- 學位論文
糖尿病論質計酬病人加入Early-CKD方案之照護成效評估
The Impact of Early-CKD Program for Patients in Taiwan Diabetes Pay-for-Performance Program
摘要
研究背景與目的：糖尿病合併慢性腎臟病(DKD)是國人進入末期腎臟病(ESRD)以及透析的主因，台灣成年糖尿病人約有三分之一患有初期慢性腎臟病(CKD)，其中三分之二的患者是經由蛋白尿檢驗發現為初期(1-3a期)。初期糖尿病腎病患者相較健康族群有超額死亡率高達5倍、全死因死亡率3倍，預期壽命減少16年，且大多數患者容易忽略自身的腎功能衰退。而臨床經驗顯示若病況進入CKD第3、4期，其腎功能將難以回復正常，僅能延緩惡化速度。並且有研究指出3b至5 期的病人eGFR 惡化速度將遞增。因此，在進入重度慢性腎臟病(CKD第4期)之前，即應給予CKD病患追蹤照護，早期診斷、早期治療，以延緩腎功能下降與腎損傷惡化，並監測醫療品質。我國於2011年起實施「初期慢性腎臟病」論質計酬照護方案(Early-CKD)，期藉由預防腎功能惡化策略，提升CKD病患的照護品質，並減輕健保醫療負擔。且直至2014年收案照護對象當中，糖尿病及Early-CKD照護方案兩者皆加入共計有9 萬餘人。本研究之目的即為探討糖尿病病人在加入Early-CKD接受照護後，對於腎功能惡化最重要的兩項生化指標eGFR與白蛋白尿，以及醫療利用、醫療費用的影響情形，以提供未來照護方案與政策之參考。 研究方法：本研究利用衛生福利部中央健康保險署之健保資料庫進行分析，資料期間為2015年至2017年之申報資料，研究母群體為中央健康保險署實施之「全民健康保險糖尿病醫療給付改善方案」收案名單中，選取腎臟病分期1至3a的對象，以有加入「全民健康保險初期慢性腎臟病醫療給付改善方案」者為介入組，未加入者為對照組，並經傾向分數配對後做比較。本研究採用羅吉斯迴歸和廣義估計式(Generalized estimating equations，GEE) 作重複測量資料分析，並以差異中之差異法(DID)來評估在控制各變項後，照護介入對上述兩項重要生化指標及醫療利用、醫療費用之影響。 研究結果：本研究分析結果顯示介入組在前測2015年至後測2017年這兩年間其eGFR分布情形隨著腎臟病分期的分布改變，但並未達到統計上顯著差異。進一步以多變項分析控制其他變項後，後測時介入組(DID)在eGFR的維持上成效比對照組顯著較佳。白蛋白尿的控制情形亦為介入組成效比對照組顯著較佳。Early-CKD方案介入後，介入組相對於對照組在整體門診次數、腎臟病相關門診次數、總醫療費用、腎臟病相關總醫療費用均有達統計上顯著較高，顯示方案介入增加了常規性腎臟病照護的照護頻率與連續性，包括衛生教育、診療、追蹤檢驗檢查等處置。而是否住院、住院天數與住院醫療費用在方案介入後則無顯著差異，顯示提高門診照護尚未能明顯減少其住院情形，或者需要更長期的觀察與分析。故Early-CKD方案的實施，對於糖尿病腎病變患者的短期間照護成效應獲得肯定。 研究結論和建議：Early-CKD方案介入後，介入組eGFR控制較對照組良好(數值較高)、白蛋白尿控制亦較對照組良好(數值較低)，即Early-CKD方案的實施，對於糖尿病腎病變患者的照護，能延緩其腎臟功能的惡化，維持較好的生理指標，進而延長患者停留初期CKD的病程，延後進入中後期CKD、ESRD。相關研究給予糖尿病合併慢性腎臟病的照護正面的肯定，建議目前的糖尿病方案可研擬與腎臟病方案之間的連結，規劃轉診模式與臨床指引，以利醫療服務提供者遵循。並且可嘗試整合各方案之間同性質的照護管理資源，以提升照護病人的效率以及運用醫療資源之效益。
並列摘要
Background and Objectives: Diabetes with chronic kidney disease (DKD) is the main cause of Taiwan people entering end stage renal disease (ESRD) and dialysis. About one-third of Taiwanese adult diabetics have early chronic kidney disease (early CKD), and two-thirds of them are found to be initial (1-3a phase) by proteinuria test. Patients with early stage diabetic nephropathy have an excess mortality rate of 5 times, a full death rate of 3 times, and a loss of life expectancy of 16 years, and most patients tend to ignore their own decline in renal function. Clinical experience shows that if the disease enters stage 3 and 4 of CKD, its renal function will be difficult to return to normal and only delay the rate of deterioration. Studies have shown that the rate of deterioration of eGFR in patients from stage 3b to stage 5 will increase. Therefore, before entering severe chronic kidney disease (CKD stage 4), CKD patients should be given follow-up care, early diagnosis, and early treatment, to delay the decline of renal function and renal damage, and to monitor medical quality. In 2011, Taiwan implemented the “Early Chronic Kidney Disease” quality care program (Early-CKD), which aims to improve the quality of care for CKD patients and reduce the burden of health care by preventing kidney deterioration. And until 2014, among the recipients of the case, DM-P4P care program along with the Early-CKD care program were added to a total of more than 90,000 people. The purpose of this study was to investigate the effects of two biochemical indicators, eGFR and albuminuria, on the deterioration of renal function, and the medical utilization and medical expenses of patients with diabetes after receiving Early-CKD program. In order to provide future care plans and reference to the policy. Methods: This study uses the health insurance database of the Central Health Insurance Department of the Ministry of Health and Welfare for analysis. The data period is from 2015 to 2017. The research group is the “Health Insurance for the National Health Insurance” plan implemented by the Central Health Insurance Agency. In the case list, subjects with stage 1 to 3a of kidney disease were selected as the intervention group with the “Healthy Benefits for Chronic Kidney Diseases in the Early Stage of National Health Insurance”. Those who did not join were the control group and compared with the trend scores. . In this study, the paired T-test was used to analyze whether the two groups of samples had a significant decrease in eGFR and an increase in albuminuria at the end of the observation period. The generalized estimating equations (GEE) were used for repeated measurement data analysis, and the difference difference method (DID) was used to evaluate the two important biochemicals involved in the control intervention after controlling the variables. Indicators and the impact of medical use and medical expenses. Results: The results of this study showed that the distribution of eGFR in the intervention group changed from the pre-test to the post-test in 2017 and the distribution of renal disease staging, but did not reach statistically significant differences. After further controlling the other variables with multivariate analysis, the post-test intervention group (DID) was significantly better than the control group in the maintenance of eGFR. The control of albuminuria was also significantly better for the interventional composition than the control group. After the intervention of the Early-CKD program, the number of outpatient visits, the number of outpatients related to kidney disease, the total medical expenses, and the total medical expenses related to kidney disease were statistically significantly higher in the intervention group than in the control group, indicating that the intervention of the program increased the routine. The frequency and continuity of care for kidney care, including health education, diagnosis and treatment, follow-up inspection and other treatment. There were no significant differences in hospitalization, hospitalization days, and hospitalization costs after the program intervention, indicating that improving outpatient care has not significantly reduced hospitalization, or requires longer-term observation and analysis. Therefore, the implementation of the Early-CKD program has affirmed the short-term care effect of patients with diabetic nephropathy. Conclusions and Suggestions: After the intervention of Early-CKD, the eGFR control in the intervention group was better than the control group (higher value), and the albuminuria control was better than the control group (lower value), that is, the implementation of the Early-CKD program for patients with diabetic nephropathy. Care can delay the deterioration of kidney function, maintain better physiological indicators, and prolong the duration of CKD in patients with early stay, and delay into CKD and ESRD in the middle and late stages. Related studies have given positive affirmation to the care of patients with diabetes and chronic kidney disease. It is suggested that the current diabetes program can be developed to link with the kidney disease program, planning referral models and clinical guidelines for the benefit of medical service providers. And try to integrate the same nature of care management resources between the programs to improve the efficiency of care for patients and the benefits of using medical resources.