血液透析與腹膜透析病患之長期醫療成本分析

Comparison the Hemodialysis and Peritoneal dialysis patients of long-term medical cost and Utilizations.

林佳燕(Chia-Yen Lin)

指導教授 ： 張睿詒

國立臺灣大學/公共衛生學院/醫療機構管理研究所/碩士(2009年)

https://doi.org/10.6342/NTU.2009.00827

摘要

研究背景與動機：末期腎衰竭(End-stage renal disease, ESRD)人口逐年快速增加以及龐大醫療費用已成為全世界共同的面臨之問題，而台灣在工業發展化及健康保險普及化的過程，也面臨ESRD病患快速成長與醫療支出高漲的問題。根據USRDS公布數據指出，臺灣的ESRD盛行率及發生率長久以來均位居世界前幾名。目前國內ESRD病患主要依賴維持性透析治療，其中又以血液透析(Hemodialysis, HD)為最大宗；約占九成以上。依照健保支付標準計算，每月支出HD病患之透析治療費用高於腹膜透析(Peritoneal dialysis, PD)病患約四成之費用，因此鼓勵提高PD利用率被視為降低透析費用的當前政策，然而轉換透析模式在透析病患之長期治療過程中也不算少見，而醫療費用是否隨模式轉換而受到影響為值得關注之處。再則，含括透析與非透析等等照護透析病患之整體透析費用情況更非以最初選擇之模式即可二分類表示。因此本研究目的在於探討最初選擇模式時，何種模式才能達到最節省醫療費用之目的；並進一步將轉換模式以及存在世代之影響納入考量。研究方法：本研究利用1997至2007年健保申報資料，並選取連續透析四個月以上之各年新增透析病患為研究對象，最後共計48,565人。觀察個案自透析開始三年內之門診透析、非透析門診、急診與住院醫療費用點數，分別以ITT及As-treated兩種研究設計方法釐清研究問題。結果：PD病患除非透析門診費用外，其餘費用支出皆低於血液透析病患；且HD各年總醫療費用點數約為PD之1.2至1.3倍之間；曾轉換模式之病患醫療費用同樣高於最初PD且未轉換者；但總體而言仍低於HD且未曾轉換者。此外，存在不同世代之新增透析病患明顯具有費用上之差異存在。結論：長期接受PD治療病患之總體醫療費用低於HD；然而節省成本之優勢於現今政策之導向下能維持多久值得深思。為避免轉換模式所帶來更高額醫療費用應該降低不適用PD的病患在最初模式選擇時誤選之比例。

關鍵字

血液透析 ； 腹膜透析 ； 醫療成本

並列摘要

Background: The number of end-stage renal disease (ESRD) enrollees and meical expenditure in the world have increased dramatically. According to the USRDS statistics, the prevalence and incidence of Taiwan is the highest in the world. Several studies report that monthly costs of hemodialysis are higher than peritoneal dialysis with out-patient dialysis expenditure and the hemodialysis use among patient with ESRD in Taiwan is above 90%. According to this, the government wanted to reduce the Nation Health Insurance (NHI) expenditure by enhances the peritoneal dialysis (PD) use. The medical expenditure of caring a dialysis patient is not only dialysis-related but also non-dialysis-related medical services. Is it cheaper in total cost of PD then in HD in Taiwan? There has no answer so far. Objectives: To compare utilization of National Health Insurance (NHI) resources in terms of health expenses, either inpatient or outpatient expenses of dialysis-related and non-dialysis-related, between HD and PD patients. Material and Method: The study examines the impact of initial dialysis modality choice and subsequent modality switches on NHI expenditure in a 3-year period from first time dialysis treatment of each patient.The data was from the NHI claims data. This study also analyzed the influence of different variables, such as gender, age group, and disease severity, to two modalities of dialysis. Result: A total of 48565 incident patient from 1998~2004 were included in the analysis. Average annual total medical expenditure for PD is cheaper than HD, and the dialysis-related expenditure was the major. Compared to “HD, no switch” subgroup, “PD, no switch” had a significantly lower expenditure. Both expenditures of “HD, switch at second year” and “HD, switch at third year” had no difference with “HD, no switch” subgroup. In the contrary, the “PD, switch at first year” had a significantly higher expenditure. Conclusion: Initial modality choice and subsequent modality switches had significant implications for out-patient dialysis-related, out-patient non-dialysis-related, emergency medical service, in-patient-related expenditure on ESRD patients care.

並列關鍵字

Hemodialysis ； Peritoneal dialysis ； intial dialysis modality ； modality switch ； medical cost

參考文獻

常逸平、錢慶文 與楊耿如 (2007)。 全民健保腹膜透析比血液透析省錢嗎。 台灣公共衛生雜誌， 26 (5)， 400-408。

陳再晉 (2006)。 我國腎替代療法經濟負擔之回顧與前瞻。 中華民國血液淨化醫學會雜誌， 11 (1)， 17-23。

蔡敦仁 (1994)。 慢性腎衰竭。 當代醫學， 21 (18)， 604-615。

Ashley, C. (2004). Renal failure — options for renal replacement therapy Hospital Pharmacist, 11 (2), 54-61.

Baboolal, K., McEwan, P., Sondhi, S., Spiewanowski, P., Wechowski, J. and Wilson, K. (2008). The cost of renal dialysis in a UK setting - a multicentre study. Nephrology Dialysis Transplantation, 23 (6), 1982-1989.