探討慢性腎臟病之醫療資源耗用與醫療療效:長期縱貫性研究

研究目的　　由於民眾生活型態、經濟狀況與人口高齡化的改變，慢性腎臟病（Chronic Kidney Disease；CKD）已經成為近年來罹患人口急速成長的疾病。依據2012 年美國腎臟資料庫（United States Renal Data System；USRDS）的國際比較資料中，台灣2010年之末期腎臟病（ESRD）的發生率，位居世界第二位，僅次於美國。過去有許多關於透析與費用相關的研究，都著重於透析病程或透析前後不同處置因子對透析後醫療資源耗用，指出導致我國末期腎臟病盛行率與發生率高的原因有很多，但並未針對CKD 之醫療支出探討，本研究期望藉由長期縱貫性探討慢性腎臟病之醫療資源耗用與醫療療效情形。研究方法　　本研究資料的來源為利用次級資料(Secondary data)，依據台灣南部某家區域教學醫院，由「門診處方與治療明細檔」、「住院處方與治療明細檔」篩選出2006年1月1日至2010年12月31日，門診診斷2次或住院診斷1次診斷碼有慢性腎臟疾患者。確認初次診斷CKD後180天內有檢驗報告值肌酐(Cr.)及排除年齡小於17歲者，經資料整併後共得1160人。探討其影響的因素來分析醫療資源耗用及醫療療效的差異性。採用SPSS for Windows 19.0版套裝軟體及STATA 10.0版套裝軟體進行資料整理與分析。研究結果　　本研究針對2007年至2009年CKD病患，探討人口學特質、疾病嚴重度、合併症與個管方式及療效，分析影響慢性腎臟病(CKD)患者其醫療資源耗用及療效之重要因子。在趨勢分析：門診醫療費用統計上第二年比第一年有顯著減少(P<0.001)，但是第三年比第二年沒明顯的減少費用(P=0.832)；住院醫療費用統計上第二年比第一年沒明顯減少(P=0.244)，但是第三年比第二年卻有相當顯著的減少費用(P<0.001)；整體上看總醫療費用第二年比第一年及第三年比第二年都有相當顯著的費用減少(P<0.001)。門診就醫次數第二年比第一年有顯著減少就醫次數(P<0.001)及第三年比第二年沒有顯著減少就醫次數(P=0.055)，住院天數第二年比第一年沒明顯減少 (P=0.435)，但是第三年比第二年有相當顯著的減少(P<0.001)。　　醫療資源耗用：1. 住院醫療費用受性別、年齡、有無高血壓及eGFR的影響，在統計上無顯著增加或減少。2. 門診醫療費用會因性別、有無急性心肌梗塞、有無糖尿病、有無高血壓、有無心血管疾病及是否進入透析治療有顯著影響。3. 門診就醫次數會因年齡、有無CKD整體照護、有無急性心肌梗塞、有無高血壓、有無心血管疾病、eGFR有顯著的影響。4. 住院天數會因有無糖尿病、有無高血壓有顯著影響。5. 醫療總費用會因有無高血壓、eGFR高低有顯著影響。　　醫療療效：1. 慢性腎臟病(CKD)患者的存活率分析，死亡病患年紀較老、較低的腎絲球濾過率、較多的重度腎臟疾病、較多糖尿病、高血壓、心血管疾病及慢性阻塞性肺部疾病的病史、且有較多進入血液透析的比例。2. CKD患者有無透析治療分析，透析患者有較低的腎絲球濾過率、較重度的腎臟疾病、較多糖尿病及高血壓病史、且有較多進入慢性腎臟病照護的比例。3. CKD患者是否加入慢性腎臟病整體照護計畫患者的存活率及透析存活率。分析發現CKD照護組病人有較低的腎絲球濾過率、較多的重度腎臟疾病、較多糖尿病、高血壓、高血脂及心血管疾病的病史、且有較多進入血液透析的比例。結論與建議　　從結果呈現出在醫療費用上面，門診醫療費用統計上第二年比第一年有顯著減少，但是第三年比第二年沒明顯的減少費用；住院醫療費用統計上第二年比第一年沒明顯減少，但是第三年比第二年卻有相當顯著的減少費用；整體上看總醫療費用第二年比第一年及第三年比第二年都有相當顯著的費用減少。門診就醫次數第二年比第一年有相當顯著減少，但是第三年比第二年沒有顯著減少，住院天數第二年比第一年沒明顯減少，但是第三年比第二年卻有相當顯著的減少。是否呈現出病患剛開始發病時可能一有症狀就亂投醫，所以在門診使用及住院天數上會比較增加，相對得在醫療費用花費上也會如此。本研究之資料來源為單一區域教學醫院，無法代表全國性資料。但是依據本研究之結果，如果能讓病患瞭解疾病的重要性，就如目前全台灣針對慢性腎臟病患者執行CKD整體照護計劃，期望腎臟病之醫療耗用情形能有更顯著的降低。

關鍵字

慢性腎臟病；醫療資源耗用；廣義估計方程式

並列摘要

Background 　　According to the data of 2012 USRDS, the highest incidence and second prevalence of end-stage renal disease (ESRD), next to America, in the world is Taiwan. Several past studies had been reported that many factors influencing medical cost before or after dialysis. However, little is known about the medical cost in chronic kidney disease (CKD). Accordingly, the present study is to analysis the outpatient and inpatient charge of CKD patients at outpatient department and the outcome of dialysis and mortality. Methods 　　The data source was from secondary data from CKD patients of outpatient and inpatient medical records in one regional hospital of Southern Taiwan from January 1, 2006 to December 31, 2010. After exclusion of age younger than 17 years old, a total of 1160 patients were enrolled. Statistical analysis was performed using SPSS 19.0 for Windows (SPSS Inc. Chicago, USA) and STATA 10. Results 　　Generalized Estimating Equation (GEE) model showed decrease in outpatient medical cost, decrease in inpatient medical cost, decrease in total medical cost, decrease in clinic visits, and decrease in hospitalization days (P < 0.001). Male, a history of acute myocardial infarction, diabetes mellitus, hypertension, cardiovascular disease and receiving dialysis were associated with increased outpatient medical cost. Old age, a history of acute myocardial infarction, hypertension, cardiovascular disease, low estimated glomerular filtration rate (eGFR) and receiving CKD care were associated with increased clinic visits. A history of diabetes and hypertension were associated with increased hospitalization days. Besides, a history of hypertension and low eGFR were associated with increased total medical cost. 　　Patients with older age, lower eGFR, more advanced CKD stages, a higher prevalence of a history of diabetes mellitus, hypertension, cardiovascular disease and chronic obstructive pulmonary disease and receiving hemodialysis showed a lower survival rate. Compared with patients without hemodialysis, patients with hemodialysis were having lower eGFR, more advance CKD stages, a higher prevalence of a history of diabetes mellitus and hypertension and receiving CKD care. Compared patients without CKD care, patients with CKD care were found to have lower eGFR, more advanced CKD stages, a higher prevalence of a history of diabetes mellitus, hypertension, dyslipidemia cardiovascular disease and receiving hemodialysis. Conclusions. 　　Our findings showed a decreasing trend in outpatient medical cost, inpatient medical cost, total medical cost and clinical visits over time. The possible explanation was that patients had doctor shopping habit while initial symptoms happened, and then resulted in the increase in the outpatient doctor seeing times and hospitalization days. The generalization ability of the results is limited because the study subjects were in one regional hospital in southern Taiwan. However, from our study, we hope CKD program intervention could lower the medical cost of CKD and the CKD patient educational program should be strengthened and propagated.