组(ISDFF组,n=200)和使用腰椎后路减压椎弓跟内固定术组(PLIF组,n=200)。所有患者完成1年术后随访。统计患者年龄、性别、住院总天数、术中出血、手术时间、手术切口长度等基本信息。采用Oswestry功能障碍指数(ODI)、日本矫形外科学会评分(JOA)及视觉模拟评分(VAS)等评价量表对两组患者术前术后症状的缓解情况进行评估。比较总医疗费用、麻醉费用、手术费用及其他费用。采用SPSS 22.0软件进行统计分析。结果ISDFF组患者平均年龄(70.84±8.93)岁,PLIF组(65.10±10.23)岁,差异有统计学意义(t=5.98,P=0.008)。ISDFF组手术时间(59.21±16.22)min,PLIF组手术时间(81.31±17.24)min,差异有统计学意义(t=13.20,P<0.001)。ISDFF组出血量(33.24±11.31)mL,PLIF组出血量(67.30±17.61)mL,差异有统计学意义(t=23.02,P<0.001)。ISDFF组手术切口长度(8.27±2.53)cm,PLIF组手术切口长度(11.15±1.91)cm,差异有统计学意义(t=11.85,P<0.001)。ISDFF组住院总时间为(15.15±0.54)d,PLIF组住院总时间为(19.86±0.97)d,差异有统计学意义(t=4.26,P<0.001)。两组术前ODI、JOA及VAS比较差异无统计学意义(P>0.05)。术后患者症状较术前明显改善,两组组内ODI、JOA及VAS术前与术后比较差异有统计学意义(P<0.05),但是两组术后组间比较,ODI、JOA及VAS差异均无统计学意义(P>0.05)。两组患者中5例出现并发症,其中PLIF组2例浅层感染,2例硬膜撕裂;ISDFF组术后出现1例棘突骨折。ISDFF住院总费57450±8670(元),PLIF住院总费75770±1640(元),差异有统计学意义(t=9.92,P<0.001)。ISDFF手术费1864±38.19(元),PLIF手术费2352±41.39(元),存在统计学差异(t=8.65,P<0.0001)。ISDFF抗菌药物使用费635.5±64.69(元),PLIF抗菌药物使用费1449±307.1(元),存在统计学差异(t=2.59,P<0.001)。ISDFF手术时一次性医用材料费38990±300(元),PLIF手术时一次性医用材料费52110±150(元),差异有统计学意义(t=5.88,P<0.001)。ISDFF组优良率为92%,PLIF组优良率为86%。本研究采用住院总费用作为衡量成本的指标,进一步做成本—效果评价。每获1例优良患者,ISDFF组消耗成本为62450元,PLIF组消耗成本为88100元。结论ISDFF有利于降低国内医保费用,符合国家降低医疗开支的改革方向,是一种值得广泛推广且具有很好的应用前景的手术方式。

Objective To analyze the clinical efficacy of inter-spinal distraction fusion and fixation and Posterior lumbar interbody fusion in the treatment of lumbar disc herniation with stenosis,and to evaluate the health economics of the two surgical methods.Methods Retrospectivly analyzed the clinical data of 400 patients with lumbar disc herniation with stenosis,who were enrolled in Beijing Friendship Hospital,Capital Medical University from Jan.2015 to Jan.2019,including 190 male cases and 210 female cases,aged from 50 to 87 years old,with the average age of 67.97.All patients were divided into two groups according to different surgical methods.Among them,200 patients used interspinous process fusion and distraction fixation(ISDFF group),the other 200 cases used posterior lumbar decompression and pedicle internal fixation(PLIF group).All patients completed the follow-up time of more than 1 year after operation.The basic information of patients′age,gender,total number of days in hospital,intraoperative bleeding,operation time,surgical incision length and other basic information were observed.The Oswestry dysfunction index(ODI),the Japanese Orthopaedic Association Score(JOA)and the visual analog scale(VAS)were used to evaluate the relief of symptoms before and after the two groups of patients.Total medical expenses,anesthesia expenses,surgical expenses and other expenses were analysed.The software of SPSS 20.0 were conducted to analyze data.Results The patients in the ISDFF group were(70.84±8.93)years old,and the PLIF group was(65.10±10.23)years old(t=5.98,P=0.008).The operation time in the ISDFF group was(59.21±16.22)min,and the operation time in the PLIF group was(81.31±17.24)min(t=13.20,P<0.001).The bleeding volume of the ISDFF group was(33.24±11.31)mL,and the bleeding volume of the PLIF group was(67.30±17.61)mL(t=23.02,P<0.001).The length of the surgical incision in the ISDFF group was(8.27±2.53)cm,and the length of the surgical incision in the PLIF group was(11.15±1.91)cm(t=11.848,P<0.001).The total hospitalization time in the ISDFF group was(15.15±0.54)days,and the total hospitalization time in the PLIF group was(19.86±0.97)days(t=4.26,P<0.001).There was no significant difference in preoperative ODI,JOA and VAS between the two groups(P>0.05).Symptoms of postoperative patients were significantly improved compared with preoperative.There were statistical differences in ODI,JOA and VAS between the two groups before and after operation(P<0.05).However,ODI,JOA and VAS were no statistical difference between the two groups after operation.Complications occurred in 5 cases of the two groups of patients,including two cases of superficial infection in the PLIF group,two cases of dural tear in the PLIF group,one case of spinous process fracture in the ISDFF group.The total hospitalization fee for ISDFF was(57450±8670)(yuan),and the total hospitalization fee for PLIF was(75770±1640)(yuan),with statistical differences(t=9.92,P<0.001).The cost of ISDFF operation was 1864±38.19(yuan),and the cost of PLIF operation was 2352±41.39(yuan)(t=8.65,P<0.001).ISDFF antibacterial drug usage fee was 635.5±64.69(yuan),PLIF antibacterial drug usage fee was 1449±307.1(yuan)(t=2.59,P<0.001).The one-time medical material cost during the ISDFF operation was(38990±300)(yuan),and the one-time medical material cost during the PLIF operation was(52110±150)(yuan)(t=5.88,P<0.001).The excellent and good rate of ISDFF group was 92%,and that of PLIF group was 86%.In this study,the total cost of hospitalization was used as an indicator to measure the cost,and further cost-effectiveness evaluation was made.For every good patient,the cost of the ISDFF group was 62450 yuan,and the cost of the PLIF group was 88,100 yuan.Conclusions ISDFF is beneficial to reduce the cost of medical insurance in China,which is in line with the direction of national reform to reduce medical expenditure.It is a surgical method worthy of wide promotion and has a good application prospect.