- 學位論文
血管通路建立時機與形式對新進入血液透析患者醫療資源耗用之影響
The Influence of the Timing and Type of Vascular Access Creation on the Medical Utilization in Incident Hemodialysis Patients
摘要
研究目的 台灣末期腎臟疾病(End-stage Renal Disease, ESRD)的發生率，以每年8%成長率逐年增高，此問題不僅對國人健康造成威脅，亦因健保透析費用逐年遞增，而對健保局帶來重大的財務負擔。其原因為目前約有90%末期腎臟疾病患者採用血液透析治療。患者接受血液透析前理應先建立血管通路，但大多數卻於初次接受透析住院時完成。因此，影響到患者住院天數和住院醫療費用，進而影響到醫療資源耗用。但目前國內外之文獻資料極少有針對血管通路建立之時機與形式來探討進入透析前後病患之醫療資源耗用情形。故本研究針對新進入透析治療患者，其血管通路建立時機、形式及重建與否，對醫療資源耗用之影響進行探討，以提供醫院管理者及醫療實務工作者之參考。 研究方法 本研究採用回溯性次級資料分析，主要資料來源為台灣南部某醫療體系之醫學中心及其受委託經營之區域教學醫院，2001年1月1日至2003年12月31日三年期間，新進入血液透析治療之末期腎臟病患者治療滿三個月者，並排除轉腹膜透析或腎臟移植者，共得486位之研究樣本，由兩家醫院資訊系統取得血管通路與透析相關之門、住診資料。依血管通路建立時機分成三組，分別為透析前一個月以上建立者、透析前一個月內建立者以及透析後建立者；血管通路形式分成二組，分別為建立動靜脈瘻管(arterial venous fistula, AVF)者與建立人工血管(arterial venous graft, AVG)者。醫療資源耗用情形，包括第一次血管通路建立之住院醫療費用，透析前一年與透析後二年之門診醫療費用、住院醫療費用以及總醫療費用。資料統計分析包括描述性統計分析、卡方檢定、t檢定、變異分析及廻歸分析等。 研究結果 研究結果發現： 血管通路於透析前一個月以上建立者有70位(14.40%)，透析前一個月內建立者有48位(9.88%)，透析後建立者有368位(75.6%)；血管通路建立形式為AVF者有407位(83.7%)，AVG者有79位(16.26%)；血管通路無重建者為420位(86.42%)，有重建者為66位(13.6%)。 新進入血液透析之ESRD患者，第一次建立血管通路住院醫療費用，透析後建立者顯著高於透析前一個月以上建立者與透析前一個月內建立者；門診醫療費用，於進入透析前的一年，透析前一個月以上建立者與透析前一個月內建立者均高於透析後建立者，但進入透析後的一年，則透析後建立者高於其他二組；住院醫療費用與總醫療費用，於進入透析後的二年，透析後建立者平均費用大多數高於透析前建立的二組。 新進入血液透析之ESRD患者，進入透析後建立AVF者之醫療費用比建立AVG者較低；血管通路有重建者不論門診、住院及總醫療費用大多數高於無重建者。 迴歸模式對ESRD患者於透析前後醫療資源耗用，整體費用預測模式中，以年齡、婚姻狀況、原發病因之糖尿病、其他疾病、合併症數目、血管通路建立時機、血管通路形式及血管通路重建與否，為顯著之影響因子。 討論與建議 本研究結果顯示，新進入血液透析之ESRD患者，自透析前12個月至透析後2年之三年總醫療費用，透析後建立血管通路者費用最高，透析前一個月內建立者費用最低；進入透析後建立AVF者醫療費用低於建立AVG者。醫療費用主要預測因子為血管通路建立時機、血管通路形式及血管通路重建與否。 由結果本研究建議病患於進入末期腎臟病時，應在適當時機選擇建立一條成熟的AVF，在心理與身體都做好準備下，順利由門診進入血液透析治療，以期降低醫療資源浪費。另為確保末期腎臟病患者之透析品質，慢性腎臟病照護計畫應設置專責人員，以提供病患血管通路建立之相關衛教與透析期間血管通路之照護。
並列摘要
In Taiwan the incidence rate of the end-stage renal disease (ESRD) increased approximate 8% annually, so did the medical expenditures of dialysis in the recent years, which has become a serious financial burden on the National Health Insurance. Near 90 % of incident ESRD patients chose hemodialysis (HD) as treatment mode, but most of them were hospitalized for initiation of dialysis and concomitantly for surgical construction of vascular access (VA). Such an arrangement resulted in increase of the hospitalized days, medical expenses, and even medical utilizations in the subsequent period. Previous studies indicated that the creation of VA can be well prepared before initiating HD and caused less medical costs. Since there has been lack of evidence-based references in Taiwan, the purpose of this study is to investigate the influences of the timing of creation, type, and reconstruction of VA on medical utilizations in the incident HD patients. Method This study was conducted through retrospective secondary data analysis. Incident ESRD patients who initiated HD from January 1st 2001 to December 31st 2003 at a medical center and a district teaching hospital in southern Taiwan were recruited. All patients survived longer than 3 months after initiating dialysis, and those treated by peritoneal dialysis or kidney transplantation were excluded. Totally 486 patients were enrolled, and the data of outpatient and inpatient services, hospitalization for dialysis and VA associated medical expenses were generated from hospital information systems. According to the timing of VA creation, they were categorized into three groups: Group A with VA creation more than one month before initiation of HD; Group B within one month prior to the first dialysis; and Group C after the initiation of HD. The types of vascular access included arterial venous fistula (AVF) and artificial vascular graft (AVG). The costs of the medical utilizations included the outpatient, inpatient, and total medical expense, respectively, classified by time period as one year before the initiation of HD and two years after the initiation of HD. Statistic data analyses included descriptive analysis, χ2-test, t-test, analysis of variances and regression analysis. Result There were 70 (14.40%), 48 (9.88%), and 368 patients (75.6%) belonged to Group A, B, and C, respectively；407 patients (83.7%) with AVF as VA, and 79 patients (16.26%) with AVG. Among them 420 patients (86.42%) did not have any reconstruction of VA, but 66 patients (13.6%) had at least once of VA reconstruction. The medical expenses of the hospitalization for the first time of VA creation were significantly higher in those patients with their VA created after the initiation of HD (Group C ) than that of patients with VA created before the initiation of HD (Groups A and B). The one-year medical expenses of outpatient service before the initiation of HD were highest in Groups A and B than Group C. It reflected the more attentions paid to patients in Group A before initiation of dialysis. On the contrary the one-year medical expenses of outpatient service after the initiation of HD were highest in Group C than that of Groups A and B, and so did the two-year inpatient and total medical expenses after initiation of HD. After the initiation of HD the medical expenses for VA type of AVF were lower than that of AVG. Patients received VA reconstruction had significantly higher medical expenses than those without reconstruction, no matter what kinds of expenses. By regression analysis the age, marital status, diabetes, other diseases, complication number, timing of VA creation, type of VA, and reconstruction were those factors with significant influence on total medical expenses. Discussion and Suggestion This study demonstrates that the total 3-year medical expenses from 12 months before and 2 year after initiation of dialysis in incident ESRD patients are highest in Group C patients who had their VA created after initiation of dialysis, but lowest in Group B patients had VA creation within one month before initiation of HD. The medical expenses for patients with AVF are lower than that of AVG. The major factors significantly in predicting medical expenses are timing of VA creation, the type of VA, and reconstruction of VA. From the results of this study, we suggest that pre-ESRD patients should receive VA creation before the initiation of HD, it costs less medical expenses. Besides, to ensure a better care quality the CKD care plan should include personnel in charge for care of VA, which may provide adequate education planning for creation of VA at appropriate time and better management of the VA.