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研究生:洪燕妮
研究生(外文):Yen-Ni Hung
論文名稱:新血液透析病人血管通路利用與品質之探討
論文名稱(外文):Utilization and Quality in Incident Hemodialysis Patients with Type of Vascular Access
指導教授:吳肖琪吳肖琪引用關係
指導教授(外文):Shiao-Chi Wu
學位類別:博士
校院名稱:國立陽明大學
系所名稱:公共衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:中文
論文頁數:148
中文關鍵詞:血液透析血管通路自體動靜脈瘻管感染血管通路暢通時間存活時間
外文關鍵詞:Hemodialysisvascular accessnative arteriovenous fistulasinfectionpatencymortality
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國內新末期腎病病人92%採用血液透析,需建置永久性血管通路,國外研究指出血管通路問題是住院主因,血管通路類型會影響病人之醫療利用、感染、栓塞等情形,國內尚未以全國資料探討透析病人血管通路問題,因此本研究目的為了解血管通路問題現況、分析自體動靜脈瘻管建置情形及相關因素、分析血管通路類型與血管通路相關醫療費用及住院利用之關係、分析血管通路類型與短期及長期品質之關係。
採回溯性世代研究法,以2002年至2005年新慢性透析病人為對象,由2001年至2006年之全民健保費用申報資料、醫療機構年底現況檔及死亡檔等次級資料庫,擷取相關變項。血管通路類型依開始透析前後一年內第一次建置之永久性血管通路分為:自體動靜脈瘻管、人工血管及永久性導管;醫療費用及住院僅計算血管通路相關問題就醫利用部分,品質指標分為短期指標(三個月及六個月內感染、通路栓塞、重建)與長期指標(未發生感染時間、血管通路初級暢通時間、次級暢通時間及存活時間)。自變項包括性別、年齡、血管通路建置時間、共病症、血紅球生成素月劑量、每週透析次數、建置通路之醫療機構特質等。根據依變項類型採用邏輯斯迴歸、複迴歸、廣義線性模式、混合模式或Cox迴歸。
2002至2005年新透析病人65歲以上約占45%,有糖尿病者約占51.9%。血管通路問題占住院比例高,透析後一年內42.5%住院人次、58.5%住院費用與血管通路有關,國內新慢性透析病人血管通路類型以採用自體動靜脈瘻管者76.7%為最多,但有逐年下降的趨勢。在透析前建置血管通路的比例占38%,影響採用自體動靜脈瘻管的因素包括性別、年齡、建置通路時間點、共病症、血紅球生成素月劑量、醫院權屬層級別及不同年度新病人等;血管通路相關住院費用以透析後第一年內最高,控制其他因素後,採用人工血管者之血管通路相關住院費用顯著高於採用自體動靜脈瘻管者;不論採用自體動靜脈瘻管或人工血管者,其感染率及栓塞情形均未達診療指引所訂之目標,自體動靜脈瘻管的次級暢通時間為1,240天、人工血管為859天已達診療指引之目標;採用自體動靜脈瘻管較人工血管發生短期感染、栓塞的比率低,但發生三個月內重建比率高、六個月內重建則無顯著差異;控制其他因素後,自體動靜脈瘻管較人工血管看長期未發生感染時間、初級暢通時間、次級暢通時間及存活時間長。
新透析病人一年內的血管通路相關問題是住院主因,採用自體動靜脈瘻管的比例較大部分國家高,但建置時間太晚。血管通路類型與通路相關醫療費用、品質指標有關,改善血管通路問題可以改善病人照護品質;建議衛政主管機關應重視血液透析病人血管通路問題,持續監測並評估不同特性之病人採用不同類型血管通路之血管通路問題住院率、感染率、栓塞率、暢通時間。
Ninety-two percent of incident end stage renal disease patients received hemodialysis, patients who choose hemodialysis require vascular access before initiation of dialysis, there is large portion of hospital admissions in hemodialysis patients are related to vascular access complications. The purpose of this study was to analyze the factors of dialysis access types of incident dialysis patients as well as the impact of access type on medical expenditure, hospitalization , short term and long term quality indicators.
A retrospective cohort study on incidental dialysis patients between year 2002 and 2005 were conducted by analyzing the related variables by using the National Health Insurance Reimbursement Database during year 2001 through 2006. All subjects were divided by their very first vascular access creation into 3 groups: arteriovenous fistula (AVF), arteriovenous graft (AVG), and permanent dialysis catheter (Perm-cath). Only the access-related expenditure and hospitalization were taken into investigation. Several short term quality indicators such as infection, thrombosis, reconstruction within 3 & 6 months, primary & secondary patency of access were recorded and analyzed. Long term qualitiy indicators such as , duration of free from infection , primary patency of initial access, secondary patency of initial access and patient survival were also taken into analysis. Independent variables in this investigation were gender, patient age, timing of access construction, comorbidities, dosage of EPO, numbers of dialysis treatment per week, and characteristics of healthcare facility. Logistic regression, multiple regression, generalized estimating equations (GEE), Mixed model, and Cox proportional hazards model were carefully chosen and applied in this investigation according to the different type of dependent variables.
The numbers of incident dialysis patents included in this investigation in 2002 through 2005 were 7472, 7456, 7402 and 8204 respectively. Forty-five percent of the population was above the age of 65. And 51.9% of the subjects were diabetic. 42.5% of the all-cause admissions during their first year of dialysis treatment were dialysis access related. And 58.5% of the expenditures on hospitalization were dialysis access related. AVF comprised of 76.7% of the first time access construction of those incident patients in our investigation. During our investigation years, however, a downward trend of the AVF construction rate were observed . There were only 38% of new dialysis patients had their access constructed before the start of their dialysis treatment. Regarding the type of access, influential factors were gender, age, timing of access construction, and comorbidities, given dosage of EPO per month, type of healthcare institute and calendar year. The access related inpatient expenditure was the highest during the first year after initiation of dialysis therapy. The access-related inpatient expenditure of AVG patients was significant higher than those of AVF patients. For both the AVF and AVG patients, the incidence of infection and thrombosis of access did not reach the standard recommanded by our guideline. The secondary patency of AVF and AVG in this study was 1240 days and 859 days respectively. Both reached the recommandation by the the guideline. The AVF patients did have lower short term access infection and thrombosis rate and higher reconstruction rate in 3 months. The access reconstruction rate in 6 months were similar between two groups of patients. After well control of other variables, the AVF patients do perform better on free from access infection, primary patency of access, secondary patency of access and patient survival.
Access-related problems were the main cause of hospitalizations of the long term dialysis patients within their first year after initiation of dialysis. We have found that the incidence of AVF construction were higher than most of other countries. However, the referral time for access construction was late. We have also found that the type of access correlates significantly to the expenditure on hospitalization and index on health care. Improvement on access related problem may impose positive impact on quality of care. We suggested that the access related problems should be paid with more attention. Continuous monitoring and efforts on caring of the access related problems such as infection, admission, thrombosis and patency is mandatory.
目錄
誌 謝 I
摘 要 II
ABSTRACT IV
表目錄 VIII
圖目錄 IX
第一章 研究緣起 1
第一節 前言 1
第二節 研究目的 3
第三節 重要英文縮寫及名詞解釋 4
第二章 文獻探討 5
第一節 血液透析用血管通路 5
第二節 血管通路建置情形與相關因素 15
第三節 血管通路類型與醫療費用及住院利用 19
第四節 國內外有關血管通路品質之研究 24
第三章 研究材料與方法 34
第一節 研究設計及架構 34
第二節 研究假說 35
第三節 研究對象與資料處理 36
第四節 統計分析 44
第四章 研究結果 45
第一節 新慢性透析病人血管通路問題整體狀況 45
第二節 慢性透析用血管通路建置情形及影響因素 54
第三節 血管通路類型與醫療費用及住院利用 62
第四節 血管通類型與短期醫療品質 75
第五節 血管通類型與長期醫療品質 91
第五章 討論 106
第一節 新慢性透析病人血管通路問題整體狀況 106
第二節 慢性透析用血管通路建置情形及影響因素 107
第三節 血管通路類型與醫療費用及住院利用 110
第四節 血管通類型與醫療品質 114
第五節 研究方法討論與限制 116
第六章 結論與建議 118
第一節 結論 118
第二節 建議 120
參考文獻 123
附錄 台灣腎臟醫學會「血液透析診療指引」之血管通路指引 130
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