腹膜透析及血液透析患者中長期醫療資源使用及成本效果

An Analysis on Mid-Long Term Medical Resources Usage and Cost Effectiveness for Peritoneal Dialysis and Hemodialysis Patients

曾譯諏(I-Tsou Tseng)

指導教授 ： 邱亨嘉

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2014年)

https://doi.org/10.6832/KMU.2014.00160

摘要

研究背景和目的：台灣末期腎臟病患透析治療的高額費用造成健保沉重負擔，透析治療包括血液透析與腹膜透析二種模式，全民健康保險局在政策上積極推動腹膜透析的治療，以降低的透析醫療費用。本研究目的為：（1）探討由門、急診入院患者中兩種透析治療之當次醫療耗用及其影響因子（2）探討腹膜透析與血液透析之中長期醫療資源使用（3）探討腹膜透析與血液透析之存活和影響因子（4）探討腹膜透析與血液透析之成本效果。
研究方法與材料：本研究是一個病歷回溯性、縱貫性之研究，收集南台灣某區域教學醫院2003年至2012年間，因末期腎病須長期接受透析治療，且於該醫院首次接受動靜脈廔管手術或腹膜透析植管手術之病患做研究。收集就醫資料包括、人口學特質、透析方式、入院方式、共病症、相關醫療費用、醫院死亡登錄資料檔及內政部死亡資料庫，形成研究樣本並進行研究分析，以SPSS軟體進行分析，
包括敘述性統計、假設檢定、存活分析、迴歸分析，費用分析、成本效果分析等。
研究結果依目的:
1.急診當次住院病患選擇血液透析住院日數明顯少於選擇腹膜透析，且達到統 計學上意義(P<0.05)，急診之當次住院病患，選擇血液透析住院當次醫療費用明顯少於選擇腹膜透析且達到統計學上意義。醫療耗用和透析治療方式、門、急診入院方式、糖尿病、高血壓、相關共併症因子有關，而且達到統計上學意義。
2. 一年及二年之透析費用，腹膜透析皆比血液透析低，但檢定結果顯示在一年及兩年內門診透析在2003~2006年份及 2007~2010年份兩種透析方式有達到統計學上顯著差異，而2011~2013年份則未達統計學上之顯著意義；門診費用及總費上出院後一年及兩年內腹膜透析皆比血液透析低且達統計學上之顯著意義。平均住院費用上選擇腹膜透析病患比選擇血液透析病患來的低，但比較兩種透析方式於各個年代間之差異性，獨立T檢定顯示無論任何年份皆無達到統計學上差異
3.以Kaplan-Meierz法來計算五年內腹膜透析與血液透析之存活率比較，在1年、3年及5年之统計，腹膜透析之存活率皆優於血液透析且達到到統計學上之差異，以Cox-regression模式來分析探討，透析方式，住院的年代、年齡、高血壓患、共病症是影響腹存活之因子。
4.以Incremental cost effectiveness ratio (ICER)成本效果增量比率，利用比值來反映存活年數所耗用的醫療資源，本研究利用存活分析計算出研究對象之二年存活率，分別為腹膜透析1.816及血液透析1.696，相對於雨種治療之醫療總成本分別為腹膜透析1,337,448元及血液透析1,497,504元，並以此計箄出腹膜透析病人相對於血液透析病人成本效果增量比率(ICER)得出，若病患因末期腎病接受透析治療之前二年若選擇腹膜透析將可節省1,333,800元。
結論與建議
腹膜透析病患1 、3 、5年之存活率高於血液透析病患，且較低成本高效果；對於年齡小於65歲、無高血壓、無糖尿病、無共病症病患應可優先考慮選擇腹膜透析為治療方式；本研究亦可提供臨床醫師未來選擇治療方式之參考，更可提供健保署是否持續推動政策之參考。

關鍵字

末期腎臟病 ； 血液透析 ； 腹膜透析 ； 成本效果 ； 成本效果增量比率

並列摘要

Background:
High medical expense of dialysis for End Stage of Renal Diseases (ESRD) has become a heavy burden for National Health Insurance Agency (NHI) in Taiwan. Dialysis treatment includes hemodialysis and peritoneal dialysis. In order to cut down the cost of dialysis, NHI has been encouraging the application of peritoneal dialysis.
Research Purpose:
(1)Identifying the differences in its medical cost and the affecting factors between two groups of patients, outpatient and those who admitted at the emergency department.
(2)Analyzing the long-term expenses of peritoneal dialysis and hemodialysis.
(3)Understanding the survival rate and affecting factors between peritoneal dialysis and hemodialysis.
(4)Evaluating the cost effectiveness of peritoneal dialysis and hemodialysis.
Materials and method:
The data was collected from a regional teaching hospital in southern Taiwan where patients were diagnosed ESRD and accepted for the first dialysis between 2003 and 2012. Information regarding demographic characteristics, type of dialysis, admission mode, comorbidities, medical expenses and mortality information were gathered from the hospital’s information system (HIS). Internal death database was analyzed with SPSS software. By using Cox-regression, statistical analysis methods include descriptive statistic, hypothesis testing, survival analysis and so on.
Result:
(1)Patients admitted from emergency department in hemodialysis group have revealed significant (P<0.05) less both in medical expenses and hospitalization days. There are also significant related with dialysis mode, admission mode, diabetes mellitus, hypertension and relative comorbidities as the affecting factors.
(2)Peritoneal dialysis is observed to bear lower cost in comparison with the average dialysis expenses during the first and second year. The statistical significant were only found in two periods, 2003-2006 and 2007-2010. There was no significant difference between 2011-2012. It also shows significant low in peritoneal dialysis in terms of both clinical and total health care cost among the patients in three different periods. However, no significant difference found in the hospital expenses for the first and second years.
(3)On Kaplan-Meier curve, there are statistical significance better 5 years survival rate in peritoneal dialysis. Data analyzed by Cox-regression hazard ratio also revealed that mode of dialysis, period of study, age, hypertension and comorbidities and the affecting factors for survival.
(4)Two years survival of peritoneal dialysis is 1.816 v.s 1.696 for hemodialysis. Total medical cost of peritoneal dialysis is 1,337,448NTD v.s 1,497,504NTD for hemodialysis. ICER result shows that there would be 1,333,800NTD saving if patient choosing peritoneal dialysis for the treatments during the first and second years.
Conclusion and Recommendation:
The research results show that patients in peritoneal dialysis group have better survival rate in the first, third and fifth years in comparison with those who in hemodialysis group. It also reveals that lower cost and more effectiveness in peritoneal dialysis. It is suggested that peritoneal dialysis could be the priority for the patients aged under 65, non-hypertension, non diabetes and no comorbidity patents. The research findings provide strong evidences for clinicians to urge the government on placing emphasis for peritoneal dialysis in the related polices.

並列關鍵字

End stage of renal disease(ESRD) ； Hemodialysis(HD) ； Peritoneal dialysis（PD) ； Incremental cost effectiveness ratio (ICER)

參考文獻

英文部分

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4.Coentrao, L.A., et al., Cost analysis of hemodialysis and peritoneal dialysis access in incident dialysis patients. Perit Dial Int, 2013. 33(6): p. 662-70.