台灣末期腎臟病患血液透析與腹膜透析成本效果分析

Abstract

研究背景 由於透析病人需要持續性的透析治療再加上所引發的高額費用，透析服務不論在台灣或是國外都是重要的議題，透析服務包括血液透析與腹膜透析二種模式，二種模式分別在成本以及效果上的比較已有許多研究。在成本效果分析(cost-effectiveness analysis)上大部分以決策分析模型(decision analytic model)進行，缺乏以個人資料(individual data)分析的研究，此外傾向分數校正方式在成本效果分析上才剛開始發展，極少應用於透析模式比較中。台灣末期腎臟病發生率與死亡率為世界前幾名，目前健保鼓勵使用腹膜透析，需要血液透析與腹膜透析成本效果分析作為實證基礎。因此本研究將以個人資料進行成本效果分析，並探討傾向分數校正方式產生的影響。 研究目的 1. 比較使用血液透析與腹膜透析病人在活情形上的差異 2. 比較使用血液透析與腹膜透析病人在醫療成本上的差異 3. 比較使用血液透析與腹膜透析病人在成本效果上的差異 研究方法 本研究採用1997至2009健保資料庫中所有透析病人的申報資料，針對1998年1月至2006年6月開始透析的新增病人觀察3年，以logistic regression計算個人選擇腹膜透析機率作為傾向分數進行配對。存活分析部分以Cox regression控制其他因素後分析二種透析模式在死亡風險上的差異。成本分析部分以線性迴歸方式比較二種透析模式在總成本、門診透析成本、急診成本、其他成本以及住院成本上差異。成本效果分析計算二種透析模式間incremental cost-effectiveness ratio(ICER)與Cost-Effectiveness Acceptability Curves(CEAC)。 結果 本研究配對後血液透析與腹膜透析各4,823個樣本，存活分析部分，腹膜透析在透初期存活情形較佳，隨著觀察期的延長腹膜透析死亡風險增加幅度大於血液透析。開始透析年2005至2006年樣本相較於1998至2000年二種透析模式死亡風險都有降低的情形，腹膜透析降低的程度較多。成本分析部分腹膜透析相較血液透析，總成本低9,658，門診透析低12,045，急診低261，其他門診高2,924，住院不顯著。成本效果分析部分相較於腹膜透析，血液透析每增加1個月存活每個月需增加13,917的成本，觀察3年每增加1年存活共需增加6,012,144成本。有糖尿病者ICER遠低於整體樣本，無糖尿病者腹膜透析為最佳方案。開始透析年2005至2006年樣本中腹膜透析為最佳方案。 結論 整體來說，血液透析相較腹膜透析成本較高但存活較好，不過血液透析與腹膜透析在成本與效果的差異會因為糖尿病狀況以及不同開始透析年病人而改變，因此在比較血液透析與腹膜透析的優劣時必須考量這些差異。

Background There are two dialysis methods, hemodialysis (HD) and peritoneal dialysis (PD). The previous studies mostly use the decision analytic model in the cost-effectiveness analysis (CEA), rather than using the individual data. Further, not so much research, until now, initially adopt the propensity score (PS) method for the cost-effectiveness analyses in dialysis modality comparison. The incidence and previence rate of End stage renal disease (ESRD) in Taiwan are high comparing to other countries. Recently, Taiwan health authorities encourage using PD; however, the cost-effectiveness analyses between PD and HD based on the evidence based was deficit. The study uses individual data to do CEA between PD and HD. Purpose 1. Compare the difference of survival between PD and HD. 2. Compare the differences of medical cost between PD and HD. 3. Compare the differences of cost utilities between PD and HD. Methods The study used the Nation Health Insurance database for the all dialysis claim data from 1997 to 2009. We only selected the new dialysis cases during 1998 Jan to 2006 June with 3 years follow up. We conducted logistic regression to calculate the possibility of selection in peritoneal dialysis and used the possibility for PS matching. The Cox regression model is used in survival analysis. Besides, we used regression model to compare the differences in total cost, outpatient cost, emergency department cost, other outpatient cost, and hospitalization cost between PD and HD. Incremental cost-effectiveness ratio(ICER) and Cost-Effectiveness Acceptability were used in cost-effectiness analysis. Results There were 4,823 patients in both dialysis mordality after PS match. In survival analyses, PD has better survival outcome comparing with HD in beginning period, but the mortality increases more rapidly in PD. In patients who start dialysis in 2005 to 2006, both dialysis modalities have lower mortality rate then in other patients, and PD decreased more than HD. In cost analyses, compare to HD, the monthly total cost, outpatient dialysis cost, emergency department cost, were lower in, 9,658, 12,045, 261, respectively in PD, while other outpatient cost increased 2,924 and hospitalization was not significant between two dialysis mordality. Regarding the cost-effectiveness analysis, compare to PD, the monthly cost with one more month survive increasing was 13,917 for HD. In the 3 year follow-up group, the total cost with one more year survive increasing was 6,012,144 for HD. The ICER for diabete patients is lower then in total sample, and PD is dominated modality in non-diabete patients. Besides, PD is dominated modality for patients who start dialysis in 2005 to 2006. Conclusions Generally, HD costs more than PD but survive better; however, those cost and outcomes difference between PD and HD varied among different diabete condition patients and patients in different dialysis starting year. Therefore, it must consider those differences when comparing PD and HD.