全民健康保險慢性腎臟病醫療給付改善方案之效果與經濟評估

Abstract

背景 慢性腎臟病之防治與照護為世界各國公共衛生界所關注之重要議題，而對台灣的醫療照護體系來說，提供治療與照護予逐年攀升的慢性腎臟病病患，更是極沉重的財務負擔。健保署分別於2006年與2011年推動「末期腎臟病前期之病人照護與衛教計畫」以及「初期慢性腎臟病醫療給付改善方案」，期望透過支付制度的設計來增進病患照護結果，進而減輕健保的醫療與財務壓力。本研究欲評估上述兩計畫於臨床面與醫療成本面的中長期成效。 研究方法 利用長庚醫療體系2008-2017去識別化的電子醫療資料，本研究以回溯性世代研究配對設計，探討接受論質計酬Early CKD或Pre-ESRD的18歲以上成年慢性腎臟病病患之臨床效果與成本效益。針對兩論質計酬計畫之主要研究終點 – 「疾病惡化」及「腎臟替代治療」，透過cause-specific hazard regression model估計計畫介入之校正後風險比值及其95%信賴區間。本研究另針對重要次族群執行次族群分析。在Early CKD方案的成本分析部份，利用Wilcoxon rank-sum test 檢視醫療費用的組間差異，再進一步透過two-part model估計每位病患的校正後花費；本研究亦計算加入Early CKD方案之遞增成本效果比值及net monetary benefit，並繪製成本效果可接受曲線。 研究結果 Early CKD方案的五年分析結果顯示，介入組病患較對照組病患呈現出39%較低機率之疾病惡化發生風險(CS-HR: 0.61, 95% CI: 0.58 – 0.64, p < 0.0001)，且整體醫療花費較介入組低。除此之外，研究結果亦指出Early CKD方案與「糖尿病醫療給付改善方案」具加成作用。針對Pre-ESRD計畫的十年分析結果則發現介入組與對照組病患接受腎臟替代治療之風險無顯著差異；不過，該計畫可顯著降低病患全因死亡之風險(CS-HR: 0.62, 95% CI: 0.45 – 0.85, p = 0.0029)。此外，病患對兩方案的順從狀況佳。 結論 本研究結果顯示Early CKD方案不僅有效降低病患的疾病惡化，更可節省成本。Pre-ESRD計畫雖未能降低病患進入腎臟替代治療之狀況，卻可顯著降低病患死亡之風險。本研究結果呼應全球因應CKD防治的策略趨勢 － 由ESRD之治療，轉至更積極的初段與次段預防，並同時提升CKD之照護品質，以改善CKD病患之健康成效。

Background The public health systems around the world have deemed the management of chronic kidney disease (CKD) a critical issue. In Taiwan, the increasing prevalence of CKD has brought a heavy financial burden to the healthcare system. To improve healthcare outcomes and furthermore relieve the finaicial burden, the National Health Insurance Administration (NHIA) of Taiwan launched a countrywide Pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program in 2006 and later an Early CKD P4P program in 2011. This study aimed to examine the mid-term and long-term effects of these two programs from clinical and financial perspectives. Methods Matched cohort studies were conducted using the electronic medical records from a large healthcare delivery system in Taiwan. The primary outcomes of interest included CKD progression and renal replacement therapy (RRT). The cause-specific hazard regression model was adopted to estimate the hazard in the P4P group as compared to non-P4P group. Subgroup analyses were also performed. Wilcoxon rank-sum test was used to compare the between-group differences in healthcare costs, and a two-part model was applied to estimate the adjusted annual costs for Early CKD patients. The study also calculated the incremental cost-effectiveness ratio (ICER) and net monetary benefit of participating in the Early CKD program. In addition, the cost-effectiveness acceptability curve (CEAC) was plotted. Results The 5-year follow-up of the Early CKD cohort demonstrated a 39% (CS-HR: 0.61, 95% CI: 0.58 – 0.64, p < 0.0001) reduced risk of CKD progression and less healthcare spending for P4P program enrolees. The results of the subgroup analysis further revealed an additive effect of the Early CKD program and diabetes P4P program on CKD progression. The 10-year follow-up of the pre-ESRD cohort did not find differences in terms of risk of RRT between P4P program enrolees and non-enrolees. Nevertheless, the risk of mortality was significantly lower in the P4P group (CS-HR: 0.62, 95% CI: 0.45 – 0.85, p = 0.0029). Patients showed good adherence to both P4P programs. Conclusion The present study results suggest that the Early CKD P4P program is not only superior to usual care to decelerate CKD progression but cost-saving. The Pre-ESRD P4P program, although not found to lower the risk of RRT, showed to reduce patients’ mortality. The study results echo the worldwide trend to shift the focus from the treatment of ESRD to more proactive primary and secondary prevention strategies while improving the quality of CKD care.