縱貫性探討高雄市不同嚴重度慢性腎臟疾病老年人之醫療資源利用

Longitudinal Study on Medical Utilizations in Elderly with Different Stages of Chronic Kidney Diseases

林明彥(Ming-Yen Lin)

指導教授 ： 邱亨嘉

共同指導教授 ： 黃尚志(Shang-Jyh Hwang)

高雄醫學大學/健康科學院/醫務管理學研究所/碩士(2006年)

https://doi.org/10.6832/KMU.2006.00014

摘要

研究背景與目的：
台灣腎臟醫學會（2003年）資料顯示台灣地區末期腎臟病（ESRD）發生率與盛行率於民國92年分居為世界第一與第二名，其中老年人（≧65歲）ESRD發生率與盛行率更高居世界之冠（United States Renal Data System，USRDS, 2004, 2005）。且在民國92年底台灣地區接受透析之ESRD病患共有36,860人，其中老年人佔45％。進入ESRD早期的慢性腎臟病（CKD），依91年台灣三高調查結果顯示，CKD Stage 3-5比例高達6.43%，其中老年人的盛行率更接近30%。台灣地區老年人的ESRD與CKD之盛行率與醫療支出關係，過去並無相關研究探討，高ESRD發生率與盛行率的高雄市，是否也是CKD之高盛行地區，因而造成老人醫療資源耗用的增加，且隨著CKD病情嚴重程度而增加其耗用。因此，本研究之目的為探討高雄市老年人CKD的疾病嚴重程度與其醫療資源耗用之關係及其影響因子，以提供衛生政策制訂單位做為CKD防治策略之參考。

研究方法：
本研究採用回溯性長期追蹤研究（retrospective longitudinal study），取材1996-1999年接受高雄市老人健康檢查的族群，連結1996-1999年全民健保資料庫之「門診處方及治療明細檔」與「住院醫療費用清單檔」，資料合併後分析老年人CKD在各年度盛行率與醫療資源耗用外，並以1997年之老年人族群（Closed cohort）為本研究之目標族群，經整併後共得7919人。腎絲球過濾率（GFR）係以健檢資料中的血清肌酸酐利用Simplfied MDRD公式計算出目標族群之，並採用美國國家腎臟基金會（NKF）對於CKD之定義，將目標族群分為輕症組（GFR≧60 ml/min/1.73m2）、CKD Stage 3a（GFR 45-59 ml/min/1.73m2）、CKD Stage 3b（GFR 30-44 ml/min/1.73m2）、CKD Stage 4（GFR 16-29 ml/min/1.73m2）、CKD Stage 5( GFR≦15 ml/min/1.73m2）。根據1996年門診A-Code或 ICD-9診斷碼定義其合併症（Co-morbidity）狀況。以卡方檢定、t檢定、變異數分析、對數回歸模式及GEE模式之統計分析樣本自1996至1999年住院風險與醫療資源耗用包括各年度門診次數、每次門診費用、住院風險及長期總醫療費用。

研究結果：
不同觀察年代其CKD的盛行率有所差異，並呈現逐年下降情況；可能為新加入健檢之健康族群所導致。CKD嚴重度越高，年代越往後對醫療資源影響越大。選取目標族群世代當研究對象時，我們發現老年人有43%之不同程度腎功能損傷，且平均GFR隨著年齡逐漸下降；男性有較高罹患CKD的風險。在控制人口學特質、肥胖因子及合併症後，老年人住院風險隨著CKD嚴重程度逐漸上升，校正後的危險對比值，各組別為CKD Stage 3a為1.2，CKD Stage 3b為1.5，CKD Stage 4為2.0，CKD Stage 5為3.2；各組皆達到統計學上顯著差異，且在CKD相關合併症（如高血壓、貧血）分層下此種趨勢依舊存在。最後以GEE分析模式結果發現，CKD Stage 3a總醫療花費比輕症組每年多2,526元，CKD Stage 3b每年多6,600元，CKD Stage 4每年多25,692元，CKD Stage 5每年多153,363元；且達統計顯著差異。

結論：
本研究以實證研究證實台灣老年人每次平均門診費用隨CKD嚴重度（輕症組

關鍵字

慢性腎臟疾病 ； 老年人 ； 住院風險 ； 醫療資源耗用 ； 廣義估計方程式

並列摘要

Objectives
Taiwan has extreme high incidence and prevalence of end stage renal diseases (ESRD) in the world, and both rank top in groups with age 65 to 75 and over 75 years. There were 36,860 ESRD persons who receiving dialysis in year 2003, and the elderly comprised 45% of total dialysis populations. Chronic kidney disease (CKD) was also epidemic in elderly in Taiwan; there were 6.43% in general population and near 30% in elderly respectively, according to Tw3H Survey in year 2002. However, there was no study to explore the associated between ESRD/CKD and medical utilizations in Taiwan. Is the CKD as the main factor responsible for the increase of cost in elderly, and whether the cost is increasing as the increase of severity of CKD stages? The aims of this study were to investigate the medical utilization of the elderly with different stages of chronic kidney diseases and to evaluate those factors associated with increase of medical utilization in Taiwan.

Method and Materials
We conducted a retrospective longitudinal study, analyzing 1996-1999 claim data from 7,919 elderly people with age over 65 years, who took annual physical check up in Kaohsiung City in year 1997. Estimated GFR was calculated by simplified MDRD formula. The CKD group was classified to Reference group (GFR≧60ml/min/1.73m2), CKD Stage 3a (GFR45-59ml/min/1.73m2), CKD Stage 3b (GFR30-44ml/min/1.73m2), CKD Stage 4 (GFR16-29ml/min/1.73m2) and CKD Stage 5 (GFR≦15ml/min/1.73m2). Other covariates including age, sex, obesity and co morbidities were incorporate into further analysis. Multiple logistic regression and General Estimating Equation (GEE) were used for evaluating the risk of hospitalization and longitudinal trend of medical cost, respectively.

Result
A total of subject comprised 63.7% with age over 70 years, 59.7% of male, and 42.9% with late CKD. Among subjects having at least two co-morbidities, the highest one in frequency was hypertension (63.4%) and the follow one was osteoarthritis (60.5%). After control age and sex, the risks of hospitalization were 1.2 for group of Stage 3a, 1.5 for group of Stage 3b, 2.0 for group of Stage 4 and 3.2 for group of Stage 5 compared to Reference group. The risk of hospitalization was raised with CKD severity, and plot was also appeared on co-morbidities associated with CKD such as hypertension and anemia. The annual total cost for groups of Stage 3a, Stage 3b, Stage 4, and Stage 5 were 2,526, 6,600, 25,692 and 153,363 N.T. dollars higher than the Reference group, respectively.

Conclusion
The evidence-based study proved a strongly association between longitudinal medical utilizations and stages of CKD in elderly in Taiwan. The increase of severity of CKD in elderly results in increase of the medical utilizations. As the government face to the impact of aging, how to release the burden of deteriorating health condition in elderly is an important challenge.

並列關鍵字

Chronic Kidney Diseases ； Elderly ； Risk of Hospitalization ； Medical Utilization ； General Estimating Equation (GEE)

參考文獻

中文部分

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2.行政院衛生署 (2004). 全民健康保險醫療統計年報. 台北, 行政院.

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