| Summary: | 碩士 === 國立陽明大學 === 衛生福利研究所 === 92 === Taiwan’s prevalence of chronic dialysis placed second around the world in 1999. Although patients with end stage renal disease (ESRD) were only 0.15% of the total insurants, their medical costs were 5.6% of the total medical cost. Other than the cost, the hospitalization rate for these patients was also higher. Many countries place surveillance on dialysis outcome to prevent over hospitalization and the high death rate associated with the disease. The purpose of this study was to assess quality of care among dialysis centers in Taiwan, we used the database for 1999 national health insurance inpatient and outpatient medical benefit, as well as the death records to analyze comparing types of treatment outcome among dialysis centers, such as the differences between observed and expected mortality rates, and standardized mortality ratio. Patients with end-stage renal disease could have doctor shopping behaviors, by using administrative data, patients were categorized as having a regular source of care if they made 75% or more of their total dialysis treatment within the same place.
The result indicated that among the chronic dialysis patients, 84.15% had a regular source of care. For new patients who were 65~74 years and having comorbidity ( hypertension, malignancy), the rate of having a regular source of care is lower than other groups. For old patients who were female, married and having other cardiovascular disease, the rate of having a regular source of care is higher than other groups. But old patients who have comorbidity (eg, diabetes) , the rate of having a regular source of care is lower than other groups. Significant lower risk of death were found for facilities such as hospital accreditation when controlling for patients and regional variables. The result for facility profile analysis showed that crude mortality in these centers was 10.0% when controlling for patients characteristics, many dialysis centers with the highest unadjusted death rates remained among the facilities with the highest adjusted mortality. Dialysis centers with higher service volume and higher proportion of patients with a regular source of care could affect quality of care. The technique of standardized mortality ratio （SMR）should be able to identify outliner centers.
This study suggested that the government should encourage and educate dialysis patients to have a regular source of care and not to receive treatments in the dialysis center with lowest service volumes. The Bureau of National Health Insurance could use the facility mortality rate, the proportion of patients having a regular source of care in dialysis centers as quality indicators of care and to identify variations in quality among different dialysis centers. The dialysis centers should strengthen their relationships with patients who are male, 64~75 years ,divorced, widowed, new patients, or having comorbidity by improving medical staff relation to meet patients’ demand.
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