背景:台灣慢性腎臟病發生率為全世界第一,醫療資源的耗用成為健保財務上一大負擔,自2003年起致力慢性腎臟病防治迄今,已成立慢性腎臟病共同照護網,期望透過鼓勵病患定期回診,使得腎臟病的預防與治療連成一個完整的體系,以增進慢性腎臟病照護品質。慢性腎臟病照護計畫已實施6年,其執行成效值得深入探究。 目的:探討影響慢性腎臟病病患定期回診之相關因素及探討回診情形對慢性腎臟病患之疾病病程的影響。 方法:本研究收集中部某醫學中心2006年至2009年參與慢性腎臟病照護網之病患共876位,根據病患基本資料、就醫需求、回診情形與疾病病程進行研究。 結果:影響病患回診因素包括腎臟病分期、教育程度、居住地、原發疾病及有無家族史。病患定期回診及回診頻率皆對於腎絲球過濾率 (glomerular filtration rate,以下簡稱GFR)及肌酸酐(Creatinine,以下簡稱Cr)變化速率皆呈顯著差異,定期較不定期回診者GFR、 Cr變化速率較緩慢;回診頻率多亦能減緩GFR、 Cr變化速率。 結論:慢性病腎臟病患配合照護計畫定期回診,可有效控制GFR及Cr的變化速率,減緩疾病惡化。
Background: The incidence of chronic kidney disease (CKD) in Taiwan is the highest all over the world. It also becomes a major burden of the healthcare system in our country. In order to reunion the prevention and treatment of the disease, there has been integrated CKD care program ever since 2003. However, the outcome of the care system of CKD is worthy our further research. Purpose: To evaluate the impact of the regular revisit and its frequency on the clinical course of the CKD patients. Methods: This study included a total of 876 patients of a medical center in Central Taiwan, who jointed the integrated CKD care program from 2006 to 2009, in order to observe the clinical progression of CKD on the initial characteristics of patients, necessity of visit, and the results of revisit. Results: The impact factors of the regular revisit of patients with CKD include the stages of CKD, the educational status of patients, the residence of patients, the underlying diseases, and the family history. The change of glomerular filtration rates (GFR) and serum creatinine levels are remarkable on patients without regular revisit in comparison of those followed regularly. Conclusion: A regular revisit is beneficial for a patient with CKD on effective control of GFR and serum creatinine level as well as slowing the disease progression.