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研究生：	林佩宜 Lin, Pei-Yi
論文名稱：	探討臺灣地區慢性透析病患住院情況 Hospitalization among Chronic Dialysis Patients in Taiwan
指導教授：	顏妙芬 Yen, Miaofen
學位類別：	碩士 Master
系所名稱：	醫學院 - 護理學系 Department of Nursing
論文出版年：	2006
畢業學年度：	94
語文別：	英文
論文頁數：	148
中文關鍵詞：	慢性透析、住院、二部分配模型、全民健康保險
外文關鍵詞：	hospitalization, two-part model, National Health Insurance, chronic dialysis
相關次數：	點閱：120 下載：2
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背景：「住院」為慢性透析病患主要的罹病指標，且大多導因於伴隨慢性腎臟病而來的合併症與併發症，透過適當的預防照護可降低這類病患的住院情況。過去探討影響慢性透析病患住院因子的研究缺乏具全國代表性的樣本，而在末期腎病（end-stage renal disease）發生率世界第一的臺灣更欠缺相關探討；再者，人口學、慢性腎臟病相關併發症，與醫院特徵等因子對住院的長期影響也較少受到討論。
目的：此研究的目的有二。第一，欲探討臺灣地區慢性透析病患在1997年至2001年間，開始透析後三年內的住院情況；第二，檢視人口學、慢性腎臟病相關併發症，與醫院特徵等三個因子對住院的影響。
方法：此回溯性世代研究採用臺灣地區健康保險研究資料庫進行次級資料分析，擷取自1997年1月1日至2001年9月30日初步入慢性透析的病患的相關資料，每位樣本自初透析三個月後連續觀察三年。使用二部模型（two-part model）分析法，區分病患在全民健保制度下的住院過程，第一部份為機率分析，第二部份為頻率分析。
結果：此世代樣本數共包含26,837位慢性透析病患，平均年齡為59歲，55%為女性；在三年的觀察期間共17,330（65%）位病患曾經住過院。整體而言，觀察期內平均約有兩次的住院，每次住院平均約11至12天；平均住院費用隨著時間增加。循環系統疾病（20%）為最常見的住院原因，其次是因透析通路導致的併發症（13% - 17%），第三位是消化系統相關事件（13% - 14%）。年齡（b = 0.01，p < .001）、合併症嚴重度（b = 1.41，p < .001）、糖尿病腎病變（b = -0.61，p < .001）、男性（b = -0.12，p < .001）、及慢性腎臟病相關併發症，包括高血壓（b = 1.75，p < .001）、貧血（b = 1.00，p < .001）、腎性骨病變（b = -4.10，p < .001）、和神經病變（b = 1.17，p < .001）皆與住院機率有關。年齡（b = 0.003，p < .001）、合併症嚴重度（b = 0.05，p < .001）、和男性（b = -0.05，p < .001）與住院次數有關。年齡（b = 0.008，p < .001）、合併症嚴重度（b = 0.08，p < .001）、糖尿病腎病變（b = 0.21，p < .001）、高血壓（b = -0.03，p < .05）、營養不良（b = 0.32，p < .01）、貧血（b = -0.08在第三年，p < .05）、神經病變（b = 0.15，p < .01）、醫學中心（b = 0.46，p < .001）、區域醫院（b = 0.21，p < .001）、及私立醫院（b = 0.11，p < .001）與住院天數有關。與平均住院費用相關因素類似於與住院天數相關因素，除了以下兩變項：腹膜透析方式（b = -0.6，p < .05）及受到醫院總額預算的影響（b = 0.12，p < .01）。
結論：早期介入可改善慢性透析病患的罹病情況。影響慢性透析病患住院的高危險特徵為高齡、高合併症嚴重度、女性與慢性腎臟病併發症；及早確認及轉介高危險群至腎臟照護團隊，適當提供整合性照護以矯正可修正因子（modifiable factors），並根據疾病進展特性給予合適的預防與管理措施，以減輕住院對慢性透析病患的影響。

Background: Hospitalization is an important indicator to evaluate the morbidity in chronic dialysis patients. The majority of hospitalization is for complications and comorbidities which can be attenuated in advance. Few studies have discussed related factors of hospitalization among chronic dialysis patients under a National database. It also lacked such researches in Taiwan, where showed the greatest incident rate of ESRD around the world. Moreover, the long term effects of demographic factors, CKD-related complication factors, and hospital characteristic factors on hospitalization were also under investigation.
Objectives: The purposes of this study were to (a) explore the characteristics of hospitalization within the three years following the initial dialysis therapy from 1997 to 2001 among chronic dialysis patients in Taiwan, and (b) examine the hospitalization in associated with demographic factors, CKD-related complication factors, and hospital characteristic factors.
Method: This research was a retrospective cohort study with a secondary data analysis method by evaluating the research databank from the National Health Insurance (NHI) program in Taiwan. Data were retrieved for all patients starting chronic dialysis therapy from December 31, 1997 to September 30, 2001. The study period for each patient was three years after three months following the initial dialysis therapy. A two-part model was used to analyze the utilization of inpatient care. The process of inpatient utilization was separated into two parts: the contact analysis and the frequency analysis.
Results: The study cohort was composed of 26,837 patients with a mean age of 59 years and over half of the cohort were females (55%). A total of 17,330 (65%) patients had experienced at least one hospital episode during the follow-up period. Overall, they had an average of two admissions and spent about 11 to 12 days each admission. The mean inpatient expenditure per admission was increased as the episodes of hospitalization increased. Circulatory events were the most frequent reason (20%) for admission, followed by dialysis access-related events (13% - 17%) and digestive diseases-related events (13% - 14%). Age (b = 0.01, p < .001), comorbidity (b = 1.41, p < .001), diabetic nephropathy (b = -0.61, p < .001), male (b = -0.12, p < .001), hypertension (b = 1.75, p < .001), anemia (b = 1.00, p < .001), renal osteodystrophy (b = -4.10, p < .001), and neuropathy (b = 1.17, p < .001) were associated with probability of hospitalization. Age (b = 0.003, p < .001), comorbidity (b = 0.05, p < .001), and male (b = -0.05, p < .001) were associated with the number of admissions. Age (b = 0.008, p < .001), comorbidity (b = 0.08, p < .001), diabetic nephropathy (b = 0.21, p < .001), hypertension (b = -0.03, p < .05), malnutrition (b = 0.32, p < .01), anemia (b = -0.08 in the third year, p < .05), neuropathy (b = 0.15, p < .01), academic medical centers (b = 0.46, p < .001), metropolitan hospitals (b = 0.21, p < .001), and private hospitals (b = 0.11, p < .001) were associated with the number of hospital days. The factors associated with hospital days were similar to those associated with inpatient expenditures. The difference mainly came from the influences of the peritoneal dialysis modality (b = -0.6, p < .05) and the hospital global budget (b = 0.12, p < .01) on expenditures.
Conclusions: Early intervention may improve the morbidity of chronic dialysis patients. The characteristics of high-risk patients for hospitalization are advanced age, with greater comorbidity, female, and with CKD-related complications. Timely identifying and referring high-risk patients to the nephrology team is a better way to properly provide coordinated care for recognized patients.

TABLE OF CONTENTS

摘要	                                                                     I
ABSTRACT                                                                 	   III
致謝	                                                                    VI
TABLE OF CONTENTS	                                                         VIII
LIST OF TABLES	                                                           XI
LIST OF FIGURES	                                                          XII
LIST OF APPENDICES	                                                         XIII

CHAPTER I  INTRODUCTION	                                                   1
  SECTION I - BACKGROUND AND SIGNIFICANCE	                                 1
  SECTION II - SPECIFIC AIMS AND RESEARCH QUESTIONS                           3
  SECTION III - SUMMARY	                                                   4
CHAPTER II  LITERATURE REVIEW	                                          5
  SECTION I - CURRENT STATUS OF CHRONIC DIALYSIS	                       5
    1 Definition of Chronic Dialysis	                                          5
    2 Demographic Trends of Chronic Dialysis Patients	                       6
    3 Summary	                                                           10
  SECTION II - HOSPITALIZATION AMONG CHRONIC DIALYSIS PATIENTS	             11
    1 Hospitalization	                                                  11
    2 Risk Factors for Hospitalization	                                14
    3 Summary	                                                           23
CHAPTER III  METHOD	                                                  27
  SECTION I - RESEARCH FRAMEWORK	                                         27
  SECTION II - RESEARCH HYPOTHESES	                                         29
    1 Factors Associated with the Probability of Hospitalization	    29
    2 Factors Associated with the Number of Admissions	                      31
    3 Factors Associated with the Number of Hospital Days	             33
    4 Factors Associated with Inpatient Expenditures	                      35
  SECTION III - DEFINITIONS	                                                  38
    1 Chronic Dialysis	                                                  38
    2 Hospitalization	                                                  38
  SECTION IV - RESEARCH DESIGN	                                         39
  SECTION V - SAMPLE	                                                  40
  SECTION VI - PROCEDURES	                                                  42
    1 Study Period	                                                           42
    2 Data Retrieving and Categorization	                                42
    3 Summary	                                                           58
  SECTION VII - DATA ANALYSIS	                                         61
    1 Descriptive Statistics	                                         61
    2 Analytic Statistics	                                                  63
  SECTION VIII - RESEARCH ETHICS	                                         67
CHAPTER IV  RESULTS	                                                  68
  SECTION I - DESCRIPTION OF SAMPLE	                                         68
    1 The Status of Chronic Dialysis Patients	                                68
    2 Characteristics of Patients with and without Hospitalization	    71
    3 Characteristics of Hospitalized Patients in Three Observation Years	    73
  SECTION II - DESCRIPTION OF HOSPITALIZATIONS IN THE FOLLOW-UP PERIOD	    76
  SECTION III - FACTORS ASSOCIATED WITH THE PROBABILITY OF HOSPITALIZATIO    78
  SECTION IV - FACTORS ASSOCIATED WITH THE NUMBER OF ADMISSIONS IN THE FOLLOW-
               UP PERIOD	                                                  81
  SECTION V - FACTORS ASSOCIATED WITH THE NUMBER OF HOSPITAL DAYS IN THE 
              FOLLOW-UP PERIOD	                                         85
  SECTION VI - FACTORS ASSOCIATED WITH INPATIENT EXPENDITURES IN THE FOLLOW-UP 
               PERIOD	                                                  92
CHAPTER V  DISCUSSION	99
  SECTION I - CHARACTERISTICS OF THE HOSPITALIZED PATIENTS	             99
  SECTION II - CHARACTERISTICS OF HOSPITALIZATIONS	                     100
  SECTION III - FACTORS ASSOCIATED WITH THE PROBABILITY OF HOSPITALIZATION  102
  SECTION IV - FACTORS ASSOCIATED WITH THE NUMBER OF ADMISSIONS	            104
  SECTION V - FACTORS ASSOCIATED WITH THE NUMBER OF HOSPITAL DAYS	   107
  SECTION VI - FACTORS ASSOCIATED WITH INPATIENT EXPENDITURES	            114
  SECTION VII - LIMITATIONS	                                                 117
CHAPTER VI  CONCLUSIONS AND SUGGESTIONS	                               118
  SECTION I - CONCLUSIONS	                                                 118
    1 Characteristics of Hospitalizations	                               118
    2 Factors Associated with the Probability of Hospitalization	   119
    3 Factors Associated with the Number of Admissions	                     119
    4 Factors Associated with the Number of Hospital Days	            120
    5 Factors Associated with Inpatient Expenditures	                     122
  SECTION II - SUGGESTIONS	                                                 123
    1 Heath Policies	                                                 123
    2 Clinical Practicing	                                                 124
    3 Research	                                                          125
CHAPTER VII  REFERENCES	                                                 127
  SECTION I - CHINESE REFERENCES	                                        127
  SECTION II - ENGLISH REFERENCES	                                        129

 
LIST OF TABLES
TABLE																  PAGE
2.1    SUMMARY OF LITERATURE REVIEWS	                                         25
3.1    MODIFIED CHARLSON COMORBIDITY INDEX AND CORRESPONDING ICD-9-CM CODE   44
3.2    THE TAXONOMY OF PRIMARY RENAL DIAGNOSIS AND ITS HOMOLOGOUS ICD-9-CM 
       CODES	                                                           50
3.3    THE ICD-9-CM CODES OF CKD-RELATED COMPLICATION FACTORS	             53
3.4    THE CATEGORIZATION AND RELATED CODES OF HOSPITAL SIZE AND HOSPITAL 
       OWNERSHIP	                                                           55
3.5    THE CATEGORIZATION AND THE CORRESPONDED ICD-9-CM CODES OF CAUSE-
       SPECIFIC HOSPITALIZATION	                                         57
3.6    FILES UTILIZED IN THE STUDY	                                         58
3.7    THE DESCRIPTION OF THE FILES AND THE VARIABLES USED IN THE STUDY	    59
3.8    THE SCALES AND EXPRESSIONS OF VARIABLES IN THE STUDY	             62
4.1    CHARACTERISTICS OF THE STUDY SAMPLE	                               69
4.2    THE STATUS OF CHRONIC DIALYSIS PATIENTS IN THE THREE-YEAR FOLLOW-UP 
       PERIOD  (N = 30,618)	                                                  70
4.3    CHARACTERISTICS OF PATIENTS WITH AND WITHOUT HOSPITALIZATION	    72
4.4    CHARACTERISTICS OF HOSPITALIZED PATIENTS IN THREE OBSERVATION YEAR    74
4.5    HOSPITAL CHARACTERISTICS OF ADMISSIONS IN THREE OBSERVATION YEARS	    75
4.6    DESCRIPTION OF HOSPITALIZATION IN THREE OBSERVATION YEARS	    76
4.7    CAUSE-SPECIFIC HOSPITALIZATION IN THREE OBSERVATION YEARS	    77
4.8    FACTORS ASSOCIATED WITH THE PROBABILITY OF HOSPITALIZATION	    80
4.9    FACTORS ASSOCIATED WITH THE NUMBER OF ADMISSIONS IN THREE OBSERVATION 
       YEARS	                                                           83
4.10   INDIVIDUAL EFFECTS OF INDEPENDENT VARIABLES ASSOCIATED WITH THE NUMBER 
       OF ADMISSIONS	                                                  84
4.11   GOODNESS OF FIT OF POISSON REGRESSION	                                85
4.12   FACTORS ASSOCIATED WITH THE NUMBER OF HOSPITAL DAYS IN THREE 
       OBSERVATION YEARS	                                                  89
4.13   INDIVIDUAL EFFECTS OF INDEPENDENT VARIABLES ASSOCIATED WITH THE NUMBER 
       OF HOSPITAL DAYS	                                                  91
4.14   FACTORS ASSOCIATED WITH THE INPATIENT EXPENDITURES IN THE THREE 
       OBSERVATION YEARS	                                                  97
4.15   INDIVIDUAL EFFECTS OF INDEPENDENT VARIABLES ASSOCIATED WITH EXPENDITURE	                                                                    98

LIST OF FIGURES
FIGURE							  	  PAGE
3.1    THE RELATIONSHIP OF HOSPITALIZATION WITH DEMOGRAPHIC FACTORS, CKD-
       RELATED COMPLICATION FACTORS, AND HOSPITAL CHARACTERISTIC FACTORS UNDER 
       THE STUDY.	                                                           28
3.2    THE TIME FRAME OF DATA COLLECTION.	                                58
4.1    RESIDUAL PLOT FOR EXPENDITURE IN THE FIRST OBSERVATION YEAR.	    92
4.2    NORMAL PROBABILITY PLOT FOR EXPENDITURE IN THE FIRST OBSERVATION YEAR: 
       Q-Q PLOT.	                                                           93
4.3    RESIDUAL PLOT FOR LOG-TRANSFORMED EXPENDITURE IN THE FIRST OBSERVATION 
       YEAR.	                                                           93
4.4    NORMAL PROBABILITY PLOT FOR LOG-TRANSFORMED EXPENDITURE IN THE FIRST 
       OBSERVATION YEAR: Q-Q PLOT.	                                         94
 

LIST OF APPENDICES
APPENDIX								  PAGE
A    THE TAXONOMY OF PRIMARY RENAL DIAGNOSIS AND ITS HOMOLOGOUS ICD-9-CM CODES	                                                                   140
B    SAS CODES FOR ANALYTIC ANALYSIS	                                        142
C    THE AUTHORIZATION OF THE NATIONAL HEALTH INSURANCE RESEARCH DATABASE	   147
D    THE APPROVAL OF HUMAN RESEARCH ETHICS COMMITTEE AT NATIONAL CHENG KUNG 
     UNIVERSITY HOSPITAL	                                                 148

                                    

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2. Bureau of National Health Insurance. (2005b). ICD-9-CM codes. Taipei, Taiwan: Department of Health, Bureau of National Health Insurance. Retrieved June 14, 2005, from http://www.nhi.gov.tw/webdata/AttachFiles/Attach_3469_1_ICD2001.xls
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