面對逐年增加的透析病患及龐大健保支出，有學者提出透析前照護來延緩患者接受透析治療的時間及衝擊。因此，了解患者透析前醫療利用行為，作為未來早期介入及處理患者問題的指引已成為當務之急，故引發研究此議題的動機。本研究目的為探討患者透析前醫療利用行為，採回溯性描述研究，以立意取樣，從2003年1月至2003年4月連續選取台南市某醫學中心的初次開始接受透析未超過兩星期的慢性腎衰竭患者共50位。研究工具包括個案基本資料和醫療利用行為自擬問卷，所得資料以質及量兩種方式進行資料分析。
結果顯示50位患者中男女各佔50%，平均年齡55.4歲，過去病史主要為高血壓。僅有23位（46%）患者在病程早期血清肌酸酐（Serum creatinine; Scr）小於或等於3.0 mg/dl時，接受初步腎功能篩檢確知腎功能異常而及早轉介腎臟科醫師，進行透析前照護包括營養指導、接受動靜脈廔管手術或腹膜透析教育等透析前準備。有6位（12%）的患者初次確知已達透析標準；10位患者未持續利用專業西醫療法來處理腎功能問題，其主因為自覺病徵不明顯；延遲轉介腎臟科醫師者共20位（40%）；轉介腎臟科時Scr分佈情形以大於或等於6.0 mg/dl時轉介者居多共20位（40%）；16位（32%）患者在透析前曾照會營養師，只有5位（10%）患者接受過動靜脈廔管手術或腹膜透析教育等透析前準備。50位患者的初次透析檢驗生化值為Scr 10.9 ± 4.5 mg/dl、BUN 117.6 ± 39.6 mg/dl、Na 136.1 ± 4.3 meq/dl、K 4.6 ± 0.9 meq/dl、HCO3- 19.3 ± 7.2 mmol/L、pH 7.47 ± 1.07 mmol/L、Hb 8.2 ± 2.0 g/dl、Hct 24.3 ± 7.5%、Ccr 4.6 ± 3.4 ml/min。
醫療照顧過程中，有4位（8%）患者嚐試專業中醫療法，18位（36%）患者使用非專業民俗療法（如：中草藥、偏方與成藥），影響原因包括：為避免接受透析、醫療信念及大眾媒體過度宣染。患者也常因對透析治療心存誤解，及恐懼未來無法調適長期透析生活，而常有拖延透析之情形。
研究結果得知普遍患者未依據美國國際健康組織（National Institutes of Health, NIH）轉介時機，在女性患者Scr大於1.5 mg/dl、男性患者Scr大於2.0 mg/dl時，適當轉診給腎臟科醫師，進行整合性透析前照護（黃，2001；Levinseky, 2002）。最後依據研究結果進行以下建議包括：（一）針對慢性腎衰竭高危險群患者，如：糖尿病、高血壓、中老年人等定期進行腎功能篩檢，讓更多患者能即早接受適當的透析前照護；（二）設立腎臟護理師掌握病患治療與追蹤過程，並適時提供相關支持及醫療訊息，以降低患者面對透析治療的恐懼且引導患者坦然面對未來透析生活；（三）藉由衛生教育舉辦加強民眾對腎疾病注意事項的正確觀念；（四）建立明確轉診指標，且針對醫療人員進行透析前照護相關教育，以提昇照護品質。

The progress of chronic renal failure (CRF) is irreversible, and it can lead to the need for dialysis therapy incidence. The annual growth of health insurance reimbursement continues to increase. In order to promote the quality of life for patients with CRF and maintain the reimbursement of health care, many authors had suggested that pre-dialysis care can help delay progression of renal disease and early interventions is necessary. Therefore, the purpose of this retrospective study was to explore the behaviors of health service utilization for patients with CRF in pre-dialysis stage. A total of 50 subjects with CRF who initiated dialysis therapy within two weeks were enrolled into this study from a medical center in Tainan. The data were collected using the demographic data sheet of patients, survey questionnaires for behaviors of health service utilization and personal interviews. Descriptive statistics and quantitative method were applied to analyze the data.
The demographic findings showed that 50% of male and 50% of female, mean age of the group was 55.4 years, and major history was hypertension. Twenty-three patients (46%) with serum creatinine (Scr) less than 3.0 mg/dl were referred to nephrologists and received pre-dialysis care, including nutritional instruction, arteriovenous access fistulae and education of peritoneal dialysis, to prepare dialysis therapy. Six patients (12%) were diagnosed with end-stage renal disease (ESRD) and needed to start dialysis therapy immediately. Ten patients (23%) had not been continuously treated with western medicine. The major reason for discontinuing treatment with western medicine was that patients did not perceive any physiological discomfort. Twenty patients (20%) were delayed referral to nephrologists. Twenty patients (20%) with Scr greater than 6.0 mg/dl transferred to nephrologists. Sixteen patients (32%) consulted nutritionist before initiated dialysis therapy. Only five patients (10%) accepted arteriovenous access fistulae, or education of peritoneal dialysis to prepare dialysis therapy.
The data of the initial dialysis was Scr 10.9 ± 4.5 mg/dl、BUN 117.6 ± 39.6 mg/dl、Na 136.1 ± 4.3 meq/dl、K 4.6 ± 0.9 meq/dl、HCO3- 19.3 ± 7.2 mmol/L、pH 7.47 ± 1.07 mmol/L、Hb 8.2 ± 2.0 g/dl、Hct 24.3 ± 7.5%、Ccr 4.6 ± 3.4 ml/min. Four patients (8%) were treated with Chinese medicine, and eighteen patients (36%) were treated with folk medicine (traditional Chinese herb). The factors of seeking non-western medicine included avoidance dialysis therapy, medicine belief and public medium exaggeratedly announce effect of folk medicine. The reasons of delay of dialysis therapy included the misunderstanding to dialysis therapy, and fear of unable to cope with impact of dialysis therapy in future life.
The findings showed that fewer male patients with Scr greater than 1.5 mg/dl and fewer female patients Scr greater than 2.0 mg/dl had any consultation to nephrologists to accept multidisciplinary pre-dialysis care. In summary, the government should regularly screen high risk population with CRF, and should establish pre-dialysis care in early phase. Nephrology clinical nursing specialists need to evaluate the consequences of multidisciplinary case management for patients, and provide enough information regarding dialysis therapy to reduce the fear of dialysis and help them understand how to live problems in their future life. In order to improve late referral to nephrologists and the quality of care to the dialysis patients, clear definition of early renal insufficiency should be established, and medical specialists should be taught the information about pre-dialysis care.

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