血液透析患者紅血球生成素使用量及影響因子之探討

Use of Erythropoietin Dosing and Associated Factors in Hemodialysis Patients

鍾宇杰(Chung Yu-Chieh)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理學研究所碩士在職專班/碩士(2012年)

摘要

研究背景與目的
台灣近年來常是全球尿毒症盛行率最高的國家，尿毒患者耗費了大量的健保資源，其中血液透析是台灣大多數尿毒症患者採用的治療方式，貧血是透析患者常見的併發症。自1989年開始導入基因重組人類紅血球生成素，明顯的改善了透析患者貧血的臨床治療，而紅血球生成素是血液透析患者最大的藥物耗用，本研究將研究台灣南部不同透析機構血液透析患者紅血球生成素使用量及影響因子。
目的一 ：探討在當前健保給付規定下，不同透析院所的紅血球生成素使用劑量之情形，血比容(Hct)數值分布是否符合腎臟醫學會血液透析臨床診療指引的建議
目的二：探討短效紅血球生成素(Eprex)及長效紅血球生成素(NESP)近年的使用趨勢
目的三：探討血比容(Hct)、機構別和其他因素對紅血球生成素使用劑量的影響
目的四：探討血液透析病患的醫療資源利用情形和影響因子
目的五：探討血液透析病患的臨床療效和影響因子
研究方法
本研究為回溯性 (Retrospective)開放的世代研究(Open cohort study)設計，收集台灣南部某區域醫院由不同醫師群診治的兩個洗腎室，以及兩家血液透析診所，2010年及2011年每個月的血比容檢驗報告資料、健保申報紅血球生成素劑量，以及2010及 2011年該區域醫院血液透析病患住院的次數及費用，這四個透析機構以台灣腎臟醫學會HOPE透析軟體建立之資料庫。研究變項: 2010年和2011年每個月的血比容(Hct)平均值，每個月全月的Eprex加NESP總用量，及2010~2011年的住院與否、次數及費用、存活情形，使用統計套裝軟體SPSS for Windows 19.0版進行資料統計分析，評估比較紅血球生成素劑量、醫療資源利用情形和臨床療效。本研究已通過屏東基督教醫院人體試驗審查委員會同意進行臨床試驗，IRB核准編號: IRB 287A
研究結果
不同透析機構的紅血球生成素劑量有顯著差異(p<0.001): 在第一洗腎室是27331U，第二洗腎室是18441U，M診所劑量15828U，D診所劑量20644U；各透析機構的患者在2010~2011接受規則透析的第一個月Hct月平均有顯著差異(p=0.002): 在第一洗腎室患者規則透析第一個月Hct月平均是32.1%，第二洗腎室是33.0%，M診所是32.4%，D診所是32.9%；各透析機構患者血比容分布也有顯著差異(p<0.001)；長效型的紅血球生成素使用量在區域醫院的兩個洗腎室與M診所有逐漸增加的趨勢；顯著影響透析病患紅血球生成素劑量的因子有機構別(p<0.001)、Kt/V(p<0.001)、Hct月平均(p<0.001)；透析病患住院次數存在有顯著差異的因子有年齡?d65歲(p=0.005)、造成尿毒原因是糖尿病(p<0.001)、透析時間?d1年(p<0.001)以及Hct<30(p<0.001)，但不同洗腎室住院次數沒有顯著差異(p=0.063)；而顯著影響透析病患住院費用的因子有造成尿毒原因(p<0.001)、透析時間?d1年(p=0.003) 、Hct<30(p=0.001)；顯著影響透析病患存活的因子有年齡(p<0.001)、造成尿毒原因(p=0.032, p=0.022)、合併症(p=0.001)，但不同洗腎室的Cox單變量存活分析並沒有顯著影響(p=0.239)。
結論與建議
結論:
1. 不同透析機構紅血球生成素劑量存在有顯著差異。
2. 不同透析機構規則血液透析第一個月Hct平均值有顯著差異
3. 長效型的紅血球生成素使用量有逐漸增加的趨勢
4. 透析機構別是紅血球生成素劑量的顯著影響因子
5. 區域醫院的不同洗腎室患者住院次數沒有顯著差異。區域醫院的洗腎室別對住院費用，沒有顯著影響。
6. 區域醫院的洗腎室別對存活與否、存活時間，沒有顯著影響
建議:
一、對中央健保局之建議: 宜依據患者特性適度調高透析給付額度，以改善患者貧血情形，進而減少透析患者的心臟血管併發症及輸血的機會。
二、對透析治療提供者的建議: 透析院所應該將血比容維持在30%以上，因為血比容<30%的患者住院次數及住院費用都較高，將血比容維持在30%以上，減少病人住院的次數及費用，有助於減少透析患者的醫療資源耗用。
透析院所可以尋求聯合採購的機會，或與廠商簽訂人工腎臟搭贈紅血球生成素的優惠價格，以節省成本。透析院所應該排除缺鐵性貧血、慢性發炎等情形來增加身體對紅血球生成素的敏感度，也可以使用皮下注射來節省紅血球生成素的用量。

關鍵字

紅血球生成素 ； 血液透析 ； 預後 ； 醫療資源使用 ； 醫療決策

並列摘要

Background: Taiwan frequently sat on the top list regarding to uremia prevalence in recent years. Uremic patients spent a lot of health care resources. Hemodialysis (HD) is the treatment used by the majority of uremic patients in Taiwan. Anemia is a common complication of HD. The introduction of recombinant human erythropoietin in 1989 significantly improved the clinical treatment of anemia in dialysis patients. Erythropoietin is the largest drug expenditure. This study was carried out to investigate the erythropoietin dosing of HD patients and impact factors among different facilities in southern Taiwan.
Purpose 1: To investigate the erythropoietin dosing among different HD facility under current national health insurance (NHI) reimbursement, compliance of hematocrit (Hct) value distribution on the clinical guidelines and recommendations for HD issued by Nephrology society
Purpose 2: To investigate the trends for use of short-acting erythropoietin (Eprex) and long-acting erythropoietin (NESP) in recent years
Purpose 3: To investigate the influence of hematocrit (Hct), different facilities, and other factors on erythropoietin dose
Purpose 4: To investigate the medical resource utilization of HD patients and impact factors
Purpose 5: To investigate the clinical efficacy of HD patients and impact factors
Method:
This study was retrospective open cohort study. We collected data from 2 HD units at a regional hospital (which were cared by different nephrologist groups) and 2 HD clinics in southern Taiwan. Data included Hct level in each month, erythropoietin doses in claims for NHI, whether admission or not, number and cost of admission in HD patients at the regional hospital in 2010 and 2011, and databank of these 4 HD facilities constructed by HOPE dialysis software offered by Taiwan Society of Nephrology. The study variants include Hct average of each month, Eprex dose plus NESP dose times 200 of each month, admission or not, admission number and cost and survival. This study uses statistical software SPSS for Windows edition 19.0 to analyze erythropoietin dosing, medical resource utilization and clinical efficacy. Pingtung Christian Hospital Institutional Review Board agreed to conduct this clinical trial, IRB approval number: IRB 287A
Result:
There is a significant difference on the erythropoietin doses among different HD facilities (p<0.001): 27331U in the first HD unit, 18441U in the second HD unit, 15828U in M-clinic, 20644U in D-clinic; Monthly Hct average of the first month accepting regular HD in patients among HD facilities during 2010~2011 has a significant difference (p = 0.002): 32.1% in the first HD unit, 33.0% in the second HD unit, 32.4% in M clinic and 32.9% in D clinic; Hct distribution of different HD facilities exists a significant difference (p <0.001); There is a growing trend in use of long-acting erythropoietin in the two HD units at the regional hospital and M-clinic; The factors have significant impact on erythropoietin dose include different facilities(p<0.001), Kt/V(p<0.001), and monthly Hct average; The factors cause significant difference on the numbers of admission include age?d 65 years of age (p=0.005), uremia causative disease is DM(p<0.001), HD history?d 1 year(p<0.001) and Hct<30(p<0.001), but the numbers of admission between this 2 HD units have no significant difference (p=0.063); The factors cause significant impact on the cost of admission in HD patients include uremia causative disease (p <0.001), duration of HD?d 1 year (p = 0.003), and Hct <30 (p = 0.001); Factors significantly affect the survival of HD patients include age (p <0.001), uremia causative diseases(p = 0.032, p = 0.022), complications (p = 0.001); but there is no significant impact on Cox survival analysis between this 2 HD units at the regional hospital(p=0.239)
Conclusion:
1. There is a significant difference on erythropoietin dose among different HD facilities.
2. The first monthly Hct average of patients accepting regular HD among different HD facilities exist significant differences
3. The use of long-acting erythropoietin show a growing trend
4. HD facilities significantly influence the erythropoietin dosing
5. No significant difference exists in the number of admission between HD units at the regional hospital. There is no significant impact on hospitalization cost between HD units.
6. There is no significant impact on survival status, survival time between HD units at the regional hospital.
Recommend:
1. To Bureau of national health insurance: Should moderately increase HD payments in accordance with the characteristics of patients, to improve anemia treatment in HD patients, thereby reducing cardiovascular complications and the chance of blood transfusion among HD patients.
2. To providers of HD: dialysis facilities should maintain the Hct above 30%. Patients whose Hct <30% correlated with increased number of admission and hospitalization costs were higher. Maintaining Hct at above 30% reduce the number and costs of admission, help reducing medical resource utilization of dialysis patients.
Dialysis facilities can seek opportunities for joint procurement, or artificial kidney signed with the vendor to take the gift erythropoietin at discounted prices in order to save costs. Dialysis facilities should find out the case of iron deficiency anemia, chronic inflammation to increase the body's erythropoietin sensitivity, they can also use the subcutaneous injection of erythropoietin to save the amounts.

並列關鍵字

Hemodialysis ； Erythropoietin dosing ； Outcome, Health care utilization, medical decision-making

參考文獻

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