長期血液透析患者血管通路阻塞後接受血管重建手術或經皮血管內成型術治療之比較研究

Comparative study of Long-term hemodialysis patients with vascular access occlusion accept the endovascular revascularization or percutaneous angioplasty treatment

范思善(Sen-Shan Fan)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2012年)

https://doi.org/10.6832/KMU.2012.00056

摘要

研究背景和研究目的:
經皮血管成形術(PTA)與血管重建手術，都是解決長期血液透析病患血管通路阻塞時之選項，但近年來數量之消長已超過正常變化。本研究目的為: (1)、瞭解哪些病人特質或因素影響病人接受不同治療方式: PTA或血管重建手術。(2)、探討不同處置以維持血管通路與其他醫療資源費用之比較。(3)、瞭解哪些病人特質或因素為影響接受血管重建手術或經皮血管成形術之因子。(4)、從健保資料庫分析臺灣血液透析病人接受PTA 或血管重建手術之趨勢六。(5)、從健保資料庫分析臺灣血液透析病人在通
路阻塞後接受PTA 或血管重建手術之醫療費用情形分佈。

研究方法與材料:
本研究取樣採兩部份: (1).以南部某區域教學醫院兩個洗腎中心(Unit1, Unit2)之所有血液透析患者為研究樣本，研究設計採回溯性，收集2010/1/1至2011/12/31之所有資料包括:人口學特質、原病症、合併症及理學檢查;是否接受PTA或血管重建手術及次數，相關醫療資源使用和費用。(2).以國家衛生研究院全國健保資料庫從1996到2005年， 5%血液透析患者所收集資料，包括5年內所有門住診點數耗用，擷取國際疾病分類(第九版)，包括血管通路重建手術(69032B, 69032BC,69032CC )及經皮血管成形術(33074A, 33074B)以SPSS統計軟體進行分析。統計分析包括描述性統計及迴歸分析。

研究結果:

1. Unit 1病人接受不同治療方式，與年齡、身高、體重、BMI、性別、教育程度、種族、宗教信仰、原發病症、主要照顧者皆無統計上顯著差異；Unit 2病人接受不同治療方式，與年齡、身高、BMI、性別、教育程度、種族、宗教信仰、原發病症皆無統計上顯著差異；但與體重、主要照顧者則有顯著相關(P<0.05)。

2. Unit 1 及Unit 2之原造瘻第一次手術選材，自體血管及人工血管使用率並無統計上顯著差異；手術之平均維持血管通路天數無顯著差異 (2298.3 ± 1914.2 vs 1842.7 ± 1827.5, p=0.170)；但較經皮血管成形術使用長久，並有統計上顯著差異 (163.0 ± 142.5, P<0.001)。

3. 以獨立性t檢定 (年齡、身高、體重)及卡方檢定顯示: Unit 1病人有無接受血管重建手術及經皮血管成形術，與年齡、身高、體重、BMI、性別、教育程度、種族、宗教信仰、主要照顧者皆無統計上顯著差異。但與原發病症則有顯著相關(P<0.05)，而Unit 2病人有無接受血管重建手術及經皮血管成形術，與年齡、身高、體重、BMI、性別、教育程度、種族、宗教信仰、主要照顧者皆無統計上顯著差異。但與主要照顧者則有顯著相關(P<0.05)。

4. 只做過OP沒做過PTA的人→在未來五年平均需要做1.48次;只做過PTA沒做過OP的人→在未來五年平均需要做2.63次；只做過OP(2次以上)沒做過PTA的有224人(366人次)→在離下次OP天數平均為328.87天; 只做過PTA(2次以上)沒做過OP的有244人(800人次)→在離下次PTA天數平均為213.66天，此2結果均有統計上之顯著差異。

5. 1996~2005年間， 3909位進入本調查之血液透析病人，在血管通路阻塞後共做了4506次不同之血管處置，在耗材、 藥費及雜項均不計算之情況下，耗用點數佔門診所有費用35.6%; 耗用點數佔住院所有費用3.99%。

結論與建議
1. 血管通路阻塞後，雖可採用不同的治療方式，但以血管重建手術預後較佳，耗用點數亦較少。
2. 由全國健保資料庫可計算出目前之血管維持費/人/年應該為70xx點，這是大量採用PTA之結果。
3. 新治療或新技術理應使醫療成本下降及效果提升，在本研究卻是相反結果，值得深思。

關鍵字

PTA ； 動靜脈瘻管 ； 血管重建手術 ； 血液透析 ； 血管維持費

並列摘要

Background: Both percutaneous transluminal angioplasty (PTA) and vascular reconstrucive surgery can solve the long-term hemodialysis patients with vascular access occlusion, but in recent years, the number of growth and decline of more than normal variation.
Research of purposes:
1. To understand which patient characteristics or factors that affect patients receiving different treatment modalities: PTA or vascular reconstructive surgery
2. To explore a variety of management in order to maintain the vascular access with other medical resources
3. To know which patient characteristics or factors that influence the acceptance of revascularization surgery or percutaneous angioplasty
4. Trend analysis from the nation health insurance (NHI) database of hemodialysis patients receiving PTA or vascular reconstructive surgery
5. Medical resources distribution analysis of hemodialysis patients in Taiwan to accept the of the PTA or vascular reconstructive surgery after vascular access occlusion (from the National Health Insurance database)
Materials and Methods:
This study samples collected in two parts:
1. All hemodialysis patients in a district teaching hospital in two renal dialysis centers (Unit1, Unit2) for the study sample, study design was applied for retrospective collection of 2010/1/1 to 2011/12/31, all the information include: demographic characteristics of the original disease, commobidities, and physical examination; whether to accept the PTA or vascular reconstructive surgery and number of related medical resource use and costs;
1. To use the National Institutes of Health National Health Insurance Database 1996-2005 of 5% of hemodialysis patients, collect data, including all five years of outpatient and inpatient consumption points, to capture the International Classification of Diseases (ninth edition), including vascular access reconstructive surgery (69032B, 69032BC, 69032CC) and vascular percutaneous angioplasty (33074A, 33074B) were analyzed using SPSS statistical software. Statistical analyzes included descriptive statistics and regression analysis.
Results:
(1) Unit 1 patient to receive different treatment modalities, age, height, weight, BMI, and gender, education level, race, religion, primary disease, primary caregivers showed no statistically significant differences in Unit 2 patients receiving different treatment modalities, andage, height, BMI, gender, education level, race, religion, primary disease showed no statistically significant difference. But with the weight, primary caregivers significantly correlated (P <0.05).weight, primary caregivers were significantly related (P <0.05)
(2) The vascular reconstructive surgery selection , Unit 1 and Unit 2, autologous blood vessels and artificial blood vessel utilization rate of no statistically significant difference. The maintenance of vascular access surgery average significant difference (2298.3 ± 1914.2 vs. 1842.7 ± 1827.5, p = 0.170), but lower than Percutaneous angioplasty using the long-term, and a statistically significant difference. (163.0 ± 142.5, p <0.001).
(3) The independence of the t test (age, height, weight) and chi-square test shows: look patients with and without receiving revascularization surgery and forming percutaneous vascular surgery, age, height, weight, BMI, gender, education level, race, religion, primary caregivers showed no statistically significant difference. But with the primary disease significantly correlated (P <0.05), Unit 2 patients with and without for vascular reconstructive surgery and percutaneous angioplasty surgery, age, height, weight, BMI, and gender, education level, race, religion, primary caregivers showed no statistically significant difference. However, with the primary caregiver is significantly related (P <0.05)
(4) a. Only after OP but PTA → need to be done again in the next five years, average 1.48 times; Only after PTA but OP → need to be done again in the next five years, average 2.63 times;
b. Only after OP (2) but PTA in 224 people (366 times) →next OP for an average of 328.87 days; Only after PTA (2) but OP 244 people (800 times ) → next PTA for an average of 213.66 days
Both two of the results are statistically significant differences
(5) From 1996 to 2005, 3909 hemodialysis patients enterred the investigation, who were made a total of 4506 different vascular disposal after vascular access occlusion, other supplies, drugs, and miscellaneous are not calculated consumption points accounted for outpatients costs of 35.6%; for inpatients 3.99%
Conclusions and recommendations
1. A. vascular access obstruction, although the different treatment modalities can be used, but better to revascularization surgery prognosis, and less consumption points
2. By the National Health Insurance database to calculate the current vascular maintenance fee / person / year should be about 72xx points, which is the result of extensive use of the PTA
3. New treatment or new technology should make cost lower and health care costs increase, the opposite is true for the results in this study then worthing pondering

並列關鍵字

PTA ； arteriovenous fistula vascular reconstruction surgery ； hemodialysis ； vascular access maintainance fee ； healthcare expenditure.

參考文獻

Clinical Practice Guidelines and Recommendations Updates (2006). National Kidney Foundation 2006; 1-196. from: http://www.kidney.org/professionals/kdoqi/pdf/12-50-0210_JAG_DCP_Guidelines-VA_Oct06_SectionC_ofC.pdf

NKF-DOQI Clinical practice guidelines for vascular access: Updates (2006). Am J Kidney Dis 148: 188-217. from:

http://www.kidney.org/professionals/kdoqi/guideline_uphd_pd_va/index.htm

Patel, A. A., Tuite, C. M., & Trerotola, S. O. (2004). K/DOQI Guidelines: What Should an Interventionalist Know? Semin Intervent Radiol, 21(2), 119-124.

Polkinghorne, K. R., Lau, K. K., Saunder, A., Atkins, R. C., & Kerr, P. G. (2006). Does monthly native arteriovenous fistula blood-flow surveillance detect significant stenosis--a randomized controlled trial. Nephrol Dial Transplant, 21(9), 2498-2506.