腎臟移植手術病患之術後醫療服務利用探討

中文摘要研究背景與目的：台灣末期腎臟疾病發生率居世界第一位，隨著盛行率的高升，末期腎臟疾病病患人數也逐年的增加，對於大多數的病患而言，腎臟移植是治療的首選，而如何提升醫療品質並控制醫療利用，則成為重要思考議題。目前國內尚無關於腎臟移植病患術後醫療服務利用與醫療結果之相關研究，於亞洲地區與華人國家中也鮮少發現利用全國性行政資料庫，針對腎臟移植病患作縱貫性醫療利用與醫療結果分析之研究，因此本研究將利用全國性資料庫進行縱貫性研究，長期追蹤腎臟移植病患術後的醫療服務利用與醫療結果。研究方法：本研究利用1996-2003年國家衛生研究院「全民健康保險學術研究資料庫(National Health Insurance Research Database )」之「住院醫療費用清單明細檔」，其中主手術碼為55.69之腎臟移植手術病患，共計1,112位，並進一步合併「門診處方及治療明細檔」及「醫事機構基本資料檔」。以廣義估計方程式(Generalized Estimating Equation；GEE)與Cox迴歸統計方法，針對人口學特質(性別、年齡)、疾病特質(合併症、併發症)、機構特質(層級別、權屬別、地區別)、手術當次醫療利用與醫療結果，探討其術後三年醫療利用(門診次數、門住診總費用)與醫療結果(死亡、再透析)之風險因子。研究結果：在術後三年醫療利用方面，門診次數風險因子為法人醫院 (vs.公立醫院少2.4次，p=0.00)、中區醫院 (vs.北區醫院多6.6次，p=0.00)、南區醫院 (vs.北區醫院少3.1次，p=0.00)，而手術當次住院天數每增加一天，其術後門診次數會減少0.1次(p=0.00)；在門住診總費用部分，風險因子為男性(vs.女性多33,456元，p=0.01)、法人醫院(vs.公立醫院少65,403元，p=0.00)；此外，利用GEE模式分析術後醫療利用情形也發現，腎臟移植病患術後門診次數、門住診總費用呈現逐年遞減的趨勢(p=0.00)。在術後三年醫療結果方面，死亡部分風險因子為男性(OR=2.65)、糖尿病(OR=6.87)，而手術當次住院天數每增加1天，其術後三年死亡的風險會增加4％；再透析醫療結果部分，風險因子為區域醫院(OR=3.12)、中區醫院(OR=2.44)、手術當次發生排斥者(OR=2.78)，而手術當次住院天數每增加1天，其再透析的風險會增加3％。結論：依據本研究結果得知，有糖尿病、周邊血管疾病、充血性心臟衰竭、腦血管疾病、感染、CMV疾病、排斥之病患將影響醫療資源的利用與醫療結果，因此建議醫療提供者及病患應特別留意，以預防併發症或其它不良事件的發生，並定期追蹤病患身體健康情形與服藥狀況。有鑑於機構特質亦為影響病患術後再透析之風險因子，故健保局未來在監控腎臟移植病患術後品質時，宜將病患施行手術所屬醫療機構特質納入考慮，以確保病患之術後醫療品質。

關鍵字

腎臟移植；醫療利用；醫療結果；再透析

並列摘要

英文摘要 Background & Objective The incidence rate of the end-stage renal disease (ESRD) in Taiwan is in the first place among the countries around the world. With the increased incidence, the number of the ESRD patients has grown dramatically. Kidney transplantation (KT) is the first choice for the majority of the ESRD patients, and it becomes an important issue of enhancing the medical quality and controlling the medical utilization. Up to the present, there is no study related to the medical utilization and medical outcome after kidney transplantation in Taiwan and conducted by using the national administration database to analyze the medical utilization in Asia. Therefore, this study analyzed the national administration database in Taiwan from 1996 to 2004 to examine the medical utilization and outcome of the patients after kidney transplantation. Methods The data of 1,112 cases underwent kidney transplantations (ICD-9-CM code 55.69) from January 1, 1996 to December 31, 2003 were obtained from National Health Insurance Research Database of the National Health Research Institutes in Taiwan. In the study, descriptive statistic, GEE model (Generalized Estimating Equation) and Cox regression were conducted to assess the relationship between independent variables (patient characteristics, nature of disease, hospital characteristics, length of stay for KT, rejection for KT) and dependent variables (medical utilization, medical outcome). Results In terms of the medical utilization three years after kidney transplantation, the risk factors of the number of outpatient visits were hospital ownership, hospital area and the length of stay for KT. The number of outpatient visits in the non-profit hospitals was 2.4 less than the public hospitals (p=0.00); in the central hospitals, the numbers of outpatient visits were 6.6 (p=0.00) more than the northern hospitals, and, in the southern hospitals, the numbers of outpatient visits were 3.1(p=0.00) less than the northern hospitals. In addition, the number of outpatient visits decreased 0.1 with an unit change in day of the length of stay for KT (p=0.00). The risk factors of the total health care expenditures were gender, hospital ownership. The total health care expenditures in male was 33,456 more than the female (p =0.01), and, in non-profit hospitals was less 65,403 than public hospitals (p=0.00). The results of the medical utilization analyzed by GEE model also reveals that the number of outpatients visits of patients underwent kidney transplantations and the total health care expenditures decreased gradually within the period of three years(p = 0.00). In terms of the medical outcome three years after kidney transplantation, male (OR=2.65), diabetes (OR=6.87), and the length of stay for KT were the risk factors of death, and the risk of death increased 4% with an unit change in day of the length of stay for KT. On the other hand, the risk factors associated with re-dialysis were regional hospital (OR=3.12), central hospital (OR=2.44) and DGF or rejection for KT (OR=2.78); in addition, when the length of stay for KT increased one day, the risk of re-dialysis increased 3%. Conclusions Based on the results of the study, the patient with diabetes, peripheral vascular disease, congestive heart failure, cerebrovascular disease, infection, CMV disease, DGF or rejection for KT has influence on the medical utilization and medical outcome. Therefore, medical providers and patients should draw attention to these factors and track the patients’ health and medicine situation regularly. The results also revealed that the hospital characteristics are one of the risk factors which may have effect on re-dialysis. In order to ensure the medical quality after kidney transplantation, the Bureau of National Health Insurance should take hospital characteristics into account.