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研究生:張秀蘭
研究生(外文):Hsiu-Lan Chang
論文名稱:影響腎衰竭病人透析前之醫療資源利用原因分析-以南部某醫學中心為例
論文名稱(外文):Analysis of Medical Resources Utilization for Patients with Renal Failure before Dialysis Therapy--A Case Study of a Medical Center in Southern Taiwan
指導教授:陳美美陳美美引用關係
指導教授(外文):Mei-Mei Chen
學位類別:碩士
校院名稱:長榮大學
系所名稱:醫務管理學系碩士班
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2008
畢業學年度:96
語文別:中文
論文頁數:81
中文關鍵詞:慢性腎衰竭醫療資源利用
外文關鍵詞:chronic renal failureutilization of medical resources
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研究動機
衛生署的統計顯示腎炎、腎臟病多年來一直位居國人十大死因之列(92、93 年為第七位),慢性腎臟病至目前是台灣十大死因的第 8 位,每 10 萬人口的死亡率由民國 79 年的 11.39%,逐年上升至 93 年的 20.7%。每年健保局投入於透析患者高達245億花費,而每年約有 8 千至 9 千個新的透析治療病患,其發生率已躍居世界首位,目前共計有 4 萬多名透析病患,在全世界的排名上盛行率僅次於日本,位居第二位,發生率第一。有鑑於醫療政策消極地治療尿毒症,然而接受透析治療的患者人數仍逐年提高,造成醫療支出大幅增加,與其如此,不如積極地尋求造成末期腎臟病的原因,故引發研究動機,期望能對於未來病人醫療照護有助益。

研究目的
探討腎衰竭病人在透析前的醫療利用影響因素,以進一步瞭解病人影響腎衰竭原因以避免造成永久性腎臟傷害,提供未來適當之透析前病人照護的指引參考,進而提供策略以減緩慢性腎臟病病人進入長期透析。

研究方法
本研究採回溯性橫斷研究方式收集南部某醫學中心1999~2004年初次透析病人,透析前三個月有住院記錄者999人,運用獨立性t檢定、單因子變異分析、皮爾森積差相關分析、複迴歸分析等研究方法,探討人口學變項、臨床血液生化檢驗值、疾病風險因子、病人照護利用(入院途徑、轉介專科醫師時機)等與醫療資源利用關係。

研究結果
研究樣本以男性病患人數多於女性,預測住院天數,性別無統計上意義。
年齡以≧65歲佔最多t值-5.12 P值<0.001有顯著統計上意義。
血液生化檢驗與住院天數差異分析,以鈣F值11.913 P值<0.001,具有統計顯著差異,薛費氏事後比較,以低血鈣對於住院天數差異性最顯著。磷F值9.024 P值<0.001具有統計顯著差異,薛費氏事後以低血磷對於住院天數差異性最顯著。白蛋白t值0.426 P值0.001具有統計顯著差異。
疾病風險因子與住院天數差異分析,首次透析前住院病患之疾病風險因子以合併多種診斷疾病最多佔30.7%,急性腎衰竭佔16.8%,糖尿病+高血壓所佔比例12.4%;以上疾病組合的分佈與住院醫療資源利用F值0.723 P值0.678未達顯著改變。
病患的醫療照護與透析前醫療資源利用的相關性分析,以年齡、鈣、磷最具有統計顯著相關性P值皆小於0.001。住院次數、肌酸酐、蛋白質、血色素也顯示有相關。
複迴歸分析在控制所有變項後影響住院因子總解釋變量為10.4%,發現以年齡、鈣、高血壓、慢性腎衰竭、磷達到統計上意義。顯示年齡愈大住院天數多。鈣、磷愈低,住院天數愈多。以高血壓、慢性腎衰竭病人疾病風險因子比其他疾病之住院天數長。
結論
進入透析前病人年齡大於65歲使用醫療資源比較多,可能與疾病複雜或老化有相關,需要關注老年照護。生化檢驗值的結果鈣、磷、白蛋白可以作為照護的指標注意電解質與營養,及早做好高血壓、慢性腎衰竭個案治療與預防腎衰竭進展。建議醫療院所加強早期診斷,健保局能全面落實全民健檢尿液血液篩檢,做好健康管理,醫療人員能協助病人適應疾病帶來的衝擊,腎衰竭第三期以上病人做好照護控制不良現象,如電解質不平衡、合併症的控制減少病人因為合併症而增加醫療資源利用。由於本研究資料來源來自於單一個案醫院,無法做誇院資料比較,後續研究者可針對健保資料庫的樣本再進行分析。
Motivation
According to statistics from Department of Health, nephritis and kidney disease have always been on the list of top ten causes of death for years (they are the seventh leading cause of death in 2003 and 2004). Chronic kidney disease is ranked number eight so far, with an increase of death rate from 11.39% every 100,000 people in 1990 to 20.7% in 2004. Every year the Bureau of National Health Insurance spends as much as 24.5 billion dollars on dialysis patients. There are about eight to night thousand new patients that need to receive dialysis therapy every year, and the occurrence rate is ranked number one in the world. Currently, there are more than 40,000 dialysis patients in Taiwan, and the prevalence rate is only after Japan and is ranked number two in the world. Owing to the passive medical policy to cure uremia as well as the increasing number of patients that need dialysis therapy, the medical expenditure has been increased dramatically. In consideration of the fact, the researcher tried to probe into the reasons that cause end-stage renal disease to make some contributions to the medical care of the patients in the future.
Purpose of Study
The study is aimed to discuss the medical resources utilization for patients with renal failure before dialysis therapy to probe into the influential factors for renal failure in an attempt to avoid permanent kidney damage and to provide a reference to guide proper medical care of patients before dialysis, and furthermore, to provide strategies to reduce the chances for patients with chronic kidney disease to receive long-term dialysis.

Methodology
Retrospective and cross-sectional method was adopted in the study and 999 patients who received dialysis for the first time and had the record of hospitalization three months before dialysis during 1999 to 2004 in a medical center in southern Taiwan were the subjects. Independent t-test, one-way ANOVA, Pearson product-moment correlation, and multiple-regression-analysis were adopted to analyze variables of demographic data, clinical blood biochemical values, risk factors for diseases, patient care utilization (such as channels of hospitalization and the timing for referral to specialized doctors) that are related to medical resources utilization. .

Results
There were more male patient samples than female ones, and the duration of hospitalization was predicted. The gender difference did not have any statistical significance. Most of the patients were ≧65 years old, with the t value of -5.12 and P value <0.001, and the age of the patients was statistically significant.
Difference analysis of the blood biochemical test and the duration of hospitalization reached significant difference statistically when the F value of calcium is 11.913, with the P value <0.001. Then in Scheffe's Test, hypocalcemia had the most significant influence on the duration of hospitalization. There showed significant difference in statistics when the F value of phosphorous is 9.024, with the P value <0.001. When examining with Scheffe's Test, it was found that low blood phosphorous had the most significant influence on the duration of hospitalization. When the t value of albumin is 0.426, the P value becomes 0.001 and reached significant difference in statistics.

When analyzing the difference between the distribution of risk factors of diseases and the duration of hospitalization, it was found that for the hospitalized patients before their first dialysis, 30.7% was diagnosed multiple diseases, 16.8% was diagnosed acute renal failure, and 12.4% was diagnosed of diabetes + hypertension. The F value and the P value of the above combinations of diseases and the medical resources utilization during hospitalization are 0.723 and 0.678 respectively, and both did not reach significant level.

When analyzing the correlation of the patients’ medical care and the utilization of medical resources before dialysis, the age, content of calcium and phosphorous all reached significant level with the P values less than 0.001. The times of hospitalization, creatinine, protein and hemachrome are also correlated.

When analyzing the correlation between the patients’ medical care and the medical resources utilization before dialysis, the t value is 0.667 and the p value is 0.505, while the t value and the p value for hospitalization channels are -0.315 and 0.753 respectively, and that does not constitute significant change.
Through multiple-regression-analysis, after controlling all the variables, the total explanatory variable became 10.4%. It was found that when examining the factors that have influences on hospitalization, factors including the age, calcium, hypertension, chronic renal failure and phosphorous reached significant level statistically. This means that the older the patients were, the longer duration of hospitalization they needed; the less content of calcium and phosphorous, the longer duration of hospitalization the patients needed. Among all the patients, patients with risk factors of hypertension and chronic renal failure had longer hospitalization duration than those with risk factors of other diseases.

Conclusion
It was found that before dialysis, patients aging 65 and above utilized more medical resources. This might have something to do with the complexity of the diseases or aging, and therefore, the aged care should be paid attention to. The biochemical test values of calcium, phosphorous and albumins can also serve as an index for the patients’ electrolyte and nutrition, so that the treatment of hypertension and chronic renal failure can be well-prepared in advance to prevent renal failure. It is suggested that the medical institutions reinforce the early-stage diagnosis and that the Bureau of National Health Insurance completely implement urine blood screening test for better health management. Thus, medical personnel can assist patients in adapting to the impacts the diseases bring, caring for some malfunctions such as electrolyte imbalance to patients in third stage renal failure or above, and controlling the combination of diseases to lower the chances of medical resources utilization for the combination of diseases. Due to the fact that all the samples were from one single hospital, the comparison of cross-hospital data could not be made. However, for successive researchers, analysis and comparison of the National Health Insurance Database can be made for further study and analysis.
目 錄

表目錄 ix
圖目錄 x
第一章 緒論……………………………………………………………………………………………………………………… 1
 第一節 研究背景與動機…………………………………………………………………………………………… 2
 第二節 研究目的 ……………………………………………………………………………………………………… 3
 第三節 名詞解釋 ………………………………………………………………………………………………… …… 4
第二章 文獻探討……………………………………………………………………………………………………………… 6
 第一節 何謂急、慢性腎衰竭……………………………………………………………………………………… 6
 第二節 慢性腎臟病病程進展……………………………………………………………………………………… 6
第三節 醫療資源利用與預測指標…………………………………………………………………………… 9
第四節 腎衰竭病人醫療服務利用與相關照護………………………………………………………… 12
第三章 研究方法 ………………………………………………………………………………………………………… 21
第一節 研究架構與研究假設……………………………………………………………………………………… 21
第二節 資料處理……………………………………………………………………………………………………… 23
第三節 研究變項之操作型定義……………………………………………………………………………… 29
第四節 研究變項之分析方法………………………………………………………………………………… 31
第四章 結果…………………………………………………………………………………………………………………… 32
第一節 描述性分析…………………………………………………………………………………………………… 32
第二節 推論性分析…………………………………………………………………………………………………… 37
第三節 研究假設結果驗證………………………………………………………………………………………… 43
第五章 結論與建議………………………………………………………………………………………………………… 47
第一節 討 論……………………………………………………………………………………………………………… 47
第二節 結 論……………………………………………………………………………………………………………… 49
第三節 建 議……………………………………………………………………………………………………………… 49
第四節 研究限制與未來研究方向…………………………………………………………………………… 50
參考文獻………………………………………………………………………………………………………………………………… 52





表目錄


表 2-1 慢性腎臟疾病分期(NKF,2002)與Creatinine對照表………………………… 59
表 2-2 慢性腎臟病(CKD)之危險因子…………..……………………………………..………………..……… 60
表 2-3 早晚期轉介定義文獻參考表………………………………………………………...…………..……… 61
表 2-3-4 CKD個案管理之分期照護理念…………………………………………………………………… 62
表 3-1 研究變項名稱與操作型定義…………………………………………………………………………… 29
表 3-2 研究變項之分析方法…………………………………………………………………………………… 31
表 3-1-2 檢驗值遺漏值…………………………………………………………………………………………………… 63
表 4-1-1 1999-2004年有首次透析病患性別分佈………………………………………………………… 32
表 4-1-2 1999-2004年有首次透析病患性別年齡分佈………………………………………………… 33
表 4-1-3 1999-2004年首次透析病患之年齡分佈………………………………………………………… 33
表 4-1-4 初次透析之基本屬性……………………………………………………………………………………… 34
表 4-1-5 生化檢驗值與醫療資源利用住院天數之概況…………………………………………… 35
表 4-1-6 疾病風險因子之特性……………………………………………………………………………………… 36
表 4-1-7 初次透析病患之醫療照護利用人數……………………………………………………………… 36
表 4-2-1 人口學特性、醫療照護在醫療資源利用住院天數之差異性分析……………… 37
表 4-2-2 疾病風險因子在醫療資源利用住院天數之差異性分析……………………………… 38
表 4-2-3 血液生化臨床檢驗值與醫療資源利用住院天數之差異性分析…………………… 39
表 4-2-4 人口學、醫療照護利用與醫療資源利用住院天數之相關分析…………………… 40
表4-2-4-1 年齡、疾病風險因子、血液生化檢驗值與醫療資源利用住院天數之相關分析………………………………………………………………………………………………………………………
64
表 4-2-5 生化檢驗值與住院天數之相關分析……………………………………………………………… 40
表4-2-6 住院天數對於人口學變化、生化檢驗值、疾病類別與轉介專科醫師之複迴歸分析………………………………………………………………………………………………………………
42
表 4-2-6-1 住院天數對於人口學變化、生化檢驗值、疾病類別與轉介專科醫師之複迴歸分析………………………………………………………………………………………………………………
65
表 4-2-7 住院天數對於人口學變化、生化檢驗值、疾病類別與轉介專科醫師取對數後之複迴歸分析………………………………………………………………………………………………
67






圖目錄

圖3-1-1研究架構………………………………………………………………………………………………………… 22
圖4-1-1 1999-2004年首次透析病患之年齡分佈……………………………………………………… 26
圖4-2-6-1複迴歸假設檢定常態分佈與線性關係假設…………………………………… 67
圖4-2-7-1複迴歸假設檢定常態分佈與線性關係假設……………………………………. 68
圖4-2-7-2複迴歸假設檢定常態分佈與變異數齊一性之假設殘差圖…………. 69
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