影響血液透析品質相關因素之分析

在台灣透析醫療已是公共衛生的一個重大議題，每年耗費在透析治療的資源已佔健保支出的前五名。而在此醫療服務之研究中，洗腎品質的好壞，會影響病人長期的存活率、罹病率及生活品質，故目前如何使病人得到良好的透析效果，已是醫療團隊非常重視的問題。過去已有諸多學者提出各種改善血液透析品質之因素，但大多為單一指標之研究，未有從照護流程全面性地找出影響透析品質之關鍵因素。為此，本研究透過KJ法，將透析流程進行分群與排序，並透過焦點團體法與德爾菲法來確認此一架構之合理性，最後，更透過層級分析法(AHP)，來建立各個構面、類別、關鍵因素之權重值，並藉此找出影響血液透析品質之關鍵因素。至此，本研究之研究成果，可提供管理者，在「管理應用」層面：(a)醫療院所藉此可重新檢視目前之透析護理流程是否有需增修或加強之處；(b)醫護人員可自我審視各個重要流程是否確實執行；(c)病患可透過此架構表來檢視自身之照護情況是否良好。(2)在「管理機制」層面：(a)主管人員可建立相關懲罰機制；(b)醫護人員可依時間與資源來建立合理之標準作業流程；(c)主管人員可藉此建立護理人員應具備之職能與工作態度。(3)在「管理決策」層面：(a)政府機構可藉此建立評量各醫療院所之工具；(b)醫療院所可藉此考量未來投入資源之方向與多寡；(c)醫療院所可建立評估透析品質之績效指標。亦期望此研究成果能使病人獲得更好的透析治療，進而改善病人之身體狀態，降低合併症之產生。

關鍵字

血液透析；透析品質；關鍵因素；層級分析法

並列摘要

Reimbursement charges for dialysis had been a significant drain in Taiwan’s health care spending. In fact, costs associated with dialysis are found to be in the top five health care spending. Researches of dialysis services have shown the quality of hemodialysis may affect patients’ long-term survival, morbidity, and life quality. Several researchers have proposed key factors influencing the quality of hemodialysis. However, most studies focused on single quality indicator and few efforts have been made to systematically search the key quality indicators in the hemodialysis process. The appropriateness of the classification and ranking is verified by focused group interview and Delphi consensus methods. The collected indicators are further hierarchically weighted by analytical hierarchy process in three levels: dimension, class, and individual indicator, and thereby establishes an instrument to summarize the most important quality indicators for hemodialysis. In the managerial application dimension, results of this study provide the managers with important tools for examining the current dialysis nursing care process. The healthcare providers themselves can use the instrument developed by this study to verify the quality of hemodialysis stepwise. Patients can also use this instrument to examine whether self-care follow the best quality procedure. In the managerial mechanism dimension, the managers can establish rewarding or punishing system based on the quality indicators. Healthcare providers can establish a standard operation procedure based on the available time and resources. The managers can also help establish the work attitude. In the managerial decision dimension, the government can establish a tool for evaluation or accreditation of various dialysis institutions, which in turn will guide the allocation of the resources from the funding source. The management team can also link these indicators to the payment system and build a pay-by-performance system. We hope results of this study can improve the quality dialysis therapy and in turn improve the overall health of patients and reduce the related complications.