台灣血液透析診療指引對末期腎臟病人接受不同血管通路處置之影響

The Impact of Taiwanese Clinical Practice Guidelines for Hemodialysis on Types of Treatments of the Creation and Maintenance of Vascular Access in End-Stage Renal Disease Patients

姜鐿晨(Yi-Chen Jiang)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士班/碩士(2015年)

摘要

研究背景與目的
台灣末期腎臟病（ESRD）高發生率與盛行率已成為政府關切之公共衛生議題，尿毒症病患的透析費用儼然成為健保支出一大財務負擔，更成為重要的醫療資源耗用之疾病。因此擁有良好的血管通路才能提供足夠的清除率，減少因透析不足而引發的各種併發症而住院；不僅可減少醫療支出，同時也提升病患的醫療品質，所以病患的血管通路照護非常重要。針對血管通路相關等問題，國內與國外開始注意血液透析病患血管通路等問題，但國內有關血管通路相關研究，尚未有利用健保資料庫進行全國血液透析使用不同血管通路處置之研究。針對台灣透析臨床診療指引已於國內實施多年，目前國內並無關與指引介入之成效評估，且無全國性資料作為研究樣本，故本研究欲以全國性資料分析血管通路阻塞治療準則對末期腎臟病患使用不同血管通路處置之影響，並進一步探討不同治療模式的死亡率和醫療資源使用之情形。

研究方法
本研究採回溯性世代研究，利用次級資料庫進行分析，主要利用全民健康保險資料庫2000年百萬抽樣歸人檔瞭解1997年至2010年台灣地區末期腎臟病(End-Stage Renal Disease, ESRD)病患透析瘻管阻塞後接受其瘻管重建手術(Fistula Reconstruction Operation)或經皮血管成形術治療(Percutaneous Transluminal Angioplasty, PTA)之趨勢變化。根據台灣腎臟醫學會在2004年建置「台灣血液透析診療指引」第一版。將研究樣本分為兩組closed cohort分別為介入前的Cohort I(1997-1999年)為及介入後的Cohort II(2004-2006年)。每位病患於首次透析瘻管建置後追蹤後續四年或直至死亡，觀察其接受透析瘻管重建手術(AVF or AVG)或PTA之變化情形。研究工具採用SPSS20.0，以卡方、獨立樣本T檢定、對數迴歸分析、Cox迴歸分析、複迴歸分析等統計方式進行資料分析及驗證假說。

研究結果
治療趨勢於2004年出現消長之情形，治療方式由傳統外科手術改以經皮血管成形術治療為主。有無接受PTA部分，Cohort II接受PTA機率較Cohort I高3.37倍，Cohort II接受瘻管重建機率顯著較Cohort I低48%，首條瘻管PTA次數部分，Cohort II接受PTA次數顯著比Cohort I多1.48次，首次瘻管類型為AVG接受PTA次數也相較AVF高，四年瘻管重建次數部分，Cohort I及Cohort II無差異，首次瘻管維持天數部分，Cohort I較Cohort II首次瘻管建置平均維持天數較長為(770 vs.694)天，且PTA執行越多次，有效果漸差之情形。在四年期間，Cohort II血管通路維持費用較Cohort I花費較高。在整體存活部份，兩世代組別於死亡率上無顯著差異。

結論與建議
研究發現CohortII不論是接受PTA次數及接受機率、血管通路維持費用皆高於Cohort I，由此可見台灣透析診療指引可能會增加PTA使用，然而CohortII 有許多病患於90天內執行PTA，這可能意味著過度使用PTA，於未來需更進一步研究和臨床建議，以驗證結果。

關鍵字

血液透析 ； 經皮血管成形術治療 ； 瘻管重建手術 ； 動靜脈瘻管維持天數 ； 動靜脈瘻管維持費用

並列摘要

Background and Purpose
The high incidence and prevalence of End Stage Renal disease (ESRD) in Taiwan has been a public issue. The expenditure of dialysis in uremic patient has become one of major burdens in health care insurance finance. Having a sustainable l hemodialysis access can not only provide a sufficient renal clearance but also decrease the complications and resulted in hospitalization. To better provide renal care, the Taiwan renal (Taiwan Society of Nephrology) issued clinical guidelines in 2004. To our best knowledge, no study revealed the changes of hemodialysis access model and associated costs after the introduction of the guideline. The purpose of this study is first to investigate the effect of occlusion treatment guidelines for ESRD on different disposition of vascular access (PTA or Shunt) by using national database. And further to explore the medical utilization and mortality by different access treatment models.

Methods
This study adopted retrospective cohort research design. The National Health Insurance Research Database was primary data source. Patients who t with ESRD (ICD-9-CM code: 585, 586) during 1997 to 2010. Patients were divided into Cohort I (1997- 1999) and Cohort II (2004- 2006) by the time Taiwanese Clinical Practice Guidelines 2004 was introduced. Each patient was followed up for 4 years since hemodialysis access (AVF or AVF) had been created. The access maintained method included access reconstruction surgery (Shunt) or percutaneous transluminal angioplasty (PTA). The SPSS 20.0 was used as statistical software. Chi-square test, T-test, mulitiple regression analysis, multiple linear regression and Cox regression were used to answer the hypotheses.

Results
The trend analysis indicated that the numbers of PTA over passed percutaneous angioplasty in 2004. Patients in Cohort II had 3.37 times (95% CI: 2.48- 4.58) likelihood to receive PTA as compared with cohort I. In terms of frequency of PTA, Cohort II received 1.48 PTAs than that of cohort I did. As compare with first AVF, first AVG had greater numbers of PTA Regarding to Fistula reconstruction frequency, no difference was found between Cohort I and Cohort II. At Fistula maintenance days, Cohort I appeared longer average days than that Cohort II in first Fistula (770 vs.694). With increasing frequency of PTA for the same fistula, the maintenance days were decreasing. For example, 418 day for first PTA, 147 for fifth PTA. Cohort II consumed more medical cost than that Cohort I over four year period. However, no difference in overall mortality between Cohorts I and II.

Conclusions
The study found that Cohort II received t more PTAs, higher vascular access maintenance costs than that of Cohort I., The results implied that the introduction of clinical guidelines might increase use of PTA. Many patients in Cohort II received PTA within 90 days which might implied over use of PTA However, further study with clinical parameters is suggested to validate the results.

並列關鍵字

Hemodialysis ； Percutaneous Transluminal Angioplasty ； Fistula Reconstruction Operation ； Arteriovenous Fistula maintenance fee

參考文獻

英文參考文獻

Allon, M., & Lok, C. E. (2010). Dialysis fistula or graft: the role for randomized clinical trials. Clinical Journal of the American Society of Nephrology, 5(12), 2348-2354.

Ayez, N., Fioole, B., Aarts, R. A., van den Dorpel, M. A., Akkersdijk, G. P., Dinkelman, M. K., & de Smet, A. A. (2011). Secondary interventions in patients with autologous arteriovenous fistulas strongly improve patency rates. Journal of vascular surgery, 54(4), 1095-1099.

Bent, C., Sahni, V., & Matson, M. (2011). The radiological management of the thrombosed arteriovenous dialysis fistula. Clinical radiology, 66(1), 1-12.

Bittl, J. A. (2010). Catheter interventions for hemodialysis fistulas and grafts. JACC: Cardiovascular Interventions, 3(1), 1-11.