| 摘要: | 依據2005 USRDS Annual Data Report (ADR) 台灣地區的腎病變末期 (End Stage Renal Disease, ESRD) 患者，每百萬人發生率384人，高居世界第一。盛行率每百萬人1,631人，居世界第二僅次於日本。因此，降低降低ESRD高發生率是非常急迫的議題，其中，減緩個案慢性腎臟疾病(Chronic kidney disease, CKD)病程進展(delay progression)成腎病變末期之速度是具有成本效益的方式，故深入探討慢性腎臟疾病病患在發展成為ESRD之過去病史、醫療利用情形、可能之危險因子，或可由其中找出降低ESRD發生率之可能方向。文獻顯示影響慢性腎衰竭病患病程進展與預後，取決於透析治療前照護品質與轉介給腎臟科醫師照護的時間；在台灣醫療型態呈現專科化的情況下影響慢性腎臟疾病轉介至腎臟科治療之影響因素是本研究想要探討的。本研究主要目的在了解台灣地區，新末期腎臟疾病患者，疾病史與醫療利用情形，並進一步分析影響轉介予腎臟科醫師之因素，期能作為一般民眾、醫療提供者、相關醫療政策制定者之參考。
本研究為回溯性資料分析，以中央健康保險局94年新核准之腎病變末期個案為研究對象，由健保資料90年至94年五年資料期間病患就醫資料為素材。主要目的在了解研究對象相關診斷與醫療利用情形，分析病患特質、疾病史、醫療利用史是否為接受腎臟科醫師照護日數之影響因素，並進一步推論影響末期腎臟疾病患者延遲轉介的可能因素。
資料分析方法包括敘述性統計、單因子變異數、卡方檢定、Bonferroni 法多重比較、Kruskal-Wallis test及Logistic Regression分析等。
本研究之主要結果如下：
一、民國94年核准「慢性腎衰竭需定期透析治療患者」之重大傷病個案，過去五年健保申報資料顯示，接近有一半比例的慢性腎衰竭疾病患者被診斷出罹患糖尿病(52.16%)；有六成至七成五比的病患被診斷出罹患高血壓(58.51%~75.62%)；同一病患被診斷出合併有高血壓、糖尿病者約佔全體病患人數之三成六(36.70%)，僅有一至二成六(10.8%~26.57%)的病患曾經被診斷為慢性腎絲球腎炎(CGN);被診斷為腎病腎炎腎症候群(Nephritis, Nephrotic syndrome and Nephrosis) 之病患比率隨著愈接近被確診為ESRD逐年增加。
二、研究對象西醫平均門診就醫次數由90年29.28次上升至94年39.65次；急診平均就醫次數由90年0.01次上升至94年0.05次；平均住院次數由90年1.15次上升至94年2.14次。94年幾乎全數病患皆有住院，主要住院原因是因慢性腎衰竭。
三、研究對象中有3273人（佔全部人數34.2%）在ESRD被確診當年才開始去看腎臟科，其中2499人於ESRD核定前三個月內才開始看腎臟科醫師，約佔94年新ESRD病患人數之26.09%，也就是大於四分之一的ESRD病患是屬於延遲轉介(Late referral)之個案。
四、年齡分組、性別、健保分局別、地區別與平均腎臟科醫師照護日數呈現顯著差異。
五、致ESRD之危險因子高血壓、糖尿病、或二項危險因子皆具者，平均腎臟科醫師照護日數達統計上顯著差異。同時具有二項危險因子者接受腎臟科醫師照護較晚，不具危險因子者則較早接受腎臟科醫師照護。
六、研究對象如果屬糖尿病患者且為「全民健康保險糖尿病醫療給付改善方案」收案對象，則接受腎臟科醫師照護之日數較短。若有參加「全民健康保險糖尿病醫療給付改善方案」且有做微白蛋白尿液檢查，接受腎臟科醫師照護日數卻最短。此二點在統計上均有顯著差異。
七、性別、年齡組別、合併有糖尿病、高血壓、就醫醫院層級，為延遲轉診之可能影響因素。
由以上結果得知，老年病患合併糖尿病高血壓等慢性疾病為台灣ESRD高發生率與高盛行率之主要因素。病患可能停留在治療慢性疾病而延遲轉介給腎臟科醫師治療，資源整合與建立跨領域跨科別之合作，已是刻不容緩的事。建議全民健康保險，應檢討實施多年之全民健康保險糖尿病醫療給付改善方案、全民健康保險高血壓醫療給付改善方案，整合為防治高血壓、高血糖、高血脂之「三高試辦計劃」，將資源做最有效運用。此外應積極推展腎臟病防治計畫，針對高危險群找出較早期慢性腎臟疾病患者，儘早轉介給腎臟專科醫師評估疾病進展與罹病風險，積極控制病情以避免變成需洗腎之個案。
According to 2005 USRDS Annual Data Report (ADR), Taiwan has the highest incidence rate(384 per million people) of End Stage Renal Disease (ESRD) in the world, reaching. Prevalence of ESRD in Taiwan is the second highest in the world, reaching 1631 per million people. How to delay progression of Chronic Kidney Disease (CKD) into ESRD has become an important public health issue in Taiwan.
Diabetes and essential hypertension remain the most important risk factors for ESRD in Taiwan. Due to alarming increase of diabetes and hypertension patients around the world, it is virtually impossible to halt the increase of ESRD cases. However, early diagnosis and management of various risk factors, early referral of patients with damaged kidneys to nephrologists, and proper multidisciplinary care could delay or even stop the progression of CKD to ESRD.
This retrospective study analyzed data of National Health Insurance (NHI) from the year 2001 to 2004, based on new ESRD cases in the year 2005. Specifically, various risk factors for ESRD were also analyzed statistically. How those patients were referred to nephrologists before ESRD was also analyzed. Risk factors of late referral to nephrologists were analyzed and identified.
Result: Late referral was defined as 90 or less days before first encounter with nephrologists. Of all the new ESRD patients in 2005, 26% were in late referral group. This figure compared relatively favorable with the data in other countries where most countries had late referral rate ranged from one-third to half the population in need of renal replacement therapy (RRT).
Various risk factors for late referral were identified: teenage, living in rural areas, had both diabetes and hypertension, and participation of NHI’s DM P4P (Pay-for-performance) programme.
Regarding how to improve caring for CKD and prospective ESRD patients, various suggestions for health authority and NHI were proposed in this study. Early detection and management of risk factors, implementing policies to encourage early referral to nephrologists, and implementing multidisciplinary corroborative health care were proposed. |
