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研究生:賴碧蓉
研究生(外文):Pi-Jung Lai
論文名稱:透析支付政策改變與腹膜透析短期技術失敗相關之探討
論文名稱(外文):Exploring the Association between Changes in Dialysis Payment Policies and the Short-Term Technique Failure of Peritoneal Dialysis
指導教授:張睿詒張睿詒引用關係
口試委員:洪冠予陳錫賢
口試日期:2013-07-05
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:公共衛生碩士學位學程
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:2013
畢業學年度:101
語文別:中文
論文頁數:85
中文關鍵詞:透析支付政策末期腎臟疾病腹膜透析技術失敗
外文關鍵詞:ESRDPayment PolicyTechnique FailurePeritoneal Dialysis
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隨著人口老化、與糖尿病等慢性疾病之盛行,慢性腎臟病(CKD)人口逐年攀升,其中引發之末期腎臟疾病(ESRD)台灣自2001年起發生率及盛行率列居世界第一。由於國內主要腎臟替代治療方式仍以透析治療為主,隨著透析人口不斷成長,透析支出已成為全民健康保險預算的沉重負擔。腹膜透析(PD)雖在許多研究中呈現較具成本優勢,台灣也在2005年開始推動一連串鼓勵PD政策,然而,基於國內外研究皆指出第一年就轉換模式的透析患者其醫療費用明顯高於未曾轉換之病患族群,因此,如何選擇治療方式降低財務負擔成為衛生主管機關重要任務,本研究將從病患和透析醫療院所層面探討鼓勵ESRD患者選擇接受PD治療支付政策前後,PD病患一年內技術失敗的趨勢變化,藉以瞭解政府在政策實施後,選擇PD治療患者其短期技術失敗之變化。
本研究屬回溯性次集資料分析,利用2003至2009年之全民健康保險申報資料選取2004年1月至2008年12月之腹膜透析新發病患,觀察病患一年內技術失敗情形,技術失敗定義包含死亡與轉換為血液透析模式。統計方法的運用包括ANOVA、卡方檢定(Chi-square test)、邏輯斯迴歸分析(Logistic Regression Analysis)進行透析支付政策與PD短期技術失敗相關之探討。
研究結果發現政策實施前技術失敗率14.29%,於一連串腹膜透析鼓勵政策實施後之技術失敗率為16.19%,在校正控制變項性別、年齡、規模層級(Center Size)、以及原發病因為糖尿病之有無後,統計顯示透析支付政策介入對腹膜透析技術失敗有統計上差異(P=0.0299),政策介入後技術失敗風險較實施前增加1.376倍。此外,研究發現腹膜透析中心規模(Center Size)PD人數25-50人技術失敗風險較PD人數規模在100人以上高1.374倍(p=0.0299)。PD人數規模小於25人時其技術失敗風險較PD人數規模大於100人高1.459倍(p=0.0001)。顯示醫療機構在腹膜透析的收治人數經驗能力會影響腹膜透析失敗率。此外,年齡愈高技術失敗風險愈高,75歲以上族群實施腹膜透析之技術失敗風險較20-44歲群體增加8.471倍(p<0.0001)。
為面對迅速攀升的透析醫療費用與服務利用率,健保局期望藉由總額及鼓勵PD支付制度的推行,有效控制日益高漲的費用。雖然,在政策鼓勵下腹膜透析病患人數有逐年增加趨勢;然而,研究中發現短期技術失敗在政策介入後也隨之增加,顯見支付制度的實施影響病患及醫療服務提供者的行為。當病患第一年轉換血液透析模式過高是否對於健保費用能達到節省成本的目的,另外在獎勵推廣腹膜透析的同時,品質的管控都值得國內於制訂相關政策時進一步檢討。

Background: With population aging and the prevalence of chronic diseases like diabetes, the number of people with chronic kidney disease (CKD) has increased annually. As an example, the incidence and prevalence rates of end stage renal disease (ESRD) in Taiwan since 2001 has been the highest in the world. Since kidney diseases in Taiwan are still mainly handled using dialysis treatment, with the increase in the number of people receiving this treatment, expenditures for dialysis have become a huge burden on the National Health Insurance’s (NHI) budget. It has therefore become an important responsibility for the health authorities to find other ways of treatment to reduce the financial strain. Although several studies have found peritoneal dialysis (PD) to be cost-effective, and a series of policies have also been implemented to encourage PD treatment since 2005, a number of studies here and abroad have pointed out that the medical costs of patients changing dialysis modality in the first year are higher than those who have not changed modality at all. This study will investigate the circumstances before and after ESRD patients are encouraged to receive PD treatment and the change of condition of PD patients within one year of technique failure from the perspective of the patient and the medical institution offering such treatment, in order to gain understanding of the changes brought about by technique failure after policy implementation by the government.
Methods:Retrospective secondary data analysis is employed using NHI data from 2003 to 2009. Records from January 2004 to December 2008 of incident PD patients were collected to investigate patient conditions within one year of technique failure. Technique failure here is defined as including death and change of treatment to hemodialysis. Statistical analysis includes ANOVA, Chi-square test, and Logistic Regression Analysis to examine the correlation between the dialysis treatment policy and technique failure. by PD.
Findings: The results show that failure rate was 14.29% before policy implementation, while post-implementation failure rate was 16.19%. Adjustments were made to control sex, age, class of hospital, and whether the patient had diabetes, and the statistical analysis showed that the policy intervention involved a significant difference on technique failure (p=0.0299). The risks of technique failure after policy intervention increased by 1.374 Moreover, the risk of failure treatment at center size<25 is 1.459 times higher than that at >100 centers. The risk also increases with age; the risk for patients over 75 years old is 8.471 times higher than that of patients within the age range of 20-44.
To face with rapidly escalating healthcare costs associated with ESRD services utilization, the Taiwan’s health authority instituted a national health insurance (NHI) program of outpatient dialysis global budget (ODBG) cap for some outpatient dialysis facilities since 2001 and extended to cover all NHI’s outpatient dialysis facilities in 2003. Although the number of patients has increased over the years, the study also found that the frequency of technique failure also increased after the policy implementation, which shows that such an implementation has influenced the behavior of the patient and treatment provider. Further discussions are made to examine whether the high number of patients opting for hemodialysis has helped save costs and whether there is a need to formulate relevant policies in Taiwan for the quality control of treatment.


目 錄
誌 謝 i
中文摘要 ii
ABSTRACT iv
表目錄 viii
圖目錄 ix
第一章 緒論 10
第一節 研究背景和動機 10
第二節 研究目的 13
第二章 文獻探討 14
第一節 國內外末期腎臟疾病流行病學概況 14
第二節 末期腎臟疾病與腎臟替代療法 16
第三節 不同替代療法使用情形 21
第四節 末期腎臟疾病透析治療模式之醫療資源耗用比較 22
第五節 影響透析模式選擇因素探討 28
第六節 影響腹膜透析技術失敗因素探討 31
第三章 研究方法 37
第一節 研究設計與研究架構 37
第二節 研究假說與研究期間 39
第三節 研究材料與資料處理 40
第四節 研究變項與操作型定義 44
第五節 統計方法 46
第四章 研究結果 48
第一節 各年新增之腹膜透析病患特質 48
第二節 政策實施前後之樣本基本特質比較 51
第三節 腹膜透析技術失敗病患基本特質 54
第四節 政策實施前後新腹膜透析病患之技術失敗差異驗證 56
第五章 討論與研究限制 61
第一節 討論 61
第二節 研究限制 63
第六章 結論與建議 64
第一節 結論 64
第二節 建議 65
參考文獻/References 67
附錄一:全民健康保險醫療服務透析治療給付項目及支付標準 79
附錄二:透析支付標準修訂沿革 82



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卓世川、陳國書(2004)。利用guide wire來矯正位移之腹膜透析導管。台灣腎臟護理學會雜誌;3-1:11-16。
吳婉如、許育瑞、林石化:腹膜透析病患之胰島素抗性與治療。腎臟與透析 2006; 18: 24-7。
黃尚志、楊五常、陳秀熙(2000)。台灣地區八十八至八十九年度透析評估工作報告。台腎醫誌;14:139-224。
張牧新、黃正明、陳進陽(2004):二十一世紀的腹膜透析治療。臨床醫學;54: 423-8。
台灣血液透析診療指引。台灣腎臟醫學會編著,民國93年12月30日。
常逸平、錢慶文(2007)。全民健保腹膜透析比血液透析省錢嗎?。臺灣公共衛生雜誌; 26(5): 400-408.
游婉鈴(2010)。慢性腎臟病患轉為末期洗腎之長期趨勢分析:成長模型之應用。
楊樹昌、王榮德(2007)。比較血液透析病患生活品質之心理計量值與效用測量值的差異並探討相關因素。臺灣公共衛生雜誌;26(2): 99-109.
王智賢、黃建鐘(2002)‧腎臟病的保護療法-多重風險因子介入 治療‧腎臟與透析,14(3),136-140。
楊五常(2012)。透析服務支付政策之評估。台灣腎臟醫學會。
楊俊毓(2006)。台灣地區腎臟病病人流行病學研究。研究計畫。高雄醫學大學公共衛生學系。
鄧安智(2010)。台灣末期腎臟病患腹膜透析與血液透析存活比較。碩士論文。台北:國立台灣大學。
雷秀麗(2001)。台灣地區慢性透析病患醫療利用及死亡率之分析。碩士論文。台北:國立陽明大學。
鄭婕筠(2004)。勞動人口慢性透析病患疾病成本分析。碩士論文。台南:國立成功大學。
楊五常,透析服務支付政策之評估,行政院衛生署101年度委託研究計畫研究成果期末報告,101年12月。
全民健康保險總額支付制度協商參考指標要覽。全民健康保險醫療費用協定委員會,中央健康保險局。
101年度全民健康保險總額支付制度協商參考指標要覽_0029876002.pdf
100年度全民健康保險總額支付制度協商參考指標要覽_0029876001.pdf
99年度全民健康保險總額支付制度協商參考指標要覽.pdf
98年度全民健康保險總額支付制度協商參考指標要覽_0029875002.pdf
97年度全民健康保險總額支付制度協商參考指標要覽_0029875003.pdf
96年度全民健康保險總額支付制度協商參考指標要覽_0029875004.pdf
http://www.mohw.gov.tw/cht/NHIC/DM1_P.aspx?f_list_no=516&fod_list_no=3953&doc_no=29875


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