台灣慢性腎臟病之管理 —末期腎臟病前期之病人照護與衛教計畫

Abstract

健保開辦後醫療亦有財務方面的要件之考量，尤其總額預算制度下，任何實證醫學的治療計畫，必須強調健保財務預算平衡及醫療資源耗用的合理性。質言之，財務平衡為健保總額預算重要的課題。爰此，本文分別從個體經濟與總體經濟的角度評估國內慢性腎臟病整合性照護在健保財務上的合理性，藉此尋找衡量出平衡兩方的觀點的方法，創造雙贏。 第三章與第五章從總體經濟的角度來看，慢性腎臟疾病的管理Pre-ESRD計畫是否能減少慢性腎臟疾病惡化。利用全國健保資料庫實際執行Pre-ESRD計畫五年後的資料，本文先回顧黃尚志教授的報告計畫結果：在臨床療效方面，病人的存活狀態(p<0.01)、延緩透析發生率(p<0.01)、接受腹膜透析率(p<0.01)，執行論質獎勵計畫(Pay for Performance, P4P)的實驗組均優於non-P4P對照組病人。然在醫療資源耗用情形方面，在開始追蹤後五年，平均每人的門診(p<0.001)與急診(p<0.001)費用均較高，住院費用(p=0.1782)則沒有差異。經本文利用5年追蹤期間存活曲線校正每人每年門診、急診、住院之醫療費用，並重估Pre-ESRD醫療費用支出的項目及醫療耗用合理性後可知，P4P實驗組醫療資源總耗用高，主要來自Pre-ESRD計畫結案後，末期腎病維持生命的透析洗腎治療。P4P實驗組病人，因累積死亡率低且接受維持生命的透析治療累積透析人數高，而墊高了P4P實驗組總體醫療資源總耗用。且扣除洗腎費用後，P4P實驗組病人與non-P4P對照組病人平均每年醫療費用沒有差異(p=0.8084)。 本論文第四章從微觀的角度討論在Pre-ESRD末期腎臟病前期照護與衛教計畫方案下腎臟科診所的照護流程，同時針對個別腎臟科診所執行Pre-ESRD之成本分析。在考量用人費用、藥品及材料成本、設備費用折舊、管理費用四個項目後可看出，從個別診所經營的角度，腎臟科診所執行Pre-ESRD計畫很難收支平衡。 台灣104年度透析醫療費用約350 億，約佔健保醫療總額5.8％，是重要的醫療資源耗用疾病。慢性腎病主要的負擔的確是來自於其後的尿毒症之透析的醫療費用，以及慢性腎病伴隨著的併發症、心血管疾病及糖尿病所帶來的影響亦是醫療費用主要耗用之處。本文建議在腎臟病早期推動整合性的醫療照護，唯有做好腎臟病管理，才有可能改善我國慢性腎病醫療資源耗用的情況。

Since the launch of the National Health Insurance (NHI) program in Taiwan, the financial issue of healthcare has gained great importance especially under the global budget system. Any treatment plan following evidence-based medicine (EBM) should also base on a reasonable budget. Therefore, in the present work, we evaluate the economical reasonability of National Health Insurance Chronic Kidney Diseases Comprehensive Care System Plan from both microeconomic and macroeconomic perspectives in order to strike a balance between and create a win-win situation. In Chapter 3 and 5, we evaluate the cost-effectiveness of Pre-ESRD patient care and health education programs in delaying the progress of chronic kidney diseases from a macroeconomic perspective using the data from National Health Insurance Research Database. We first review the report of Dr. Shang-Zhi Huang (2014). It was reported that comparing the patients under Pay for Performance (P4P) plan with control group (non-P4P), patients in P4P(Pay for Performance) group had better clinical outcomes including survival rate (p<0.01), delayed onset of dialysis (p<0.01), and higher rate of peritoneal dialysis (p<0.01) but cost significantly more medical resources including outpatient expenditure (p<0.001) and emergency expenditure (p<0.001) after 5-year follow-up. However, in the present work, after calibrating the medical expenditure with survival curve and performing re-evaluation on the reasonability of expenditure items, we showed that the high-cost of P4P plan came from its lower mortality rate and higher rate of dialysis. Furthermore, after subtracting the cost for dialysis, the medical expenditures between 2 groups have no differences (p=0.8084). In Chapter 4, we discussed the care process of a chronic kidney disease patient under the Pre-ESRD patient care and health education programs and performed a cost analysis from the perspective of a primary-care physician. After considering the personnel cost, material cost, equipment depreciation and overhead cost, we showed that a primary-care physician participating the Pre-ESRD program could hardly strike a balance between income and expenditure. Dialysis cost about 35 billion dollars annually in Taiwan, representing 5.8% of annual health insurance global budget, and is an important resource-utilizing disease. The burden of chronic kidney diseases mainly comes from dialysis and the complications of CKD including cardiovascular diseases and diabetes. We recommended that effective management of kidney disease is the only possible way to improve the cost-effectiveness of the comprehensive medical care program for early-stage kidney disease.