| Summary: | 碩士 === 高雄醫學大學 === 醫務管理學研究所碩士在職專班 === 100 === Background: Taiwan frequently sat on the top list regarding to uremia prevalence in recent years. Uremic patients spent a lot of health care resources. Hemodialysis (HD) is the treatment used by the majority of uremic patients in Taiwan. Anemia is a common complication of HD. The introduction of recombinant human erythropoietin in 1989 significantly improved the clinical treatment of anemia in dialysis patients. Erythropoietin is the largest drug expenditure. This study was carried out to investigate the erythropoietin dosing of HD patients and impact factors among different facilities in southern Taiwan.
Purpose 1: To investigate the erythropoietin dosing among different HD facility under current national health insurance (NHI) reimbursement, compliance of hematocrit (Hct) value distribution on the clinical guidelines and recommendations for HD issued by Nephrology society
Purpose 2: To investigate the trends for use of short-acting erythropoietin (Eprex) and long-acting erythropoietin (NESP) in recent years
Purpose 3: To investigate the influence of hematocrit (Hct), different facilities, and other factors on erythropoietin dose
Purpose 4: To investigate the medical resource utilization of HD patients and impact factors
Purpose 5: To investigate the clinical efficacy of HD patients and impact factors
Method:
This study was retrospective open cohort study. We collected data from 2 HD units at a regional hospital (which were cared by different nephrologist groups) and 2 HD clinics in southern Taiwan. Data included Hct level in each month, erythropoietin doses in claims for NHI, whether admission or not, number and cost of admission in HD patients at the regional hospital in 2010 and 2011, and databank of these 4 HD facilities constructed by HOPE dialysis software offered by Taiwan Society of Nephrology. The study variants include Hct average of each month, Eprex dose plus NESP dose times 200 of each month, admission or not, admission number and cost and survival. This study uses statistical software SPSS for Windows edition 19.0 to analyze erythropoietin dosing, medical resource utilization and clinical efficacy. Pingtung Christian Hospital Institutional Review Board agreed to conduct this clinical trial, IRB approval number: IRB 287A
Result:
There is a significant difference on the erythropoietin doses among different HD facilities (p<0.001): 27331U in the first HD unit, 18441U in the second HD unit, 15828U in M-clinic, 20644U in D-clinic; Monthly Hct average of the first month accepting regular HD in patients among HD facilities during 2010~2011 has a significant difference (p = 0.002): 32.1% in the first HD unit, 33.0% in the second HD unit, 32.4% in M clinic and 32.9% in D clinic; Hct distribution of different HD facilities exists a significant difference (p <0.001); There is a growing trend in use of long-acting erythropoietin in the two HD units at the regional hospital and M-clinic; The factors have significant impact on erythropoietin dose include different facilities(p<0.001), Kt/V(p<0.001), and monthly Hct average; The factors cause significant difference on the numbers of admission include age?d 65 years of age (p=0.005), uremia causative disease is DM(p<0.001), HD history?d 1 year(p<0.001) and Hct<30(p<0.001), but the numbers of admission between this 2 HD units have no significant difference (p=0.063); The factors cause significant impact on the cost of admission in HD patients include uremia causative disease (p <0.001), duration of HD?d 1 year (p = 0.003), and Hct <30 (p = 0.001); Factors significantly affect the survival of HD patients include age (p <0.001), uremia causative diseases(p = 0.032, p = 0.022), complications (p = 0.001); but there is no significant impact on Cox survival analysis between this 2 HD units at the regional hospital(p=0.239)
Conclusion:
1. There is a significant difference on erythropoietin dose among different HD facilities.
2. The first monthly Hct average of patients accepting regular HD among different HD facilities exist significant differences
3. The use of long-acting erythropoietin show a growing trend
4. HD facilities significantly influence the erythropoietin dosing
5. No significant difference exists in the number of admission between HD units at the regional hospital. There is no significant impact on hospitalization cost between HD units.
6. There is no significant impact on survival status, survival time between HD units at the regional hospital.
Recommend:
1. To Bureau of national health insurance: Should moderately increase HD payments in accordance with the characteristics of patients, to improve anemia treatment in HD patients, thereby reducing cardiovascular complications and the chance of blood transfusion among HD patients.
2. To providers of HD: dialysis facilities should maintain the Hct above 30%. Patients whose Hct <30% correlated with increased number of admission and hospitalization costs were higher. Maintaining Hct at above 30% reduce the number and costs of admission, help reducing medical resource utilization of dialysis patients.
Dialysis facilities can seek opportunities for joint procurement, or artificial kidney signed with the vendor to take the gift erythropoietin at discounted prices in order to save costs. Dialysis facilities should find out the case of iron deficiency anemia, chronic inflammation to increase the body''s erythropoietin sensitivity, they can also use the subcutaneous injection of erythropoietin to save the amounts.
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