糖尿病患加入腎臟病照護計畫之成效評估

Abstract

研究背景與目的：糖尿病和慢性腎臟病這兩項慢性病是國人進入透析的主要病因，2006年約有9,600多人新進入透析治療，透析病患若要脫離長期透析治療之行列，僅能透過腎臟移植處置或死亡，而數據顯示國內每年境內腎臟移植人數僅將近300名，所以腎臟移植仍追不上進入透析病患的速度，因此，在尚未進入透析前，即給予慢性腎臟病病患介入照護，早期發現、積極治療，以延緩進入透析治療的時程及維護照護品質，是現今世界各國共同努力的目標。臺灣、日本及美國的糖尿病病人佔新進入透析族群已超過了四成，直至2010年臺灣因為糖尿病進入透析的比率更高達45.7%，突顯出糖尿病族群在進入透析階段防治上的重要性。本研究之目的，即為探討糖尿病病患在加入Pre-ESRD慢性腎臟病照護計畫後，對於醫療利用、醫療費用及進入長期透析情形作討論，以提供未來糖尿病和慢性腎臟病照護政策之參考。 研究方法：本研究利用衛生福利部中央健康保險署之健保資料庫進行分析，資料期間為2006年至2011年之申報資料，研究母群體為中央健康保險署實施之「全民健康保險糖尿病醫療給付改善方案」收案對象名單，選取其中腎臟病分期3至5的對象，以有加入「全民健康保險末期腎臟病前期（Pre-ESRD）之病人照護與衛教計畫」者為介入組，未加入者為對照組，並經傾向分數配對後，介入組和對照組皆為1,980人，共3,960人。本研究採用羅吉斯迴歸和廣義估計式(Generalized estimating equations，GEE) 作重複測量資料分析，並以差異中之差異法(DID)來評估在控制各變項後，計畫介入對醫療利用及醫療費用之影響，另以Kaplan–Meier法繪製存活曲線及計算存活率，並依據Log-rank test比較兩組樣本在進入透析時間是否有差異。 研究結果：本研究觀察糖尿病患在尚未進入透析前的期間，加入慢性腎臟病照護計畫之影響，在醫療利用方面，介入組腎臟病相關門診就醫次數皆較對照組顯著增加，介入組從10.6次增加為17.6次、對照組從5.8次增加為7.7次，但腎臟病相關住院天數皆未達顯著差異，介入組2.8天上升為5.4天，對照組2.0天上升為3.5天；醫療費用方面，介入組腎臟病相關的總醫療費用與門診費用均較對照組為增加，介入組分別增加71,905點與51,812點、對照組分別增加81,076與71,257點，但腎臟病相關的住診費用卻未達統計上顯著差異，介入組增加20,093點、對照組增加9,820點。在進入透析情形，介入組存活曲線下面積較對照組為大並達統計上顯著差異，因此在計畫介入後，介入組能延後進入長期透析之時程。 研究結論和建議：糖尿病患加入Pre-ESRD慢性腎臟病照護計畫後一年內，其門診次數、總醫療費用、門診醫療費用均有顯著上升，且介入組進入長期透析的時程較對照組為延後，顯示Pre-ESRD計畫的實施，短期間可增加門診醫療利用與費用，並延緩腎臟功能惡化的情形。建議相關當局可就糖尿病和慢性腎臟病發展以病人為中心之整合性照護模式，鼓勵高風險族群參與Pre-ESRD慢性腎臟病照護計畫，以降低晚期腎臟病發生率為最終目的。

Background and Objectives: Diabetes and chronic kidney disease (CKD) are the major cause of people into dialysis in Taiwan. In 2006, about 9,600 new patients into the dialysis treatment. Dialysis patients must be treated a kidney transplant or death from dialysis treatment. Although the number of kidney transplants each year is nearly 300 in Taiwan, kidney transplant is still lagging behind the speed to those entering dialysis. Early detection and early treatment to delay entering dialysis schedule and maintain quality of care is the world common goal today. Diabetes patients has exceeded 40% into dialysis treatment in Taiwan, Japan and the United States. Until 2010, dialysis ratio due to Diabetes was as high as 45.7% in Taiwan, highlighting the significant impact on the populations of diabetes prevention and treatment of chronic kidney disease. The purpose of this study is to evaluate patients with diabetes after joining the Pre-ESRD chronic kidney disease care program on medical use, medical costs and the entry time of dialysis. Methods: This study adopted the NHI claim data from 2006 to 2011. The population is people joined the diabetes pay-for-performance project. These diabetes patients who joined Pre-ESRD chronic kidney disease care program were recruited as the intervention group and who never joined were control group. After using propensity score matching, the intervention and control groups are 1,980 people respectively, a total of 3,960 people. In this study, logistic regression and Generalized Estimating Equations(GEE) were applied to predict the influence and we use Difference-in-Difference(DID) method to evaluate the impact of the Pre-ESRD program by comparing the health care utilization and costs. Kaplan-Meier method to calculate survival curve, and Log-rank test were test for the differences between the two groups into the dialysis time. Results: In health care utilization, the intervention group significantly increased on overall and nephrology-related physician visits. However, the hospitalization and length of stay were not significantly different. Total and outpatient medical costs significantly increased in intervention group. Inpatient medical costs was not significantly different after the intervention of Pre-ESRD chronic kidney disease care program. Results of survival analysis, the time of entry into dialysis was delayed in the intervention group. Conclusions and Suggestions: The Pre-ESRD chronic kidney disease care program seemed to increase the outpatient medical utilization and health care costs, enhancing quality of health care and slow the case of kidney function deterioration. Suggested that the relevant authorities can establish patient-centered integrated care for diabetes and chronic kidney disease. Encouraging high-risk groups to participate in Pre-ESRD chronic kidney disease care program, to reduce the incidence of end-stage renal disease.