末期腎臟病患合併症、醫療資源利用及預後之相關因素探討

研究背景與目的:台灣末期腎臟疾病(End-Stage Renal Disease，ESRD)的盛行率、發生率不斷攀升，目前已與高血壓、糖尿病同列為台灣人的三大重要慢性疾病，另外根據USRDS 2006年年報指出，2004年台灣的末期腎臟病發生率為全球最高，盛行率則僅低於日本；末期腎臟疾病也造成嚴重的財務負擔，全球許多國家皆以極大比例的醫療費用照護少數的末期腎臟病患，若要建立有效的疾病管理模式應該先對於末期腎臟病患接受透析治療前的醫療利用情形有所了解，並且了解末期腎臟病患過去疾病診斷，找出末期腎臟病患高危險群，因此了解在進展至末期腎臟病患前是否得到足夠之醫療照護是非常重要的，本研究目的為探討末期腎臟病患Pre-ESRD前三年的疾病診斷、透析治療前後的醫療利用情形與進入透析後的死亡情形。研究方法: 本研究利用2000、2001、2002、2003年末期腎臟疾病新個案進行分析，研究設計分為三部份，在Pre-ESRD疾病診斷部份，使用新個案往前回溯前三年，Pre-ESRD前四年以及進入透析後ㄧ年的醫療利用，使用新個案往前回溯前四年，往後追蹤第一年的醫療利用，死亡情形的部份，新個案往後追蹤至2004/12/31止。研究結果: 末期腎臟病患在Pre-ESRD前三年有較晚被診斷慢性腎臟病以及較晚至腎臟科就診的情形，在Pre-ESRD前四年以及後ㄧ年的住院利用，病患的住院次數、住院天數、住院費用隨著接近病程的演進而增加，在前三個月急速增加，透析治療前(三個月、一個月)以及進入透析後(三個月、一個月)的住院利用較高，透析後(三個月、一個月)又較透析前(三個月、一個月)的住院利用高；其整體第一年的死亡率為9.5%、第二年為9.3%、第三年為6.6%、第四年為13.1%，四年累積死亡率為38.5%，本研究末期腎臟病新個案的第二年、第三年及第四年的死亡率較國內外的研究低；另外合併有慢性腎臟病及糖尿病患者，合併有慢性腎臟病及糖尿病及心血管疾病患者預估將增加進入透析治療後六個月之總醫療費用(扣除透析)(扣除透析)、門診費用(扣除透析)、住院費用；增加進入透析後之死亡風險，先前有至腎臟科就診者相對於先前未至腎臟科就診者，預估將減少進入透析治療後六個月之總醫療費用(扣除透析)、門診費用(扣除透析)；降低進入透析後之死亡風險。討論與建議:建議衛生主管機關可以參考美國國家腎臟基金會所推展的腎臟早期評估計劃(Kidney early evalution program,KEEP)針對慢性腎臟病的高危險群進行大型篩檢以利早期診斷慢性腎臟病，並將計劃的概念推展至各級醫療院所，建立整體性慢性腎臟病照護網，健保局對此可研擬適當的給付方法產生誘因或許能有所成效；另外對於民眾必須進行衛生教育宣導建立良好的保健觀念與認知，若罹患慢性腎臟病後則應該定期追蹤，不要讓民眾因為逃避害怕而導致疾病進展嚴重，應給予正確的觀念以防止尋求不正確的治療方式讓病情惡化，對於基層醫師及其他專科醫師則可以繼續教育的方式，讓其熟悉慢性腎臟病防治的觀念。

關鍵字

末期腎臟疾病；醫療資源利用；死亡率

並列摘要

Research background and purpose: The prevalence and incidence of End-Stage Renal Disease(ESRD) soar unceasingly, and has classified with hypertension and diabetes mellitus as Taiwanese's the three important chronic diseases, moreover according to USRDS 2006 annual report, the incidence of ESRD in 2004 are highest in the global countries, then the prevalence only lower than Japan. ESRD also created the serious financial burden and make many countries spend enormous proportion medical expense to look after the minority of patients. It should realize the situation about medical utilization of Pre-ESRD and past diagnosis of disease on patients and find out high risk group if want to establish the effective disease management mode. Therefore, it is very important to understand if obtain enough medical treatment and care to patients from in progress to latter stage. This research purpose mainly discuss ESRD patients in previous three year disease diagnosis situation, Pre-ESRD and after dialysis medical utilization, death situation after dialysis. Methods: This research design divided into three parts by analysing the ESRD new case in 2000-2003, the new case of Pre-ESRD diagnosis retrospect past three years. New case in past four years as well as one year after dialysis, adopt retrospective four years and track back first year of medical utilization. The mortality of new case trace until the end of 2004/12/31. Results: ESRD patients were diagnosed late with chronic kidney disease (CKD) as well as the situation which received late Nephrology examination in past three years of the Pre-ESRD.Hospital utilization of ESRD patients in four year before and one year after dialysis treatment, hospitalizations, inpatient days and costs increase along with progression of course of disease, especially rapid in the first three months before dialysis treatment, and hospital utilization of the first and third months after dialysis treatment is higher than the first and third months before dialysis treatment.The mortality rate of new case on ESRD patients whole first year is 9.5%, and the series are 9.3%, 6.6% and 13.1% from the second to fourth year. All four years of accumulated mortality rates is 38.5%. The mortality rates of new ESRD case from the second to fourth year are lower than domestic and foreign literature. CKD patients with diabetes、CKD patients with diabetes and besides cardiovascular disease were estimated that will increase total medical、inpatient expense and outpatient expense in latter six months after dialysis and increase mortal risk after dialysis. Patients who had saw a Nephrology doctor formerly is opposite to never diagnosed, were predicted will reduce total medical and inpatient expense in latter six months after dialysis treatment and then reduce mortal risk after dialysis. Discussion and suggestion: Suggest the health authorities refer to kidney early evalution program(KEEP) promted by National Kidney Foundation (NKF) . This program mainly focus on high risk group of CKD to carry on large-scale screen in order to diagnose early and popularize the concept to all levels of health institutes, then establish the integral CKD care network. It may be available for Bureau of National Helath Insurance to draw up suitable payment method by induce factor. Moreover it must establish health care cognition by declaring hygiene education to populace. It should track regularly if suffers from CKD and don't let the populace cause the disease to be serious in progress because of escaping fear, further offer the correct notion and prevent from seeking error treatment to cause the aggravation of disease. Finally, familiarizing CKD control concept by continuing education in primary doctor and other specialist.