論質計酬計畫方案對初期腎臟病人整體照護效益評估

背景　　目前在台灣末期腎臟病之盛行率為世界第一，2010年台灣慢性腎臟病的盛行率為11.9％，影響超過250萬人，而2010年台灣腎臟醫學會指出國內約有6萬人長期洗腎並且每年新增2000人，對全民健康保險所造成的負擔每年高達300億元，已經超越治療所有癌症病人的支出。　　中央健保局自2011年，實施「慢性腎臟病論質計酬試辦計劃」，期望藉由支付方式，鼓勵醫療人員，提供具效益與完整性的服務項目，使慢性腎臟病病人的病情得到良好控制，以降低慢性腎臟病病人的病情惡化和減少醫療資源的利用。過去文獻多著重在初期試辦的論質計酬試辦計畫成效評估，但未就病患自覺照護能力及滿意度之完整性研究，尤其此論質計酬計畫實施不久，更少相關研究。目的本研究之研究目的如下：目的一、探討初期慢性腎臟病個案、參與論值計酬與否，人口學特性、疾病特質、醫療機構特質之情形。。目的二、探討初期慢性腎臟病個案、參與論值計酬與否，其臨床指標之情形。目的三、探討初期慢性腎臟病個案、參與論值計酬與否，其自我健康照護能力之情形。目的四、探討初期慢性腎臟病個案，參與論值計劃與否、其整體就醫滿意度之情形。方法　　本研究採用初級資料分析，依目的別同時採用回溯性和前瞻性研究設計。研究對象為eGFR分期為Stage1 -3a，機構樣本抽樣為全台參與改善方案的醫療院所，病人樣本為參加論質計酬計劃病患(研究組)，沒有參加論質計酬計劃(控制組)。調查時間為2013.7.11-12.17就醫病患，共計1196人。研究材料是以問卷和醫院臨床生化樣本，問卷共二項、一 PSQ-18(Patient Satisfaction Questionnaire Short Form-18)來測整體滿意度，二為自我照護評估表PACIC(Patient Assessment of Chronic Illness)來評估自我照護能力。統計工具採用SPSS20.0，分析方法包括獨立樣本T檢定、卡方檢定、複迴歸分析和羅吉斯迴歸等結果。結果　　納入分析樣本數共1196人，Non–P4P病人有363人(27.5%)，P4P病人有833人(72.5%)，平均罹病年齡為63.3歲，其中男性佔57.11% ，女性佔42.89%，其他人口學基本資料部分，在性別、年齡、BMI上無顯著差異。臨床檢驗值數值上，P4P病人腎絲球過濾eGFR平均值高於Non-P4P病人(67.1±26.16、63.6±23.26 ，P＝0.028)。P4P病人和Non-P4P病人在血清肌酐算Scr平均數值無顯著差異(2.1±10.4、2.1±8.10，P＝0.921) 。目的三、四結果發現參加論質計酬方案計畫的病患，其自我健康照護能力愈好，總體平均值達4.15分，其對醫療整體滿意度也就愈高總平均值達4.27分。結論與建議　　本研究發現P4P病患對疾病控制及自我照護能力較Non-P4P佳，有助於提升病患自我照顧能力。此結果顯示初期腎臟病參加論質計酬計劃方案是具有正向的成效，未來可將政策發展至其他慢性病照護。

關鍵字

初期腎臟病；論質計酬；臨床指標；自我健康照護評估；滿意度

並列摘要

Background The prevalence of terminal (CKD) renal disease in Taiwan is standing at the first place of the world. In 2010, the documented cases of chronic kidney disease (CKD) in Taiwan are about 2.5 million, 11.9% of the population. In 2010, Taiwan Society of Nephrology reported that there are 600,000 undertaking the dialysis for their CKD and with increased cases of 2000 per year. The medical expenditure is up to 300 billion per year, and is much more than the expenditure of cancers in Taiwan. National Health Insurance Administration had started the CKD payment improvement program since 2011 by Pay-for-performance(P4P)model.The P4P is to encourage physicians & medical co-workers to provide more effective and complete service so that could alter progression of CKD, avoid complication and decrease medical resource utilization. The past studies of P4P were mostly focus on the effectiveness assessment; research issues about co-morbidity, patient self-care ability and patient satisfaction were limited. Never the less, studies about P4P of CKD are few because lack of long term follows up. Purpose This study has several purposes as followings: 1. To investigate the demographic, disease, and medical provider difference in CKD patients with hypertension with or without the intervention of P4P program 2. To investigate the biochemistry change in CKD patients with hypertension with or without the intervention of P4P program 3. To investigate the self-care ability in CKD patients with hypertension with or without the intervention of P4P program 4. To investigate the overall satisfaction in CKD patients with hypertension with or without the intervention of P4P program Methods This is a study using primary and secondary data analysis. According to the purposes, both retrospective and prospective design was applied in this study. The patients in the study were from a regional hospital and their CKD were defined from stage 0 to stage 3a according to their eGFR. The patients in P4P and non-P4P were study and control group respectively. From July 2013 to December 2013, 1196 patients were identified for secondary data analysis. The control group was selected using Patient Satisfaction Questionnaire Short Form-18 (PSQ-18) for overall satisfaction and Patient Assessment of Chronic Illness (PACIC) for assessment of self-care ability. The statistical tool in this study was the software SPSS 20.0 using independent t test, chi-square test, difference in difference, linear regression and logistic regression. Result For purpose 1, 2, there are 1196 patients were included in this study. The mean age of the patients was 63.3 years. The proportion of male and female were 54.6% and 45.4% respectively. There is no epidemiologic significant difference beware P4P & non-P4P groups including gender, age and BMI. As for the clinical data, the average Scr of P4P and Nou-P4P also has no significant difference(21 ± 10.4 vs. 21 ± 8.1, P=0.921) However, the eGFR of P4P is higher than Non-P4P (67.1 ± 26.16 vs. 63.6± 23.26, p=0.028) with significant difference.For purpose 3, 4, P4P patients also had better self-care ability (average points 4.15) and higher medical care satisfaction (average points 4.27). Conclusion and suggestion In this study, P4P group had better disease control and self-care ability than non-P4P group, which could decrease the CKD complications. The study revealed positive result of P4P program in CKD patients and the program could be applied to other chronic disease care in the future.