臺灣博碩士論文加值系統

研究背景與目的
　　腎炎、腎徵候群及腎變性病位居十大死因之八，每十萬人口死亡率自1995年的16.57%上升至2005年的21.2%。台灣腎臟醫學會（2005年）資料顯示台灣地區末期腎臟病（ESRD）發生率與盛行率位居世界第一與第二名。截至2004年底台灣地區共計有38,709名ESRD患者正接受長期透析治療，且透析治療每年花費健保總額約250億新台幣。由此可見腎臟疾病確實是扼殺國人健康、經濟的重要疾病之一。過去國內外的學者大多關注於透析患者的照護及透析前後的醫療資源利用，或專注於高危險群的CKD患者，未能全面性的探討台灣地區CKD患者的醫療資源利用情形及影響其病程快速演進的危險因子，然而在所有腎臟疾病中，慢性腎臟疾病(CKD)患者仍占絶大多數，若能及早發現其致病因子或高危險群，有效的延緩CKD患者病程進入ESRD或避免其死亡。因此本研究目的為全面性探討台灣地區全人口慢性腎臟疾病之病程相關危險因子及其醫療資源耗用的情形，並與非慢性腎臟疾病患者相比較，供衛生政策制定當局針對慢性腎臟疾病患者規劃出完善的疾病管理方針，以期能提高慢性腎臟疾病患者治療的效率，進而節約醫療資源的使用。

研究方法
　　本研究採回溯性緃貫性研究(Retrospective longitudinal study)，研究期間為2000/1/1-2004/12/31止。研究樣本為2000~2004年1%健保資料庫中經定義為CKD Group；並利用2000年CKD Group，經由性別、年齡及投保分局別經1:3匹配(matching)為Non CKD Group。探討CKD、Non CKD Group在不同因子(性別、年齡、合併症)之醫療資源利用；並長期追縱2000年 CKD、Non CKD Group病程相關風險因子暨資源利用情形。以卡方檢定、t檢定、迴歸分析、Cox存活分析之統計方法，探討研究樣本病程風險因子暨醫療資源利用情形。

研究結果
2000-2004年CKD盛行率、合併症盛行率確實隨著年度而增加，然而就醫科別及醫療資源利用並未隨著年度而增加。CKD患者醫療資源利用顯著高於Non CKD患者，且不同年齡層、性別及不同合併之CKD患者醫療資源利用皆顯著高於Non CKD患者，有罹患合併症之CKD患者總醫療費用是有罹患合併症之Non CKD患者的2倍；沒有罹患合併症之CKD患者總醫療費用是沒有罹患合併症之Non CKD患者的4倍；且病患的死亡率、醫療資源利用與費用的上漲與年齡、合併症有其顯著的關係。影響CKD患者進入透析療法的主要因子包括性別、就診於腎臟內科、就診於內科、糖尿病、高血壓及貧血；影響CKD患者死亡的主要因子包括年齡、性別、就診於內科、糖尿病、貧血、腦血管栓塞及鬱血性心臟病。CKD患者的死亡風險顯著高於Non CKD患者，尤其是年齡大於45歲以上的CKD患者其死亡風險顯著的高於Non CKD患者；CKD合併糖尿病、高血壓、肝病、貧血及腦血管栓塞者其死亡風險皆顯著的高於Non CKD患者。

結論
有效的控制合併症的嚴重程度不但能降低患者的死亡率及其病程的演進，且能有效的控制醫療資源的耗用；當診斷發現腎臟疾病，應即時轉介給腎臟專科醫師，能有效的延緩CKD患者病程的演進及有效的降低CKD患者的死亡率。故如何制訂相關政策，規劃有效介入措施以減緩CKD病程演進所造成之醫療費用，著實挑戰著衛生政策制訂單位。

Background
Nephritis, nephrotic syndrome and nephrosis is the eighth disease of top ten causes of death. The mortality rate is from 16.75% in 1995 up to 21.2% in 2005 per 100,000 people. The high incidence and prevalence rate of ESRD in Taiwan takes the world first and second places, shown the data by Taiwan Society of Nephrology in 2005. In the end of 2004, there are 38,709 patients in Taiwan have took receiving dialysis. In addition, the total amount of cost in NHI is up to 25 billion NT dollars. In this case, it is obvious to know that Nephritis, nephrotic syndrome and nephrosis is the most severe disease to damage the health and economy in the nation. In the past, the scholars concentrate on the care of dialysis patients, the Medical resource utilization of dialysis or pay attention to the high risk group of CKD patients. They don’t probe into the Medical resource utilization of Taiwanese CKD patients and the impact of progression risk factor in comprehensive way. Nevertheless, CKD is majority one in all Kidney Diseases. The earlier find the risk factor or high-risk group, the better increase survival rate. Hence, the purpose of this research is for comprehensive study the relative risk factor of Kidney Diseases and for the usage of medical resource percentage in Taiwan area. Furthermore, by comparison with non-CKD, the purpose of this research is as a reference for authority, which draws up a complete managerial project, in order to improve the efficiency in recovering of CKD patients.

Method and Materials
This research adopts retrospective longitudinal study in the term of 2000/1/1-2004/12/3. The research samples are from the 1% CKD Group defined by NHI Research Database during 2000/1/1-2004/12/31. Non CKD group are matched by gander、age and bureau of insurance with CKD. It’s from various factors including gender, age and co-morbidity to make a research of the Medical resource utilization and have long trail in relative factors of CKD and Non CKD Group.
Researching sample in Medical resource utilization by Chi-square test, Independent-t Test, Regression Analysis and Cox Survival Analysis of statistics method.

Result
Incidence and prevalence rate of CKD increases by years from 2000 to 2004, but the patients who have CKD treatment don’t increase by years. There is obviously to see the higher usage of medical resource utilization by CKD patients than non-CKD patients. The cost of medical treatment in CKD patient who are with related co-morbidities is twice than Non-CKD patients.
The cost of medical treatment in CKD patient who are without related co-morbidities is quadruple than Non-CKD patients. Age and co-morbidities significance influence mortality rate and medical resources Medical resource utilization.The main factors including sex, medical history, DM, hypertension and Anemia affect CKD patients to receive dialysis. The critical reasons of death of CKD patients are age, sex, medical history, DM, hypertension and Anemia, CVA/TIA and CHF. The risk of death of CKD patients is higher than non-CKD patients, especially for the age above 45years old. CKD without related co-morbidities (include DM、hypertension、liver disease、Anemia、CVA/TIA) mortality risk is higher than non-CKD patients.



Conclusion
It could decrease the mortality rate and medical resource utilization when the disease is under control. While diagnosing Kidney diseases, the Dr. has to referral to Nephrologists. The patient will get a proper treatment. How to make the relative medical policy to go through the medical process of CKD patients is a challenge to the authority.

中文摘要 I
Abstract III
誌　謝 VI
表目錄 VIII
圖目錄 X
圖目錄 X
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 4
第三節 研究重要性 5
第四節 名詞解釋 7
第二章 文獻探討 9
第一節 慢性腎臟疾病之定義與盛行 9
第二節 慢性腎臟疾病之病程相關危險因子 13
第三節 慢性腎臟疾病之醫療資源利用 17
第三章 材料與方法 19
第一節 研究設計與研究架構 19
第二節 研究假說 22
第三節 資料來源與研究對象 25
第五節 統計分析方法 40
第四章 研究結果 42
第一節 2000~2004年台灣地區CKD患者年盛行率、就醫科別、合併症盛行情形及總醫療費用耗用趨勢 43
第二節 探討目標族群(2000年世代)不同因子下之醫療資源利用情形 53
第三節 縱貫性比較2000年CKD與Non CKD 醫療資源利用之差異 67
第四節 長期追蹤2000年CKD患者進入透析或死亡之相關風險因子 72
第五節 比較2000年CKD與Non CKD 死亡之風險因子 86
第五章 討論與建議 92
第一節 結果與討論 92
第二節 研究限制與未來研究方向 108
第三節 結論 110
第四節 建議 112
參考文獻 114
附錄 119
附錄一 119
附錄二 125

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