探討末期腎臟病病人延遲血液透析之相關因素及資源耗用

中文摘要研究目的: 本研究的目的在探討末期腎臟病(End Stage Renal Disease, ESRD)病人延遲進入血液透析治療病人特性、臨床特性、機構特性之長期趨勢，進而評估影響其醫療資源耗用與醫療療效之相關因素。研究方法: 本研究採回溯性縱貫性研究，利用1997年至2012年之全民健保資料庫、醫療機構檔及死亡檔、重大傷病醫療資源使用等次級資料庫分析，探討主要診斷ICD-9代碼(585, 586等)延遲接受透析治療慢性腎病之病人，研究期間共15年。採描述性統計及推論性統計(卡方檢定、獨立樣本T檢定、複迴歸分析、Kaplan - Meier 存活分析、 Cox Analysis)，探討末期腎臟病人延遲透析之長期趨勢，並評估人口學因子、共病症因子、醫院層級、時間特性對於其醫療資源耗用及醫療療效之影響。研究結果: 1. 描述性統計結果延遲血液透析病人特性:1997-2012年期間以T2(2002-2007)年所佔人口數為410人最多；女性多於男性，年齡以45-64歲病人為主，共病症指標(CCI)以2分的病人居多；其中以醫學中心病人居多。 2. ESRD病人延遲透析於醫療資源耗用方面研究結果比較延遲透析與非延遲透析醫療之療總費用及門診就醫次數，延遲透析病人在醫療總費用上以第一年為基準逐年比較，延遲透析病人在第二年至第三年均有明顯增加；相對於非延遲透析之病人在醫療總費用上第二年未明顯增加；第三年醫療費用明顯增加P﹤.001，第四、五年醫療費用支出減少推論應該是病人病情穩定之故。分析延遲進入透析門診就醫次數結果，延遲透析病人在第二年門診就醫次數略明顯增加，第四年及第五年門診就醫次數明顯減少。157.8±0.11次(P=0.002)、157.7±0.4次(P﹤0.001)；而非延遲透析之病人在門診就醫次數並未隨著透析時間有減少，但均不顯著。 3. 末期腎臟病病人延遲進入長期透析治療之人口學特性與死亡率增加有顯著相關方面，本研究Cox分析結果年齡、性別、嚴重共病症指數(CCI) 、末期腎臟病病人延遲透析年齡每增加1歲死亡風險增加1.07倍(HR=1.07，P＜0.001)；男性延遲血液透析死亡風險是女性的1.40倍(HR=1.408，P＜0.001)。結論與建議: 本研究為國內首次針對末期腎臟病病人延遲透析長期趨勢之研究(1997-2012)，提供影響其醫療資源耗用及死亡存活率之相關因子，並透過不同的屬性之統計分析，雖然有健保研究資料庫之限制因素，仍可作為後續研究之參考。

關鍵字

末期腎臟病；延遲治療；血液透析

並列摘要

Abstract Aims: The purpose of this study is to explore the characteristics, clinical features, and log-tern trend of characteristics of hospitals in end-stage renal disease (ESRD) patients, who delay into the hemodialysis (HD). The study further assesses the related factors of their consumption of medical resources and medical efficacy. Methods: This study uses retrospective longitudinal study using the 1997-2012 National Health Insurance database, medical institutions stalls and stalls death, major injuries and other medical resources secondary database analysis to discuss the main diagnostic ICD-9 codes ( 585, 586, etc.) of patients with chronic kidney disease receiving delay HD treatment. A total of follow-up period is 15 years. We use descriptive statistics and inferential statistics (chi-square test, independent samples t test, multiple regression analysis, Kaplan - Meier survival analysis, Cox Analysis), to explore long-term trends of delay HD treatment in ESRD patients, and assess demographic factors, comorbidity factors, the hospital level, characteristics of time for medical resources and medical efficacy influence. Results: 1. Descriptive statistics of delay HD patients characteristics: There are 410 people in T2 (2002-2007), most during the period of 1997-2012. There are more women than men, and focus on aged 45-64 years, comorbidity index (CCI) of 2 scores, and the medical center patients. 2. Total cost of medical care increased during 2nd and 3rd year (vs. 1st year) in delay HD patients. Total cost of medical care does not increase in 2nd year, but increased in 3rd year (vs. 1st year, p < 0.001) in non-delay HD patients. Besides, total cost decreased during 4th and 5th year, which may be due to stability of patient’s condition in non-delay HD patients. The number of outpatient visits increased during 2nd year, and decreased in 4th and 5th years in delay HD patients (vs. 1st year, p < 0.001), whereas no significant change in non-delay HD patients. 3. Old age (per 1 year, HR: 1.07, p < 0.001), male (vs. female, HR: 1.41, p < 0.001) are associated with increased overall mortality in delay HD patients. Conclusions and suggestions: This is the first study to explore long-terms trend (1997-2012) of delay HD in ESRD patients, which provide the related factors influencing medical resource consumption and mortality. Through statistical analysis of different properties, this study may act as a reference although limited health-care database factors.