門診透析總額制度對末期腎臟病照護品質之影響

The Impact of Outpatient Dialysis Global Budget Cap on Healthcare Quality of End-stage Renal Disease Patients

許雅蓉(Ya-Jung Hsu)

指導教授 ： 張睿詒

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2013年)

https://doi.org/10.6342/NTU.2013.01987

摘要

隨著醫療科技的進步，末期腎臟疾病病人得以藉由腎臟移植、血液透析及腹膜透析等腎臟替代性療法延續生命。近年來台灣地區接受門診透析治療的病人人數逐年提高，大幅增加了醫療支出。為了有效控制醫療費用上漲的壓力，健保局於2003 年1 月實施門診透析總額支付制度，將所有透析門診費用獨立設定總額，支付門診透析費用。本研究利用全民健康保險資料庫選取末期腎臟病病患作實驗組與具慢性腎臟疾病但非末期腎臟病患的對照組，並採用事件研究法中之事前事後對照組比較研究法（輔以廣義估計方程式校正的差異中之差異法），探討2000 年至2005年門診透析總額制度的實施對於末期腎臟疾病病人進行血液透析治療之醫療照護品質(急診、住院醫療利用與照護連續性)影響。

本研究結果如下：
一、門診透析總額實施後，研究對象急診醫療利用無顯著變化。
二、門診透析總額實施後，研究對象住院醫療利用無明顯改變。
三、門診透析總額實施後，研究對象之照護連續性無明顯變化。

綜上所述，本研究提供建議如下：
一、對衛生主管機關之建議：
雖然本研究尚未發現門診透析總額制度對末期腎臟病患者之照護品質有明顯的危害，但由本研究結果顯示，由於門診透析總額制度與其他相關政策之間會產生交互作用，因此可能存在相輔相成之加成作用，亦有可能會產生抵銷政策影響效果的情況，導致政策作用無法明確檢視。因此在多方政策實施的同時，更需注意各政策措施的實施時點安排及其相互效應，詳密規劃長遠策略，避免新制度莽撞介入導致政策成效不彰甚至出現反效果。
二、對後續研究者之建議：
由於本研究之資料限制，建議未來研究在進行分析時，能增加樣本研究期間，長遠觀察門診透析總額之政策介入對末期腎臟病患者照護品質之影響。此外，健保資料庫中資料對照護品質之代表指標有限，若後續研究能再納入其餘指標，不限制於健保資料庫中之指標，如取得末期腎臟病患者之臨床生化指標之資料，應可使照護品質之衡量層面更為周全。

關鍵字

末期腎臟疾病 ； 門診透析 ； 住院醫療利用 ； 急診醫療利用 ； 照護連續性

並列摘要

With the development of medical technology, patients who have end-stage renal disease (ESRD) could prolong their life by renal replacement therapy such as kidney transplant, hemodialysis and peritoneal dialysis. In Taiwan, the Bureau of National Health Insurance facing the pressure of the growth of dialysis medical expenditure, because the number of dialysis patients increase year by year. In order to control the medical expenditure, the Bureau of National Health Insurance implemented outpatient dialysis global budget cap on all dialysis providers in Janunary of 2003. The purpose of this study is to investigate the impact of outpatient dialysis global budget cap on healthcare quality (including emergency room utilization, inpatient service utilization, continuity of care) of ESRD patients from 2000 to 2005. We conduct this study by using a before and after study design with a comparison group.

Based on a difference in difference strategy and the generalized estimating equation approach, this study found the results as follows:
1. After launching the outpatient dialysis global budget cap, the emergency room utilization of ESRD patients does not increase significantly.
2. After launching the outpatient dialysis global budget cap, the inpatient service utilization required by ESRD patients does not have obvious change.
3. After launching the outpatient dialysis global budget cap, the continuity of care on ESRD patients does not have obvious change, either.

In summary, this study is proposed as follows:
1. For healthcare authorities:
Although this study has not found that the policy of outpatient dialysis global budget cap significantly harms healthcare quality of ESRD patients. However, the interaction between the outpatient dialysis global budget policy and other related policies may exist, so there may be complicated effects leading the impact of outpatient dialysis global budget policy can not be examined isolatedly. Therefore, we suggest healthcare authorities to pay more attention to the interactive effects of various policies when a new healthcare policy is prepared to be implemented.
2. For future researchers:
Due to the limitations of this study, it is recommended that future research can increase the sample period to investigate the long-term effect of the outpatient dialysis global budget cap on healthcare quality of ESRD patients. In addition, we suggest future study to develop and use more proper healthcare quality indicators to capture the impact of outpatient dialysis global budget cap on healthcare quality of ESRD patients, accurately.

並列關鍵字

end-stage renal disease ； outpatient dialysis global budget cap ； emergency room utilization ； inpatient service utilization ； continuity of care

參考文獻

台灣腎臟醫學會 (2010)。慢性腎臟病防治手冊。台北：行政院衛生署國民健康局。

吳肖琪、黃麟珠、雷秀麗、吳義勇：從健保透析申報資料定義並分析國內慢性腎衰竭病患透析情形。台灣衛誌 2004；23(5)：419-27。

吳明儒 (2007)。評估腎臟功能的方法。腎臟與透析，19(2): 45-49。

許碩芬、楊雅玲 (2007)。醫療提供者之行為策略－賽局理論之應用。管理學報，24(6): 657-670。

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。