臺灣博碩士論文加值系統

研究背景與目的：
台灣腎臟醫學會（2003年）資料顯示台灣地區末期腎臟病（ESRD）發生率與盛行率於民國92年分居為世界第一與第二名，其中老年人（≧65歲）ESRD發生率與盛行率更高居世界之冠（United States Renal Data System，USRDS, 2004, 2005）。且在民國92年底台灣地區接受透析之ESRD病患共有36,860人，其中老年人佔45％。進入ESRD早期的慢性腎臟病（CKD），依91年台灣三高調查結果顯示，CKD Stage 3-5比例高達6.43%，其中老年人的盛行率更接近30%。台灣地區老年人的ESRD與CKD之盛行率與醫療支出關係，過去並無相關研究探討，高ESRD發生率與盛行率的高雄市，是否也是CKD之高盛行地區，因而造成老人醫療資源耗用的增加，且隨著CKD病情嚴重程度而增加其耗用。因此，本研究之目的為探討高雄市老年人CKD的疾病嚴重程度與其醫療資源耗用之關係及其影響因子，以提供衛生政策制訂單位做為CKD防治策略之參考。

研究方法：
本研究採用回溯性長期追蹤研究（retrospective longitudinal study），取材1996-1999年接受高雄市老人健康檢查的族群，連結1996-1999年全民健保資料庫之「門診處方及治療明細檔」與「住院醫療費用清單檔」，資料合併後分析老年人CKD在各年度盛行率與醫療資源耗用外，並以1997年之老年人族群（Closed cohort）為本研究之目標族群，經整併後共得7919人。腎絲球過濾率（GFR）係以健檢資料中的血清肌酸酐利用Simplfied MDRD公式計算出目標族群之，並採用美國國家腎臟基金會（NKF）對於CKD之定義，將目標族群分為輕症組（GFR≧60 ml/min/1.73m2）、CKD Stage 3a（GFR 45-59 ml/min/1.73m2）、CKD Stage 3b（GFR 30-44 ml/min/1.73m2）、CKD Stage 4（GFR 16-29 ml/min/1.73m2）、CKD Stage 5( GFR≦15 ml/min/1.73m2）。根據1996年門診A-Code或 ICD-9診斷碼定義其合併症（Co-morbidity）狀況。以卡方檢定、t檢定、變異數分析、對數回歸模式及GEE模式之統計分析樣本自1996至1999年住院風險與醫療資源耗用包括各年度門診次數、每次門診費用、住院風險及長期總醫療費用。

研究結果：
不同觀察年代其CKD的盛行率有所差異，並呈現逐年下降情況；可能為新加入健檢之健康族群所導致。CKD嚴重度越高，年代越往後對醫療資源影響越大。選取目標族群世代當研究對象時，我們發現老年人有43%之不同程度腎功能損傷，且平均GFR隨著年齡逐漸下降；男性有較高罹患CKD的風險。在控制人口學特質、肥胖因子及合併症後，老年人住院風險隨著CKD嚴重程度逐漸上升，校正後的危險對比值，各組別為CKD Stage 3a為1.2，CKD Stage 3b為1.5，CKD Stage 4為2.0，CKD Stage 5為3.2；各組皆達到統計學上顯著差異，且在CKD相關合併症（如高血壓、貧血）分層下此種趨勢依舊存在。最後以GEE分析模式結果發現，CKD Stage 3a總醫療花費比輕症組每年多2,526元，CKD Stage 3b每年多6,600元，CKD Stage 4每年多25,692元，CKD Stage 5每年多153,363元；且達統計顯著差異。

結論：
本研究以實證研究證實台灣老年人每次平均門診費用隨CKD嚴重度（輕症組<Stage 3a<Stage 3b<Stage 4<Stage 5）與觀察年度增加（年度越往後，費用越高）。CKD相關合併症族群其住院風險亦隨著CKD不同嚴重度上升；最後，在控制時間及合併症效應後，長期總醫療費用費用仍維持這種趨勢。故如何制訂相關政策，規劃有效介入措施以減少老年人因CKD所造成之醫療費用，實挑戰著衛生政策制訂單位。

Objectives
Taiwan has extreme high incidence and prevalence of end stage renal diseases (ESRD) in the world, and both rank top in groups with age 65 to 75 and over 75 years. There were 36,860 ESRD persons who receiving dialysis in year 2003, and the elderly comprised 45% of total dialysis populations. Chronic kidney disease (CKD) was also epidemic in elderly in Taiwan; there were 6.43% in general population and near 30% in elderly respectively, according to Tw3H Survey in year 2002. However, there was no study to explore the associated between ESRD/CKD and medical utilizations in Taiwan. Is the CKD as the main factor responsible for the increase of cost in elderly, and whether the cost is increasing as the increase of severity of CKD stages? The aims of this study were to investigate the medical utilization of the elderly with different stages of chronic kidney diseases and to evaluate those factors associated with increase of medical utilization in Taiwan.

Method and Materials
We conducted a retrospective longitudinal study, analyzing 1996-1999 claim data from 7,919 elderly people with age over 65 years, who took annual physical check up in Kaohsiung City in year 1997. Estimated GFR was calculated by simplified MDRD formula. The CKD group was classified to Reference group (GFR≧60ml/min/1.73m2), CKD Stage 3a (GFR45-59ml/min/1.73m2), CKD Stage 3b (GFR30-44ml/min/1.73m2), CKD Stage 4 (GFR16-29ml/min/1.73m2) and CKD Stage 5 (GFR≦15ml/min/1.73m2). Other covariates including age, sex, obesity and co morbidities were incorporate into further analysis. Multiple logistic regression and General Estimating Equation (GEE) were used for evaluating the risk of hospitalization and longitudinal trend of medical cost, respectively.

Result
A total of subject comprised 63.7% with age over 70 years, 59.7% of male, and 42.9% with late CKD. Among subjects having at least two co-morbidities, the highest one in frequency was hypertension (63.4%) and the follow one was osteoarthritis (60.5%). After control age and sex, the risks of hospitalization were 1.2 for group of Stage 3a, 1.5 for group of Stage 3b, 2.0 for group of Stage 4 and 3.2 for group of Stage 5 compared to Reference group. The risk of hospitalization was raised with CKD severity, and plot was also appeared on co-morbidities associated with CKD such as hypertension and anemia. The annual total cost for groups of Stage 3a, Stage 3b, Stage 4, and Stage 5 were 2,526, 6,600, 25,692 and 153,363 N.T. dollars higher than the Reference group, respectively.

Conclusion
The evidence-based study proved a strongly association between longitudinal medical utilizations and stages of CKD in elderly in Taiwan. The increase of severity of CKD in elderly results in increase of the medical utilizations. As the government face to the impact of aging, how to release the burden of deteriorating health condition in elderly is an important challenge.

中文摘要 I
英文摘要 III
誌 謝 V
表目錄 VII
圖目錄 VIII
第一章 緒論 9
第一節 研究背景與動機 9
第二節 研究目的 12
第三節 研究重要性 13
第四節 名詞解釋 14
第二章 文獻探討 16
第一節 人口老化對世界的衝擊 16
第二節 影響慢性腎臟疾病醫療資源耗用的風險因子 23
第三節 慢性腎臟疾病之醫療資源耗用及影響因子 25
第三章 材料與方法 27
第一節 研究架構與研究假設 27
第二節 研究設計與資料來源 30
第三節 研究樣本與材料 31
第四節 研究變項與操作型定義 33
第五節 統計分析方法 37
第四章 研究結果 40
第一節 1996-1999年高雄市老年人CKD盛行情形與醫療資源耗用 40
第二節 目標族群（1997年）樣本基本資料 43
第三節 目標族群各年度醫療資源耗用分析 46
第四節 探討目標族群醫療資源耗用之預測因子 56
第五節 建構CKD老年人長期醫療資源耗用模式 58
第五章 結論與建議 67
第一節 研究目的、假說與結果討論 67
第二節 研究限制與未來方向 79
第三節 結論 81
第四節 建議 83
參考文獻 85
附 錄 92

中文部分

1.行政院衛生署 (2004). 中華民國九十三年衛生統計（一）公務統計年報. 台北, 行政院.

2.行政院衛生署 (2004). 全民健康保險醫療統計年報. 台北, 行政院.

3.楊五常、黃尚志，台灣慢性腎臟疾病之負擔（2004）

4.黃尚志，91-92台灣透析重大傷病卡申請報告，台灣腎臟醫學會（2004）

5.吳玲珠 (2006). 探討新進入血液透析之末期腎臟並患者其血管通路建立時機與形式對醫療資源耗用之影響. 醫療機構管理學研究所. 高雄, 高雄醫學大學.

6.林子郁 (2002). 末期腎臟疾病患者於不同透析治療階段之醫療費用風險因子探討. 公共衛生研究所, 高雄醫學大學.

7.邱美清 (2004). 末期腎臟疾病患者進入透析前之醫療服務利用及其影響探討. 公共衛生研究所, 高雄醫學大學.

英文部分

1.(2003). "From the Centers for Disease Control and Prevention. Public health and aging: trends in aging--United States and worldwide." JAMA 289(11): 1371-3.

2.Ajzen I, F. M. (1980). Understanding attitudes and predicting social behavior, Englewood Cliffs: Prentice-Hall.

3.Amos, A. F., D. J. McCarty, et al. (1997). "The rising global burden of diabetes and its complications: estimates and projections to the year 2010." Diabet Med 14 Suppl 5: S1-85.

4.Anderson, G. F. and P. S. Hussey (2000). "Population aging: a comparison among industrialized countries." Health Aff (Millwood) 19(3): 191-203.

5.Atkins, R. C. (2005). "The epidemiology of chronic kidney disease." Kidney Int Suppl(94): S14-8.

6.Bakris, G. L., M. Williams, et al. (2000). "Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group." Am J Kidney Dis 36(3): 646-61.

7.BALLINGER, G. A. (2004). "Using Generalized Estimating Equations for Longitudinal Data Analysis " Organizational Research Methods 7(2): 127-150.

8.Barrett, B. J. (2003). "Applying multiple interventions in chronic kidney disease." Semin Dial 16(2): 157-64.

9.Becker, B. N., R. Breiterman-White, et al. (1997). "Care pathway reduces hospitalizations and cost for hemodialysis vascular access surgery." Am J Kidney Dis 30(4): 525-31.

10.Briganti, E. M., P. Branley, et al. (2002). "Smoking is associated with renal impairment and proteinuria in the normal population: the AusDiab kidney study. Australian Diabetes, Obesity and Lifestyle Study." Am J Kidney Dis 40(4): 704-12.

11.Chadban, S. J., E. M. Briganti, et al. (2003). "Prevalence of kidney damage in Australian adults: The AusDiab kidney study." J Am Soc Nephrol 14(7 Suppl 2): S131-8.

12.Chen, J., P. Muntner, et al. (2004). "The metabolic syndrome and chronic kidney disease in U.S. adults." Ann Intern Med 140(3): 167-74.

13.Chou, P., C. L. Li, et al. (2001). "Epidemiology of type 2 diabetes in Taiwan." Diabetes Res Clin Pract 54 Suppl 1: S29-35.

14.Clase, C. M., A. X. Garg, et al. (2002). "Prevalence of low glomerular filtration rate in nondiabetic Americans: Third National Health and Nutrition Examination Survey (NHANES III)." J Am Soc Nephrol 13(5): 1338-49.

15.Cockcroft, D. W. and M. H. Gault (1976). "Prediction of creatinine clearance from serum creatinine." Nephron 16(1): 31-41.

16.Collins, A. J. (2005). Chronic Kidney Disease Detection Programs and their Implications for the Health Care System. Taipei, Taiwan.

17.Eriksen, B. O. and O. C. Ingebretsen (2006). "The progression of chronic kidney disease: a 10-year population-based study of the effects of gender and age." Kidney Int 69(2): 375-82.

18.Fishman, P., M. Von Korff, et al. (1997). "Chronic care costs in managed care." Health Aff (Millwood) 16(3): 239-47.

19.Go, A. S., G. M. Chertow, et al. (2004). "Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization." N Engl J Med 351(13): 1296-305.

20.Grossman, M.(1972). "On the Concept of Health Capital and the Demand for Health." Journal of Plitical Economy 80:223-5

21.Gregory, D. D., M. J. Sarnak, et al. (2003). "Impact of chronic kidney disease and anemia on hospitalization expense in patients with left ventricular dysfunction." Am J Cardiol 92(11): 1300-5.

22.Hallan, S., R. de Mutsert, et al. (2006). "Obesity, smoking, and physical inactivity as risk factors for CKD: are men more vulnerable?" Am J Kidney Dis 47(3): 396-405.

23.Haroun, M. K., B. G. Jaar, et al. (2003). "Risk factors for chronic kidney disease: a prospective study of 23,534 men and women in Washington County, Maryland." J Am Soc Nephrol 14(11): 2934-41.

24.Health, D. o. (2003). Identification, Evaluation, and Treatment of Overweight and Obesity in Adults in Taiwan. Washington, DC:Department of Health.

25.Health, D. o. (2004). Statistical Annual Report of Medical Care, National Health Insurance

26. Hemmelgarn, B. R, Zhang, J, Manns, B. J, et al. "Progression of kidney dysfunction in the community-dwelling elderly. " Kidney Int May 8.

27.Huang, K. C., M. S. Lee, et al. (2005). "Obesity in the elderly and its relationship with cardiovascular risk factors in Taiwan." Obes Res 13(1): 170-8.

28.Hunsicker, L. G. (2004). "The consequences and costs of chronic kidney disease before ESRD." J Am Soc Nephrol 15(5): 1363-4.

29.I., Rosenstock (1966). Why people use healh services, Millbank Memorial Fund Quarterly: 94-121.

30.Joyce, G. F., E. B. Keeler, et al. (2005). "The lifetime burden of chronic disease among the elderly." Health Aff (Millwood) 24 Suppl 2: W5R18-29.

31.Kramer, H., A. Luke, et al. (2005). "Obesity and prevalent and incident CKD: the Hypertension Detection and Follow-Up Program." Am J Kidney Dis 46(4): 587-94.

32.Kurella, M., J. C. Lo, et al. (2005). "Metabolic syndrome and the risk for chronic kidney disease among nondiabetic adults." J Am Soc Nephrol 16(7): 2134-40.

33.Lakdawalla, D. N., D. P. Goldman, et al. (2005). "The health and cost consequences of obesity among the future elderly." Health Aff (Millwood) 24 Suppl 2: W5R30-41.

34.Lan, T.-Y. (2003). "Population Aging in Taiwan:Future Health Implications." Taiwan Journal of public health 22(3): 237-244.

35.Levey, A. S., J. P. Bosch, et al. (1999). "A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group." Ann Intern Med 130(6): 461-70.

36.Levey, A. S., Greene T, Kusek J, Beck GJ, Group MS (2000). " A simplified equation to predict glomerular filtrtion rate from serum creatinine." J Am Soc Nephrol 11: 828A.

37.Li, S., R. N. Foley, et al. (2005). "Anemia and cardiovascular disease, hospitalization, end stage renal disease, and death in older patients with chronic kidney disease." Int Urol Nephrol 37(2): 395-402.

38.Lin, T., P. Chou, et al. (2004). "Predicting factors associated with costs of diabetic patients in Taiwan." Diabetes Res Clin Pract 63(2): 119-25.

39.Lindeman, R. D., J. Tobin, et al. (1985). "Longitudinal studies on the rate of decline in renal function with age." J Am Geriatr Soc 33(4): 278-85.

40.Long, D. A., R. Reed, et al. (2006). "The cost of lifestyle health risks: obesity." J Occup Environ Med 48(3): 244-51.

41.Lubitz, J., L. G. Greenberg, et al. (2001). "Three decades of health care use by the elderly, 1965-1998." Health Aff (Millwood) 20(2): 19-32.

42.Manns, B., M. Tonelli, et al. (2005). "Establishment and maintenance of vascular access in incident hemodialysis patients: a prospective cost analysis." J Am Soc Nephrol 16(1): 201-9.
43.Menon, V. and M. J. Sarnak (2005). "The epidemiology of chronic kidney disease stages 1 to 4 and cardiovascular disease: a high-risk combination." Am J Kidney Dis 45(1): 223-32.

44.Mecked H., B. (1974). The health belief model and perosonal health behavior. New Jersey.

45.Nasr, C. E., B. J. Hoogwerf, et al. (1999). "United Kingdom Prospective Diabetes Study (UKPDS). Effects of glucose and blood pressure control on complications of type 2 diabetes mellitus." Cleve Clin J Med 66(4): 247-53.

46.National Center for Chronic Disease Prevetion and Health Promotion, C. (1999). Chronic disease notes and reports:special focus.Healthy Aging: 12:3.

47.Newhouse, J. P.(1997). "Medical-care expenditure: a cross-national survey
." J Hum Resour 12(1):115-25

48.Nygaard, H. A., M. Naik, et al. (2004). "Clinically important renal impairment in various groups of old persons." Scand J Prim Health Care 22(3): 152-6.

49.Pan, W. H., H. Y. Chang, et al. (2001). "Prevalence, awareness, treatment and control of hypertension in Taiwan: results of Nutrition and Health Survey in Taiwan (NAHSIT) 1993-1996." J Hum Hypertens 15(11): 793-8.

50.Pisoni, R. L., E. W. Young, et al. (2002). "Vascular access use in Europe and the United States: results from the DOPPS." Kidney Int 61(1): 305-16.

51.R., A. (1996). A behavioural model of families'' use of health services center for Health Administration Studies, university of Chicago.

52.Ramirez, S. P., S. I. Hsu, et al. (2003). "Taking a public health approach to the prevention of end-stage renal disease: the NKF Singapore Program." Kidney Int Suppl(83): S61-5.

53.Shrestha, L. B. (2000). "Population aging in developing countries." Health Aff (Millwood) 19(3): 204-12.
54. Smith, D. H, Gullion, C. M, Nichols, G, et al. "Cost of medical care for chronic kidney disease and comorbidity among enrollees in a large HMO population." J Am Soc Nephrol 15(5):1300-6

55.The National Kidney Foundation, I. (2002). "K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification Part 4. Definition and classification of stages of chronic kidney disease. " American Journal of Kidney Disease 39: S46-S75.

56. United States Renal Data System（2005）. Annual Date Report. International Comparison. http://www.usrds.org/2005/pdf/12_intl_05.pdf

57.Vupputuri, S., V. Batuman, et al. (2003). "Effect of blood pressure on early decline in kidney function among hypertensive men." Hypertension 42(6): 1144-9.

58.Wang, H., L. Zhang, et al. (2005). "Prevention of the progression of chronic kidney disease: practice in China." Kidney Int Suppl(94): S63-7.

59.Warnock, D. G., W. McClellan, et al. (2005). "Prevalence of chronic kidney disease and anemia among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort Study: baseline results." Kidney Int 68(4): 1427-31.

60.Yang, Z., E. C. Norton, et al. (2003). "Longevity and health care expenditures: the real reasons older people spend more." J Gerontol B Psychol Sci Soc Sci 58(1): S2-10.

61.Young, J. H., M. J. Klag, et al. (2002). "Blood pressure and decline in kidney function: findings from the Systolic Hypertension in the Elderly Program (SHEP)." J Am Soc Nephrol 13(11): 2776-82.