臺灣博碩士論文加值系統

背景：本研究的目的是估計高齡血液透析個案的發生率、平均餘命、預期生命損失、年身醫療費用與終身醫療費用，並依年齡，性別和糖尿病的有無做分層分析。
方法：我們以國家衛生研究院的全民健康保險研究資料庫做分析；從1997年7月1日起至2005年12月31日，在重大傷病證明明細檔中新發生的末期腎臟病且接受血液透析的65歲以上個案，共有24,243位，計算依年齡與性別分層的末期腎臟病且接受血液透析的發生率與65歲以後20年的累積發生率。在排除3,423位癌症個案之後，追蹤這些個案至2006年年底；並藉由Monte Carlo方法從生命表建立一與個案在年齡與性別相匹配的參考人口，接著以末期腎臟病個案與參考人口之間的存活函數做外推，並依年齡、性別與糖尿病的有無做分層分析；進一步分析個案之年醫療費用與終身醫療費用，並依年齡、性別與糖尿病的有無做分層分析。
結果：高齡糖尿病末期腎臟病個案相較於沒有糖尿病的平均餘命來得短；而65-79歲間的糖尿病男性與女性，平均預期生命損失分別為10.6-5.8年與12.3-7.3年。65歲的糖尿病與非糖尿病個案未來20年進展成末期腎臟病且接受血液透析的累積發生率，分別為0.07472-0.09282與0.01572與0.01995。藉由防治末期腎臟病對高齡族群潛在所能增加之預期生命在男性為5,430.1年，女性為10,177年。高齡糖尿病末期腎臟病個案年醫療費用明顯高於非糖尿病者，隨者年齡的增加，這樣的趨勢仍然存在，只是差距縮小。
結論：未來20年高齡糖尿病個案進展成末期腎臟病且接受血液透析的風險，是沒有糖尿病高齡人口的5倍；高齡慢性腎臟病與末期腎臟病的防治是相當重要的，特別是高齡糖尿病個案。

BACKGROUND: The objective of this study is to quantify the incidence rate, life expectancy (LE), expected years of life lost (EYLL), cost per year and lifetime cost in the elderly with ESRD under maintenance hemodialysis after stratification by age, sex and the presence of diabetes.
METHODS: We conducted a population-based study by using National Health Insurance Research Database (NHIRD). We identified all incident ESRD cases aged over 65 and under maintenance hemodialysis from registry files of catastrophic illnesses in Taiwan from July 1, 1997 to December 31, 2005. There were 24,243 cases; the age- and sex-specific incidence rates and cumulative incidence rates of ESRD between age 65 and 84 years (CIR65-84) were calculated. After excluding 3,423 cases with malignancy, their survivals were followed through the end of 2006. The survival function for an age- and sex-matched reference population was generated by using the Monte Carlo method from the life table of the general population; survival ratio between ESRD cohorts and referents was used for lifetime extrapolation after stratification by age, sex, and the presence of diabetes. Cost per year and lifetime cost (including healthcare expenditures of ambulatory care and inpatient care) were further analyzed after stratification by age, sex, and the presence of diabetes.
RESULTS: The elderly with diabetes and ESRD seem to have a shorter LE than those without diabetes. The estimated average EYLL were 10.6-5.8, and 12.3-7.3 years for males and females with diabetes aged between 65 and 79. The CIR65-84 of requiring hemodialysis in the elderly with diabetes were 0.078 and 0.099 for males and females, but those without diabetes were 0.017 and 0.020 for males and females. The life years potentially saved by successful prevention of ESRD could be 5,430.1 and 10,177 life years in males and females, respectively. The cost per year was higher in those with diabetes than those without diabetes, and the trend persisted as the age advanced, although the differences between those with and without diabetes narrowed in the oldest old group.
CONCLUSION: The likelihood of developing ESRD for the elderly with diabetes in the coming 20 years was nearly 5 times of the risk in the elderly without diabetes. Prevention of ESRD among the elderly is of great importance, especially among the elderly with diabetes.

目錄
中文摘要....................................................I
英文摘要...................................................II
致謝......................................................IV
目錄.......................................................V
表目錄....................................................VII
圖目錄...................................................VIII
第壹章、研究背景及動機.........................................1
第一節、高齡糖尿病的流行病學....................................1
第二節、高齡慢性腎臟病的流行病學.................................3
第三節、高齡末期腎臟病的流行病學.................................5
第四節、高齡醫療利用與醫療費用...................................8
第貳章、研究目的.............................................12
第參章、文獻查證.............................................13
第一節、臨床腎功能的評估......................................13
第二節、慢性腎臟病的定義......................................16
第三節、平均餘命與預期生命損失..................................17
第四節、糖尿病、慢性腎臟病與末期腎臟病的平均餘命...................19
第五節、高齡慢性腎臟病與末期腎臟病的醫療費用......................22
第肆章、研究方法.............................................24
第一節、研究族群與資料收集.....................................24
第二節、累積發生率...........................................26
第三節、長期血液透析族群之存活函數估計...........................27
第四節、長期血液透析族群之存活函數外推...........................28
第五節、預期生命損失的估計.....................................29
第六節、估算防治末期腎臟病所增加之預期生命........................30
第七節、推估末期腎臟病的年醫療費用與終生醫療費用...................32
第伍章、研究結果.............................................33
第一節、發生率與累積發生率.....................................33
第二節、平均餘命與預期生命損失..................................34
第三節、防治末期腎臟病所增加之預期生命...........................38
第四節、末期腎臟病的年醫療費用與終生醫療費用......................39
第陸章、討論................................................42
第一節、發生率的探討..........................................42
第二節、累積發生率的意義......................................44
第三節、年齡對平均餘命與預期生命損失的影響........................45
第四節、性別對平均餘命與預期生命損失的影響........................47
第五節、糖尿病對平均餘命與預期生命損失的影響......................48
第六節、平均餘命與預期生命損失的應用.............................49
第七節、慢性腎臟病與末期腎臟病年醫療費用的比較.....................51
第八節、研究限制.............................................52
第柒章、結論與建議...........................................53
第一節、結論................................................53
第二節、建議................................................54
第捌章、參考文獻.............................................55
第一節、中文部份.............................................55
第二節、英文部份.............................................56
附錄一、101年成大醫學院研究生研究論文競賽優勝獎狀..................66
附錄二、本論文刊登於Diabetes Care全文.........................67

表目錄
表1-1、2000-2010年65歲以上人口健保就醫費用......................8
表1-2、2000-2010年80歲以上人口健保就醫費用......................9
表3-1、新版台灣公式與目前國際公式的比較..........................14
表3-2、慢性腎臟病的定義與分期..................................16
表3-3、高齡透析個案存活分析的研究...............................21
表5-1、高齡糖尿病與非糖尿病患者發生末期腎臟病且接受血液透析的發生率 (1/106 人-年) 與新發生個案數 (括弧)，以年齡、性別與歷年分層........33
表5-2、高齡血液透析患者平均餘命與預期生命損失的比較................35
表5-3、一年之中可預防的末期腎臟病個案數與所增加之預期生命...........38
表5-4、高齡血液透析患者年醫療費用與終生醫療費用的比較...............40

圖目錄
圖1-1、台灣慢性腎臟病的盛行率...................................4
圖1-2、2009年世界各國末期腎臟病發生率............................5
圖1-3、2009年世界各國糖尿病造成末期腎臟病的比率....................6
圖1-4、2009年世界各國糖尿病造成末期腎臟病的發生率..................6
圖1-5、2000-2010年65及80歲以上人口健保就醫費用比較...............9
圖1-6、2004年台灣慢性腎臟病、鬱血性心衰竭、糖尿病與末期腎臟病所佔比例.10
圖1-7、2004年台灣慢性腎臟病、鬱血性心衰竭、糖尿病與末期腎臟病醫療費用比例........................................................11
圖3-1、糖尿病與非糖尿病之平均餘命...............................19
圖3-2、慢性腎臟病平均餘命.....................................20
圖3-3、2007-2009美國65歲以上慢性腎臟病每人每年醫療費用............22
圖3-4、1996-1999年高齡慢性腎臟病各分期門診醫療利用...............23
圖3-5、1996-1999年高齡慢性腎臟病各分期每人每年醫療費用............23
圖4-1、研究流程圖...........................................25
圖4-2、糖尿病與非糖尿病進展至末期腎臟病的病程.....................30
圖5-1、高齡血液透析患者與年齡、性別相匹配的參考族群平均存活之差異.....36
圖5-2、高齡血液透析患者(A)平均餘命與(B)預期壽命損失，以年齡、性別與糖尿病的有無做分層..............................................37
圖5-3、高齡血液透析患者醫療費用的比較...........................41
圖6-1、死亡及末期腎臟病風險與年齡及腎絲球濾過率的關係...............43
圖6-2、末期腎臟病對於糖尿病與非糖尿病在平均餘命上的影響.............50

中文部份
行政院新聞局 (2012)。全民健康保險。
行政院衛生署 (2011)。2010年主要死因分析。
行政院衛生署國民健康局 (2003)。台灣地區高血壓、高血糖、高血脂之盛行率調 查。
行政院衛生署國民健康局 (2010)。慢性腎臟病防治手冊。
行政院衛生署國民健康局 (2011)。2007年台灣地區高血壓、高血糖、高血脂之追蹤調查研究。
行政院衛生署國民健康局 (2011)。2011台灣慢性腎臟病科技研究報告發表。
沈德昌、顏兆熊 (2009)。老年人之糖尿病。台灣醫界，52，499-502。

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