建立末期腎臟疾病患者資源耗用關聯群之初探

研究背景與目的：健保局規劃未來末期腎臟疾病患者之醫療費用時，採論人計酬（capitation）或論病例計酬（per case）制度，然而我國目前針對末期腎臟疾病患者之病例組合(Case Mix）之相關研究並不多見，因此本篇研究主要探討末期腎臟疾病病患於透析治療階段之醫療費用風險因子，並建構透析病人於不同原發病因及合併症之下所產生之病例組合(Case Mix)，主要預期達成之研究目的如下：(1)分析末期腎臟疾病患者十大類不同原致病因素之醫療資源耗用情形。(2)建立末期腎臟疾病病人分類系統。(3)建構末期腎臟疾病患者資源耗用關係群。期能有效預測未來末期腎臟疾病患者在透析治療階段之醫療費用，保障透析病患獲得更具連續性、可近性與公平性之照護模式，以提升醫療資源使用效率與透析之照護品質，同時用以做為醫院提供服務及健保局擬定論人計酬支付標準之參考。研究方法： ? 本研究設計之目的在發展末期腎臟疾病患者資源耗用關聯群，亦即以患者的特徵(基本資料、末期腎衰竭原致病因、就醫習慣)為預測變項，資源耗用為目標變項，建立患者的分類系統，以提供未來實施前瞻性支付制度時的參考。本研究中採用橫斷性之研究設計(Retrospective cross-sectional study Design)的方式去收集本研究中研究對象之資料，研究對象之主要資料來源分別為台灣腎臟醫學會90年1月到12月年透析患者之資料檔，及中央健康保險局高屏分局90年之「門診處方及治療明細檔」及「住院醫療費用清單檔」，藉此瞭解末期腎臟病患者在不同致病因素之下之病患分群，並進一步分析各病患群之醫療資源耗用差異狀況，藉以建構資源耗用關係群。研究結果： 1研究顯示殘障復健階段病患有罹患併發症的病患，其醫療資源耗用會有顯著的提升，且在併發症中只要有『其他感染』再合併其他常見之透析病患併發症，其醫療資源耗用會有明顯之增加。 2.以原發病因和併發症為主要分類依據發展之醫療資源耗用模式中，發現原發病因對於醫療資源的耗用程度之影響沒有合併症所產生之影響高，且在五個不同模式中發現，以原發病因和併發症為主要分類依據發展之醫療資源耗用模式中對於門診的醫療資源耗用之解釋力比較高，在住院部分的醫療資源耗用之解釋力比較低。 3.以併發症為主要分類依據發展之醫療資源耗用模式中可以看到合併症中的『其他感染』對於醫療資源耗用的多寡有著決定性的影響，若是病患有發生『其他感染』則其醫療資源之耗用就會急遽升高。 4.影響末期腎臟疾病患者醫療資源耗用的因素包含病患特質的『年齡』、『原發病因』中的『腎臟實質疾病』、『糖尿病』、『遺傳性疾病』、『紅班性狼瘡』，合併症中的『糖尿病』、『心臟疾病』、『腦血管疾病』、『腸胃疾病』、『癌症』、『肝臟疾病』、『其他感染』。 5.根據文獻中提出之病例組合分類系統條件基本原則，本研究中的各個模式中，以門診費用模式1-3、住院費用模式2-3、扣除透析費用之門診模式4-3、扣除透析費用之住院模式5-3的解釋力較高，其驗證前對醫療資源耗用之解釋力分別為11.60%、6.13％、15.02％、7.64％。驗證後之解釋力分別為25.25％、10.26％、19.13％、9.49％。這四組為本研究中門診費用與住院費用資源耗用關聯群中較佳的建構結果。討論與建議：有關單位在檢討末期腎病需長期洗腎病患論人計酬支付制度時，可以先建立一個嚴謹的病患疾病編碼，然後將原發病因、併發症等因素列入費用給付的考慮，並針對變異較小的門診血液透析末期腎臟疾病患者可優先考慮實施論人計酬。若未來將末期腎病需長期洗腎病患的住院費用也納入論人計酬制度支付，必須有配套的風險校正方能避免醫療院所有逆選擇狀況。未來末期腎臟病患實行論人計酬，則『其他感染』這一合併症，更是亟需注意，否則可能會造成醫院收入方面的虧損。此外本研究僅選取病患特質、原發病因、合併症、醫院層級去建立病患之資源耗用的關聯群，但病患分類結果的正確率都不高，顯示除了對於資源的測量需要更精確外，尚須繼續探討影響資源耗用的因素，分析出這些重要變項後，從中選擇適合的變項去建立一個分類正確比率更高的病患組合，未來的研究應該擴大研究範圍，才能提升病例組合分類系統的價值。

關鍵字

血液透析； CHAID ；資源耗用關聯群；末期腎臟疾病

並列摘要

Background and Objectives When the Bureau of National Health Insurance is going to plan the medical expenditure of ESRD in the future, it will pay by capitation or by per case. And the present study of ESRD’s case mix in Taiwan is rare. Our main study purpose is to discuss the factors to the ESRD’s patient dialysis medical expenditure, and develop the ESRD’s patient case mix of different original aetiology and different complications. The expect purposes are: (1) Find the ten different original aetiology ESRD patient’s Medical Resource Utilization. (2) Construct ERSD patient classification system. (3) Develop the ESRD patients’ Groups for Medical Utilization to make patients have more continuously, accessibility and equity medical care. And promote the efficiency and the quality of care to be use for the hospital or the Bureau of National Health Insurance. Methods The purpose of our study is to develop the ESRD patients’ Groups for Medical Utilization and to construct the patients’ classification system for the prospective payment system’s reference. The predict variable is patients’ characteristic (the basic data, ESRD’s original aetiology, the seeking of care), and target variable is resources utilization. This study is a retrospective cross-sectional study. The case resource is Taiwan society of Nephrology’s dialysis patient data set (from Jan to Dec 2001), and the 2001’s Ambulatory care expenditures by visits database and Inpatient expenditures by admissions database of Bureau of National Health Insurance Kao-Ping Branch. Results 1. When rehabilitant patient has complication, the medical resource utilization will significant increase, further more, if the complication includes “other complication” and other dialysis patient’s common complications, the utilization will obviously increase. 2. The original aetiology’s effect in less than complications. And in a few different model construct by original aetiology and complication can explain more in ambulatory care utilization than inpatient care utilization. 3. In the medical resources utilization model constructed by complications, we can see the critical effect of if there is “other complication” or not. If there has “other complication” the medical resources utilization will rapid raise. 4. The factors effect the ERSD’s patient medical resource utilization include patients characteristics: “age”, original aetiology: “『intrinsic renal disease』、『Diabetes Mellitus』、『Hereditary Disease 』、『Systemic lupus erythematosus』”and complication: “『Diabetes Mellitus』、『Heart Disease』、『Cerebral Vascular Disease』、『Gastrointestinal Disease』、『Cancer』、『Liver Disease』、『other infection』” According to the reference’s case mix classification basic rule, our Ambulatory care model 1-3, Inpatient care model 2-3, Ambulatory care without dialysis expenditure model 4-3, Inpatient care without dialysis expenditure model 5-3 have higher explanation. Before the verify are 11.60 %, 6.13 %, 15.02 % and 7.64%. After the verify is 25.25%, 10.26 %, 19.13 % and 9.49％. Discussion and Suggestions When consider the payment of ESRD patient, we must build up an architectonic patient disease code, include original aetiology and complication. To the little variance of ambulatory ESRD dialysis patient, we can priority pay by capitation. If we are going to adapt capitation in inpatient care, must have the additional risk-adjusted project to prevent adverse selection. If the payment system is conduct by capitation, must consider the”other complication.”This will make hospital have more expenditure on ESRD patients. Our study only choose the patient characteristics, original aetiology, complication and hospital level to construct the utilization model, and the classified correct rate is not good, shows there is other real factor effect the utilization. It is supposed to more detail analysis the factor to build a better classification stander in the future.