末期腎臟疾病患者進入透析前之醫療服務利用及其影響探討

Service Utilization Review of Pre-End-stage Renal Disease Patients and It’s Consequent Effects

邱美清(Mei-Ching Chiu)

指導教授 ： 毛莉雯

高雄醫學大學/健康科學院/公共衛生學研究所/碩士(2004年)

摘要

研究背景與目的：
根據台灣腎臟醫學會的統計資料顯示，截至民國九十年底止台
灣地區透析病患人數已增加至35,189 人，盛行率為每百萬人口1,449 人、粗發生
率為每百萬人口331 人。如何有效管理末期腎臟疾病不斷攀升之盛行率及發生
率，及其相對所需花費的龐大醫療支出與社會成本，是目前國內外腎臟醫療照護
提供者與衛生主管機關極力關注的課題。事實上基於疾病管理(Disease
Management)之預防原則，未進入透析前之慢性腎臟疾病患者，其先前服務利用
方是管理之重點；但目前之相關研究仍側重於末期腎臟疾病患者進入透析治療後
之服務利用評估及其醫療品質，故本研究擬針對新進入長期透析治療滿六個月之
末期腎臟疾病患者，瞭解其進入長期透析治療前、後六個月之醫療服務利用情
形；進而探討先前醫療服務利用及相關處置情形對後續服務利用之影響與差異。

研究方法：
本研究採回溯性之次級資料分析，主要資料來源為台灣腎臟醫學會年
度調查資料，以及全民健康保險局高屏分局申報資料檔。研究樣本係擷取高屏地
區民國九十年度新進入透析治療滿六個月的903 位ESRD 患者，同時依其透析前
之不同處置將研究樣本分為三組，分別為：病患在此階段是否有被轉介到腎臟專
科醫師下接受診治、是否有預先建立好人工血管通路以及是否有接受紅血球生成
素(EPO)注射；在醫療服務利用方面之變項包括有：病患進入透析治療前、後六
個月之門急診次數；住院頻率、天數；總醫療費用；門急診醫療費用；與住院醫
療費用。統計分析包括描述性統計、相關分析、t 檢定、卡方檢定及迴歸分析等。

研究結果;
1、本研究之分析樣本為903 位新進入血液透析治療滿六個月以上之ESRD 病患，
其中在轉介腎專部分有633 位（70％）病患在透析前六個月期間有轉介到腎專
就診；在注射EPO 部分有387 位（43％）病患在透析前六個月期間有接受EPO
注射治療；在血管通路部分有90 位（10％）病患在透析前六個月期間有預先
建立好血管通路才進入透析治療。
2、ESRD 患者在進入透析前六個月期間，其最主要之醫療費用支出為住院醫療
費用；在進入透析後六個月期間則以常規透析費用為最主要之醫療費用支出。
3、ESRD 患者在進入透析前六個月期間有做先前相關處置（轉介腎專、注射
EPO、預建血管通路）者，其進入透析前六個月之醫療服務利用頻率與費用，
並未顯著高於沒有做上述先前相關處置者。
4、ESRD 患者在進入透析前六個月期間有做先前相關處置（轉介腎專、注射
EPO、預建血管通路）者，其進入透析後六個月之醫療服務利用頻率與費用
將顯著低於沒有做上述先前相關處置者。
5、ESRD 患者在進入透析前即轉介到腎臟專科醫師下接受診治並開始注射EPO
其進入透析前、後六個月期間之醫療服務利用頻率與費用都將顯著低於有轉
介但沒有注射EPO 者。
6、ESRD 患者在進入透析前即轉介到腎臟專科醫師下接受診治且預先建立好血
管通路，其進入透析後六個月之住院與總醫療費用將低於有轉介但沒有預先
建立好血管通路者。
7、本研究在控制了人口學特質、臨床評估狀態、就診機構特性等各變項後，發
現先前處置中的轉介腎專與注射EPO 兩變項，對於末期腎臟疾病患者進入透
析後之總醫療費用與住院醫療費用具有顯著之預測能力。

討論與建議：
由本研究結果得知，ESRD 病患在進入透析前六個月期間即接受腎
臟專科醫師的專業照護、及早接受貧血治療、或預先建立好血管通路才進入透析
治療者，其進入透析後六個月期間之醫療利用頻率與費用支出將顯著低於沒有做
上述先前處置者。此外，在全部903 個樣本中只有10％的樣本有預建血管通路；
在轉介腎專的633 個樣本中只有60％的樣本有注射EPO、13％的樣本有預建血
管通路，顯示出上述觀念目前尚未被多數腎專醫師與病患所接受。因此，將來在
規劃ESRD 整體照護計畫時應更加重視先前處置的部分，使患者在進入透析前即
能在專科醫師審慎的追蹤與控制下，接受各項必要之先前相關處置與治療，避免
病患因病情急速惡化而必須經由急診或住院開始進入透析治療，使病患能在心理
與身理皆做好準備下才經由門診進入透析治療，減少透析初期之不穩定性以及後
續醫療利用與花費。

關鍵字：末期腎臟疾病前期、透析、醫療服務利用、疾病管理

關鍵字

疾病管理 ； 醫療服務利用 ； 透析 ； 末期腎臟疾病前期

並列摘要

Background and Objectives
According to the statistics provided by the Taiwan Society of Nephrology, by the end
of 2001 amount of patients on dialysis has increased to 35,189 that is nearly 5,000
people more than the amount of 30,129 in 2000. How to manage the rapid increasing
prevalence and incidence of dialysis patients and their associated health care costs and
social resources had been a global issue for care providers and health policy makers in
Nephrology. In fact, based on preventative principles of disease management,
previous utilization of service of chronic patients with renal disease before being on
dialysis is the key of management. However, previous related research still focused on
evaluation and quality of medical care of utilization of service of patients with
end-stage renal disease. Therefore, this research plans to investigate how new patients
with end-stage renal disease who have been on dialysis for six months utilize medical
service before and after being on dialysis; furthermore, this research discusses effects
and differences of previous utilization of medical service and related management on
following utilization of service.

Methods
This research adopts retrospective cross-sectional study design . The data sources
included the Taiwan Society of Nephrology and the Kaohsiung-Pingtung Branch of
the Bureau of National Health Insurance. The study population was the pre-ESRD
patients who began to receive dialysis more than 6 months in 2001(n=903). The study
sample is classified by into three groups by the timing of nephrology referral, the
AV-Shunt status, and Epoetin (EPO) injection. The variables of service utilization are
comprised of the number of outpatient visits; hospitalization (frequency and days);
total medical expenses; ambulatory, emergency, and hospitalization expenses. The
statistic plan includes descriptive analysis, correlation analysis, t-test, pair-t test,
Chi-square test, and analysis of variance.

Results
1. Six months before patients with ESRD are on dialysis, the major medical expense
is hospitalization charge; six months after they are on dialysis, the major medical
expense is regular dialysis charge.
2. Patients with ESRD who received related treatment (transferring to nephrology
referral, EPO injection, establishment of A-V shunt) six months before they are on
dialysis don’t either use more medical service or spend more on medical service
than people who didn’t receive related treatment in advance during this period of
time.
3. While having been on dialysis for six months, patients with ESRD who received
related treatment (transferring to nephrology referral, EPO injection,
establishment of A-V shunt) six months before they are on dialysis utilize less
medical service and spend noticeably less on medical service than people who
didn’t receive related treatment in advance.
4. ESRD patients who receive treatment from nephrology referrals and have
injections of EPO before they are on dialysis utilize medical service and spend far
less six months before and after getting on dialysis than those who receive
treatment from nephrology referrals but not having injections of EPO.
5. ESRD patients who receive treatment from nephrology referrals and make A-V
shunt in advance before they are on dialysis utilize medical service and spend far
less six months after getting on dialysis than those who receive treatment from
nephrology referrals but not making A-V shunt in advance. Unfortunately, among
633 samples of those who receive treatment from nephrology referrals, only 13﹪
of them make A-V shunt in advance, indicating that such notion hasn’t been well
accepted by most of nephrology referrals and patients.
6. Comparing with previous research additional variance in regression analysis of
this research is previous treatments. Either predicative mode of overall expenses
or predicative mode of expense minus dialysis expense is more persuasive,
indicating that previous treatments are of great importance in terms of predication
of medical expense of patients with ESRD who are on dialysis.

Discussion and Suggestions
Based on this research, patients with ESRD who receive nephrology referral’s
professional medical care, receive earlier treatment on anemia or establish A-V shunt
before being on dialysis use less medical service and spend less than people who
don’t receive abovementioned treatments on medical expense. In addition, among all
of 903 samples, only 10﹪of them make A-V shunt in advance; among 633 samples of
those who receive treatment from nephrology referrals, merely 60﹪of them have
injections of EPO and only 13﹪of them make A-V shunt in advance, indicating that
such abovementioned notions haven’t been well accepted by most of nephrology
referrals and patients. Therefore, in terms of planning for overall ESRD medical care,
importance of the advancement of measures should be highly valued in hope that
patients will be able to receive mandatory treatments in advance under nephrology
referrals’ surveillance and control to prevent patients’ health from deteriorating and
getting on dialysis right after emergencies or hospitalization. In this case, patients will
only start to be on dialysis when they are totally mentally and physically prepared,
and eventually instability of initial period of dialysis and utilization and expense of
medical service will be restricted.

Key words
Pre-End-stage Renal Disease (P-ESRD)、Dialysis 、Service Utilization、Disease
Management

並列關鍵字

Service Utilization ； Dialysis ； Pre-End-stage Renal Disease (Pre-ESRD) ； Disease Management

參考文獻

參考文獻

中文部分

中央健康保險局、台灣腎臟醫學會編印。（2000）。透析病患照護手冊。台北市：

全民健康保險醫療費用協定委員會。

中央健康保險局。（ 2001 ）。90 年重大傷病門診住院費用統計表。