末期腎病變病患合併左心室功能不良執行冠狀動脈攝影之成本效果

研究目的：本研究針對末期腎病變血液透析病患接受心臟超音波檢查，依左心室功能變化，接受冠狀動脈攝影，早期診斷有冠心病者，早期接受心導管介入性治療或外科繞道手術，期以降低死亡率，減少猝死、心肌梗塞和心衰竭發生。同時探討醫療資源利用與療效比較。研究方法：從2004年7月1日至2005年12月31日某區域教學醫院血液透析中心末期腎病變病患575人接受心臟超音波檢查，其中177人(30.8%)屬於左心室功能不良。進行回溯性的研究，收集病歷及健保申報電腦檔原始資料，繼續追蹤至2006年12月31日。使用MS Excel 2003及SPSS 12.0統計軟體分析。研究結果： 177位左心室功能不良的末期腎病變病患有89位接受冠狀動脈攝影，其中有78人(87.6%)證實有冠心病，11人為正常冠狀動脈攝影。另外88人未接受冠狀動脈攝影。三組患者之人口學及臨床特徵大致相同。三組的30個月累積死亡率分別為24.4%，27.3%，44.3%。有冠心病者78人共進行113次介入性治療(包括6次CABG)，總醫療費用是NT＄18,178,189元，每人平均住院費用是NT＄233,054元，在追蹤的30個月內有19人死亡，59人存活，每人的存活代價是NT＄308,104。88人未接受冠狀動脈攝影，在追蹤的30個月內共有39人死亡，49人存活。88人中有19人發生急性心肌梗塞而接受緊急介入性治療，共進行27次介入性治療(包括3次CABG)，總醫療費用是NT＄5,747,374元，每人平均住院費用是NT＄302,491元，在追蹤的30個月內有15人死亡，4人存活，每人的存活代價是NT＄1,436,833元，而累積死亡率更高達79%。由Cox proportional hazards model 比較十個變項與死亡率的關聯性發現年齡和糖尿病有統計意義。結論與建議：末期腎病變血液透析病患比一般群眾的死亡率高許多，有一半的死因是心臟血管疾病，主要以冠心病為主。早期診斷有冠心病者，早期接受冠狀動脈介入性治療或外科繞道手術，以降低死亡率，並且減少醫療費用。同時由醫療資源利用情形可以了解提升生活品質，延長壽命，是要付出相當的花費。

關鍵字

末期腎病變；心臟超音波；冠狀動脈攝影；經皮冠狀動脈介入性治療；冠狀動脈繞道手術

並列摘要

OBJECTIVES: End-stage renal disease patients in hemodialysis received echocardiography and coronary angiography to early diagnose coronary artery disease and receiving early percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) to reduce mortality and prevent sudden cardiac death, acute myocardial infarction, congestive heart failure and improving quality of life. We also survey the resources utilization and cost effectiveness analysis. METHODS: We retrospectively studied ESRD patients (n=575) at a regional teaching hospital between July 2004 and December 2005 who received echocardiography and one hundred seventy-seven patients revealed left ventricular dysfunction. Among the left ventricular dysfunction patients eighty-nine received coronary angiography (CAG) and seventy-eight had diagnosis of coronary artery disease (CAD), the other eleven patients revealed normal coronary angiogram. The rest eighty-eight patients rejected coronary angiography initially. Detailed cost data were collected initially and up to December 2006 following the further intervention procedure. Detailed chart records reviewed for collecting clinical related data. RESULTS: Baseline clinical characteristics were similar beween the three groups. Seventy-eight patients with coronary artery disease were proceded 113 PCI procedures (including 6 CABG procedures) in the 30 months follow-up period. The total hospital expenditure was NT$18,178,189 and mean in-hospital cost was NT$233,054. Fifty-nine patients were survived during the follow-up period and the adjusted survival cost up to NT$308,104. Nineteen patients got acute myocardial infaction among the rejected CAG group received emergency PCI or CABG procedures. The total expenditure was NT$5,747,374 and mean in-hospital cost was NT$302,491.Only four patients were survived during the follow-up period and the adjusted survival cost up to NT$1,436,833.Thirdty months cumulative mortality was 24.4%,27.3% and 44.3% respectively among CAD,normal CAG and rejected CAG patients; AMI patients’cumulative mortally up to 78.9%. CONCLUSION: High mortality was noted in ESRD patients, especially post myocardial infarction. Early CAD diagnosis and early treatment may improve survival and reduce hospital cost.