臺灣博碩士論文加值系統

Background: End-Stage Renal Disease (ESRD) patients in Taiwan are increasing year by year.
This ranked Taiwan as number one in incidence and prevalence in ESRD patients worldwide.
Dialysis is one of the treatment choices for ESRD patients. Since Taiwan has implemented
National Health Insurance (NHI), the utilization of dialysis increased rapidly. Due to the
urgency of a problem, it necessary to investigate survival and hospitalization among dialysis
patients.
Objectives: The purpose of this study is to compare PD and HD in five years survival and
hospitalization within 1st year, 2nd and 3rd year since 2001 to 2005 in Taiwan and which factors
influence them.
Method: Secondary data from the NHRI database was used to analyze the survival and also
hospitalization of dialysis patients. The researcher chose dialysis patients who took dialysis for
more than 3 months. We used the Propensity Score Matching Method to analyze 38023 cases by
using Nearest Neighbor within Caliper (1.0) to get the matched cases between dialysis groups
(PD and HD). We got 2797 pairs to be analyzed by Kaplan Meier as univariate survival
analysis, and Cox Proportional Hazard Model adjusted for age, gender, hospital location,
hospital type, presence of Diabetes Mellitus, and Charlson Comorbidity Index as multivariate
survival analyses and paired t-test and also Multiple Linear Regression for hospitalization.
Result: We found significant results for survival and hospitalization in univariate analysis, thus
we rejected the null hypotheses. There is a difference between PD and HD in survival and
hospitalization. PD patients had better survival than HD patients. From the multivariate analysis,
we found only age, gender, hospital location, dialysis modality, presence Diabetes Mellitus and
comorbid conditions had significant results. PD patients had better survival when they were
younger (less than 65 years-old), female, not having DM, and less comorbidity conditions.
Meanwhile, HD patients had better survival when they were older (more than 65 years-old),
having DM and greater comorbid condition. Age, gender, dialysis modality, presence of DM
and comorbid condition were have relationship to hospitalization within 1st year. Meanwhile,
gender was excluded in association for hospitalization within 2nd and 3rd year. Increasing age or
CCI score, PD group, female, and DM patients were associated with greater hospitalization
within 1st, 2nd and 3rd years.
Conclusion: PD and HD groups have differences in survival and hospitalization adjusted for
age, gender, hospital location, hospital type, presence of DM and Chalson Comorbidity Index.
This factors should be considered when choosing type of dialysis regarding patient’s
characteristics.

Background: End-Stage Renal Disease (ESRD) patients in Taiwan are increasing year by year.
This ranked Taiwan as number one in incidence and prevalence in ESRD patients worldwide.
Dialysis is one of the treatment choices for ESRD patients. Since Taiwan has implemented
National Health Insurance (NHI), the utilization of dialysis increased rapidly. Due to the
urgency of a problem, it necessary to investigate survival and hospitalization among dialysis
patients.
Objectives: The purpose of this study is to compare PD and HD in five years survival and
hospitalization within 1st year, 2nd and 3rd year since 2001 to 2005 in Taiwan and which factors
influence them.
Method: Secondary data from the NHRI database was used to analyze the survival and also
hospitalization of dialysis patients. The researcher chose dialysis patients who took dialysis for
more than 3 months. We used the Propensity Score Matching Method to analyze 38023 cases by
using Nearest Neighbor within Caliper (1.0) to get the matched cases between dialysis groups
(PD and HD). We got 2797 pairs to be analyzed by Kaplan Meier as univariate survival
analysis, and Cox Proportional Hazard Model adjusted for age, gender, hospital location,
hospital type, presence of Diabetes Mellitus, and Charlson Comorbidity Index as multivariate
survival analyses and paired t-test and also Multiple Linear Regression for hospitalization.
Result: We found significant results for survival and hospitalization in univariate analysis, thus
we rejected the null hypotheses. There is a difference between PD and HD in survival and
hospitalization. PD patients had better survival than HD patients. From the multivariate analysis,
we found only age, gender, hospital location, dialysis modality, presence Diabetes Mellitus and
comorbid conditions had significant results. PD patients had better survival when they were
younger (less than 65 years-old), female, not having DM, and less comorbidity conditions.
Meanwhile, HD patients had better survival when they were older (more than 65 years-old),
having DM and greater comorbid condition. Age, gender, dialysis modality, presence of DM
and comorbid condition were have relationship to hospitalization within 1st year. Meanwhile,
gender was excluded in association for hospitalization within 2nd and 3rd year. Increasing age or
CCI score, PD group, female, and DM patients were associated with greater hospitalization
within 1st, 2nd and 3rd years.
Conclusion: PD and HD groups have differences in survival and hospitalization adjusted for
age, gender, hospital location, hospital type, presence of DM and Chalson Comorbidity Index.
This factors should be considered when choosing type of dialysis regarding patient’s
characteristics.

TABLE OF CONTENT
ACKNOWLEDGEMENT iv
ABSTRACT v
TABLE OF CONTENT vi
LIST OF TABLES ix
LIST OF FIGURES xi
CHAPTER I:
INTRODUCTION 1
1.1 BACKGROUND 1
1.2 RESEARCH PROCEDURE 3
1.3 RESEARCH OBJECTIVES 4
1.4 RESEARCH CONTRIBUTION 5
CHAPTER II: LITERATURE REVIEW 7
2.1 END-STAGE RENAL DISEASE 7
2.2 DIALYSIS MODALITY 11
2.3 DIALYSIS SURVIVAL.13
2.4 HOSPITALIZATION 19
CHAPTER III: RESEARCH METHODOLOGY 24
3.1 CONCEPTUAL FRAMEWORK 24
3.2 RESEARCH HYPOTHESES 25
3.3 RESEARCH DESIGN 26
3.3.1. Study Design 26
3.3.2. Sampling 26
3.3.3. Data Source 28
3.3.4. Statistical Analysis 28
Descriptive Analysis 28
Propensity Score 28
Survival Analysis 32
Hospitalization 34
3.4 OPERATIONAL DEFINITIONS 36
CHAPTER IV: RESEARCH RESULTS 38
4.1 DESCRIPTIVE ANALYSIS 38
4.1.1. Patient Characteristics Since 2001-2005 38
4.1.2. Descriptive Population in Every Year 41
4.1.3. Characteristics Distribution in Dialysis Groups 47
4.2 PROPENSITY SCORE 51
4.3 KAPLAN MEIER 57
4.4 COX PROPORTIONAL HAZARD 59
4.5 HOSPITALIZATION 69
CHAPTER V: DISCUSSION 74
5.1 DISCUSSION 74
5.1.1. Patient Characteristics 74
5.1.2. Survival 75
5.1.3. Hospitalization 76
5.2 HYPOTHESES CONFIRMATION 76
5.3 STUDY LIMITATION 77
CHAPTER VI: CONCLUSION AND RECOMMENDATION 78
6.1 CONCLUSION 78
6.2 RECOMMENDATION 79
6.2.1. Healthcare administrators 79
6.2.2 Clinical Practitioners 79
6.3 IMPLICATION FOR FURTHER RESEARCH 80
REFERENCES 81
APPENDICES 87

Al-Wakeel, J. S., Mitwalli, A.H., et al. (2002). Morbidity and Mortality in ESRD Patients on
Dialysis. Saudi J Kidney Dis Transpl (13), pp 473-7. Retrieved from
http://www.sjkdt.org/text.asp?2002/13/4/473/33101.
Arora, P., Kausz, A. T., et al. (2000). Hospital Utilization Among Chronic Dialysis Patients. J
Am Soc Nephrol, vol 11, pp 740-746. Retrieved from
http://jasn.asnjournals.org/cgi/reprint/11/4/740.
Beddhu, S., Burns., F., et al. (2000). A simple comorbidity scale predicts clinical outcomes and
costs in dialysis patients. The American Journal of Medicine, 108(8), pp 609-613.
Beddhu, S., Zeidel, M.L., et al. (2002). The effects of Comorbid conditions on the outcomes of
patients undergoing peritoneal dialysis. Am J Med, 112, pp 696-701.
Bloembergen, W. E., Port, F. K., et al. (1995). A Comparison of Mortality Between Patients
Treated With Hemodialysis and Peritoneal Dialysis. Journal of the American Society of
Nephrology, vol 6, pp 177-183.
Brown, F. (2000). ICD-9-CM Coding Handbook. US: Health Forum.
Bureau of Health Promotion, Taiwan. (2007). The current situation and prospect of CKD
prevention and control. Retrieved from
http://www.bhp.doh.gov.tw/English/files/1180944725
Carlson DM, Duncan DA, Naessens JM, Johnson WJ. (1984). Hospitalization in Dialysis
Patient. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/6492872.
Chan, Y. H. Biostatistic 203: Survival Analysis. Singapore Med J 2004 Vol 45(6) : 249.
Retrieved from http://www.sma.org.sg/smj/4506/4506bs1.pdf
Chen, Y.M., et al. (2008). Outcomes of Stage 3-5 chronic kidney disease before end-stage renal
disease at a single center in Taiwan Retrieved from www.karger.com/nec.
Chiang, C.K., tsai, T.J., et al. (2004). Health-Related Quality of Life of Hemodialysis patients in
Taiwan: A Multicenter Study. Blood Purification, vol 22, pp. 490-498.
Choi, P., & Brown, E. A. (2003). Peritoneal Dialysis. Medicine, vol 31, pp 70-73. Retrieved
from http://sdos.ejournal.ascc.net/pdflinks/09031517522827200.pdf.
Davis, K., & Huang, A. T. (2008). Learning from Taiwan: Experience withUniversal Health
Insurance. Ann Intern Med, 148 (4), pp 313-314.
D’Agostino, R. B. (2004). Tutorials in Biostatistics: Statistical Methosds in Clinical Studies
(Volume 1). Boston:John Wiley& Sons.
Dehejia, R. H., & Wahba, S. (2002). Propensity Score-Matching Methods For Nonexperimental
Causal Studies. The Revies of Economics and Statistics, 84(1), 151-161.
Department of Health, Taiwan. (2008). Health Statistic Taiwan. Retrieved from
http://www.doh.gov.tw.
Field, A. (2005). Discovering Statistics Using SPSS. London: Sage Publications.
Gokal, R., & Nallick, N. P. (1999). Peritoneal Dialysis. Lancet, vol 353; pp 823-828.
Goodkin, D. A. et al. (2003). Association of comorbid conditions and mortality in Hemodialysis
patients in Europe, Japan and the United States: The dialysis outcomes and Practice
Patterns Study (DOPPS). JASN vol 14 pp 3270-3277.
Grassmann, A., et al. (2005). ESRD patients in 2004: Global overview of patients number,
treatment modalities and associated trends. Nephrology Dialysis Transplantation vol 20
number 12 pp 2587-2593.
Holland, D., C. & Lam, M. 2000. Predictors of hospitalization and death among pre-dialysis
patients: a retrospective cohort study. Nephrol Dial Transplant, vol 15, pp 650-658.
Retrieved from http://ndt.oxfordjournals.org/cgi/content/full/15/5/650.
83
Hung, K.Y., Hsu, W. A., et al. 1995. Continuous Ambulatory Peritoneal Dialysis in The
Elderly: A 7-Year Experience. Postgrad Med Journal, vol 71, pp 160-163. Retrieved
from http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2398176&blobtype=pdf.
Ignatavicius, D. D., Workman, M. L., Mishler, M. A. (1999). Medical Surgical Nursing Across
the Health Care Continuum. Philadelphia: W. B Saunders.
Jaar, B. G., et al. (2005). Comparing the Risk for Death with Peritoneal Dialysis and
Hemodialysis in a National Cohort of Patients with Chronic Kidney Disease. Ann Intern
Med, vol 143, pp 174-183.
Jassal, S. V., Trpeski, L., et al. (2007). Changes in survival among elderly patients initiating
dialysis form 1990 to 1999. CMAJ, 177(9), pp 1033-1038. Retrieved from
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2025619
Jennette, J. C., Olson, J. L., Schwartz, M. M., Silva, F. G. (2007). Heptinstall’s pathology of the
kidney, 6th ed, vol 2. Philadelphia: Lippincoltt Williams & Wilkins.
Kleinbaum, D.G. 1996. Survival Analysis: A Self-Learning Text. New York: Springer.
Metcalfe, W., Khan, I.H., et al. (2003). Hospitalization in the first year of renal repalcement
therapy for End-Stage renal Disease. The Quartely Journal of medicine, 96 (12), pp 899-
909.
Miskulin, D (2005). Characterizing comorbidity in dialysis patients: Principles of measurement
and application in risk adjustment and patients care. Peritoneal Dialysis International,
25(4), 320-332.
Murphy, S. W., Folley, R. N., et al. (2000). Comparation mortality in hemodialysis and
peritoneal dialysis in Canada. Kidney International, 57, pp 1720-1726.
National Kidney Faoundation. (2002). Part IV: Definition and classification of stages of chronic
kidney disease. American Journal of Kidney Disease, 39(2), s46-s75.
Pandya, P.,& Farrington, K. (2003), Haemodialysis. Medicine, vol 31, pp 66-69. Retrieved from
http://sdos.ejournal.ascc.net/pdflinks/09031715363502318.pdf.
Peeters, P., Rubleeb, D., et al. (2000). Analysis and interpretation of cost data in dialysis:
review of Western European literature. Health Policy, vol 54, pp 209-227
Powe, N. (2001). Patients, Populations and Policy: Patient Outcomes In Chronic Kidney
Disease. Transactions of The American Clinical and Climatological Association,
Vol.112. Retrieved from
http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2194417&blobtype=pdf.
Prischard, S.S. (2000). Comorbidities and their impact on outcome in patients with end-stage
renal disease. Kidney International, vol 57, Suppl.74, pp. S-100-S-104.
Reilly, R. F., & Perazella, M. A. ( 2005). Nephology in 30 Days. Boston: Mc Graw Hill.
Rennke, H. G., & Denker, B. M. (2007). Renal Pathophysiology: The Essentials. (2nd Ed.).
Philadelphia: Lippincott Williams & Wilkins.
Sankarasubbaiyan, et al. (2007). Challenges and Limitations of Maintenance Hemodialysis in
Urban South India. Hemodialysis International, vol 11, pp 485–491.
Sayin, A., Mutluay, R. et al., (2007). Quality of Life in hemodialysis, peritoneal dialysis and
transplantation patient. Transplantation proceedings, vol 39, pp 3047-3053.
Sennfalt, K., Magnusson, M., Carlsson, P. (2002). Comparison of Hemodialysis and Peritoneal
Dialysis- A Cost Utility Analysis. Peritoneal Dialysis International, vol 22, pp 39-47.
Retrieved from www.pdiconnect.com/cgi/reprint/22/1/39.pdf.
Song, Y. S., Jung, H., et al. (2007). Survival Analysis of Korean End-Stage Renal Disease
Patients According to Renal Replacement Therapy in a Single Center. J Korean Med
Science, vol 22, pp 81-8. Retrieved from http://jkms.kams.or.kr/2007/pdf/02081.pdf.
85
Stason, W. B & Barnes, B. A. (1985). The Effectiveness and Costs of Continuous Ambulatory
Peritoneal Dialysis. Washington: US Government printing office. Retrieved from
http://www.fas.org/ota/reports/8531.pdf.
Torpy, J. M., Lynm, C. & Glass, R. M. (2007). Chronic Kidney Disease. JAMA, vol 298, no.10.
USRDS, 2007. Comparing the burden of Chronic Kidney Disease in the US and Taiwan: When
is an ‘epidemic’ an epidemic?. Retrieved from
http://www.usrds.org/2007/pres/04U_asn07_taiwan_epidemic.pdf
USRDS, 2008. Atlas ESRD, Six: Morbidity and hospitalization. Retrieved from
http://www.usrds.org
USRDS, 2008. Atlas ESRD, Twelve: International Comparison. Retrieved from
http://www.usrds.org
USRDS,(1996). Annual Data Report: Chapter V: Patient Mortality and Survival. Retrieved
from http://www.usrds.org/download/1996/ch05.pdf
Vonesh, E. F., Snyder, J. J., Foley, R. N. & Collins, A. J. (2006). Mortality studies comparing
peritoneal dialysis and hemodialysis: What do they tell us?. International Society of
Nephrology. Retrieved from http://www.kidney-international.org
Watson, S. 2004. Human body systems: The urinary system. USA: greenwood press.
Winkelmayer, W. C., Glynn. R. J., et al. (2002). Comparing Mortality of Elderly Patients on
Hemodialysis versus Peritoneal Dialysis: A Propensity Score Approach. Journal of the
American Society of Nephrology, vol 13, pp 2353-2362.
Xue, J. L., Chen, S. C., Ebben, J. P., et al. (2002). Peritoneal and hemodialysis: I. Differences in
Patient characteristics at initiation. Kidney International, 61, 734-740.
Yang, W. C. & Hwang, S. J. (2008). Incidence, prevalence and mortality trends of dialysis endstage
renal disease in Taiwan from 1999 to 2001: The impact of national health insurance. Nephrology Dialysis Transplantation, vol 23; pp 3977-3982.
Yang, W. C., et al. (2001). The impact of diabetes on economic costs in dialysis patients:
Experiences in Taiwan. Diabetes Reseach and Clinical Practice, vol 54, pp S47-S54.