探討非癌疾病末期緩和醫療政策對ESRD病人的醫療利用及臨床療效的影響

研究目的由於台灣末期腎臟病發生率(每百萬人口458)及盛行率(每百萬人口3,138)相當高(USRDS, 2015)，進而影響國家醫療費用支出。依照中央健保署統計，ESRD病人數約占就醫人口數的1%，但是其醫療支出卻占國家醫療總支出的7%。2009年9月1日，中央健保署將八大非癌末期安寧療護納入服務範圍，其中「急性腎衰竭，未明示者」及「慢性腎衰竭及腎衰竭，未明示者」病人均納入給付。本研究的目的即探討非癌疾病末期緩和醫療政策對ESRD病人醫療利用及臨床療效的影響。具體目的包括分析非癌ESRD住院病人選擇安寧緩和醫療的影響因子，以及了解非癌ESRD住院配對病人在死亡前1個月有無接受安寧緩和醫療，在其住院天數及住院醫療費用上的差異。研究方法本研究為回溯性次級資料研究，資料來源包括2009-2012年全民健保資料庫中的全國住院費用清單明細檔DD，和基本資料檔(如承保檔、醫事機構基本資料檔、重病傷病檔等)。研究的樣本為年滿18歲以上，以ICD-9-CM診斷碼前三碼為585、586慢性腎衰竭，且有重大傷病卡(長期透析)，並且排除有任何癌症相關診斷(ICD9CM 140-208或重大傷病卡為惡性腫瘤)慢性腎衰竭ESRD病人。統計分析方法包括：描述性統計分析、獨立樣本t檢定及卡方檢定、羅吉斯回歸分析、複回歸分析、傾向分數配對分析等。研究結果依目的一將資料庫篩選後，共39885位非癌ESRD住院病人，其中有116位(0.29％)在2009年到2012年間接受安寧緩和醫療，平均年齡約為73.37(±12.22)歲，59.48％為男性。年齡、CCI、敗血症、失智症、透析時間，在2個族群中是有顯著差異的。進行multivariate logistic regression後發現，高齡(≧75歲)、CCI得分高、透析時間愈長，以及前一年住院次數多，都是影響ESRD住院病人願意接受安寧緩和醫療的原因。在醫療機構級別的分析中，也發現到機構中有安寧病房的設置，以及就醫機構所在的區域，也是影響非癌ESRD住院病人選擇接受安寧緩和醫療的因素之一。目的二的研究是以1:5的傾向分數配對分析，將非癌ESRD病人分為接受安寧緩和醫療的病例組及未接受安寧緩和醫療的對照組，來探討配對病人在死亡前1個月住院天數、住院醫療費用的差異。研究結果發現死亡前1個月內(含)總住院天數，有接受安寧緩和醫療的非癌ESRD住院病人相較於未接受安寧緩和醫療的非癌ESRD住院病人多出3天；在費用上也有明顯節省，總住院醫療費用(少115,799)。此外，從接受安寧緩和醫療的非癌ESRD病人死亡前31日轉入緩和醫療住院每人醫療費用分佈看來，在死亡前2週，越早接受安寧緩和醫療的非癌ESRD住院病人，其能節省的住院醫療費用愈多。結論與建議依安寧緩和醫療機構或單位設置的目的，是為了能提供末期病人一個全人、全家、全程與全隊的四全照護，並且涵蓋病人身、心、社會、靈，提供舒適護理，陪伴病人及家屬自然的迎接臨終的到來。這項研究結果提供了有關可能使ESRD住院病人接受安寧緩和醫療的因素，以及醫療利用的相關影響。就ESRD病人接受安寧緩和醫療的影響因子研究結果中可以發現，其實具有相關因素的ESRD病人，其面臨死亡已不遠矣。這項研究結果也提供了ESRD病人醫療人員可以透過數據報告或佐證資料，經由團隊對病程審慎的預估，以及與病人、家屬之間良好的溝通，讓病人及家屬參酌如何在生命末期時維護生活品質與存活的價值，使安寧緩和醫療得以及早介入。

關鍵字

末期腎臟疾病；安寧緩和醫療；血液透析；暫緩透析或撤除透析；醫療利用

並列摘要

Background: Taiwan has high incidence and the prevalence of end stage renal disease (ESRD) and also high medical costs due to ESRD. The national health insurance administration (NHIA) reported the numbers of ESRD patients were about 1% of whole medical population, but their medical costs of ESRD were up to 7% of total national expenditure. Since September 1st 2009, hospice/palliative care policy was extended to those patients with “the eight categories of non-cancer end-stage diseases” (e.g., acute kidney injury and chronic kidney failure). The purpose of this study was to evaluate the association between the extension of palliative/hospice care policy for patients with ESRD and their health utilization and medical costs. Two specific objectives were studied in this study: First, this study examined associated factors that may affect ESRD patients decide to receive hospice. Second, this study compared patient health utilization (e.g., length of stay) and medical costs one month before patients died between matched ESRD patients with and without receiving hospice care. Methods: Based on two specific aims, this study conducted a retrospective cross-sectional study design and a retrospective case and control cohort study using population-based National Health Insurance Research Database (NHIRD) from 2009 to 2012. Patients with ESRD were identified based on the ICD-9-CM 585 and 586 and had received regular dialysis therapy. Patients with any diagnoses related to cancer were excluded. Statistical analysis included descriptive, independent t-test, Chi-square test, logistic-regression, multiple linear regression and propensity score method. Results: For the specific objective 1, total 39,885 ESRD patients were identified and 116 patients (0.29%) admitted to hospice ward during study period from 2009 to 2012. The average age of ESRD patients who admitted into hospice ward was about 73.37(±12.22) years old and 59.48% were male. Baseline variables, including patients’ age, Carlson comorbidity index [CCI], ESRD related comorbidities (e.g., sepsis, dementia) and the time of initiating dialysis were statistical significance difference between two groups. After adjusting for covariates, older age (≧75 year-old), more severe according to CCI, longer duration of dialysis, frequent hospitalizations within one year prior to index date, frequent treated hospitals with hospice ward were significantly associated with decisions of receiving hospice care among ESRD patients. As to the specific objective 2, 1:5 propensity score matching was used to match ESRD patients who received (case group) and did not admit hospice ward (control group) one month prior to their death. Total numbers of case and controls were 111 and 555. The results indicated that length of days of hospitalization were 3 days more and lower medical costs ($115,799 NT) for the case group. In addition, the study finding suggested that ESRD patients admitted into hospice ward more than two weeks prior to patients’ death were associated with better cost-saving. Conclusion and recommendations: The purpose of hospice care was to provide affordable terminal care which covered biologic-psychologic-social-spiritual and comfortable nursing care to the end of death for patients and their relatives. This study provided better understanding regarding associated factors that may influence the decision of receiving hospice care among ESRD patients and the health utilization as well as medical costs when compared with ESRD patients with and without receiving hospice care. The study findings can help medical staff to communicate with patients and families earlier about future prognosis and care plan and to improve patients’ quality of life at end of life.