Utilization and Quality in Incident Hemodialysis Patients with Type of Vascular Access

• Main Authors: Yen-Ni Hung, 洪燕妮
• Other Authors: Shiao-Chi Wu
• Format: Others
• Language: zh-TW
• Published: 2009
• Online Access: http://ndltd.ncl.edu.tw/handle/12529727769072181657

博士 === 國立陽明大學 === 公共衛生研究所 === 97 === Ninety-two percent of incident end stage renal disease patients received hemodialysis, patients who choose hemodialysis require vascular access before initiation of dialysis, there is large portion of hospital admissions in hemodialysis patients are related to vascular access complications. The purpose of this study was to analyze the factors of dialysis access types of incident dialysis patients as well as the impact of access type on medical expenditure, hospitalization , short term and long term quality indicators. A retrospective cohort study on incidental dialysis patients between year 2002 and 2005 were conducted by analyzing the related variables by using the National Health Insurance Reimbursement Database during year 2001 through 2006. All subjects were divided by their very first vascular access creation into 3 groups: arteriovenous fistula (AVF), arteriovenous graft (AVG), and permanent dialysis catheter (Perm-cath). Only the access-related expenditure and hospitalization were taken into investigation. Several short term quality indicators such as infection, thrombosis, reconstruction within 3 & 6 months, primary & secondary patency of access were recorded and analyzed. Long term qualitiy indicators such as , duration of free from infection , primary patency of initial access, secondary patency of initial access and patient survival were also taken into analysis. Independent variables in this investigation were gender, patient age, timing of access construction, comorbidities, dosage of EPO, numbers of dialysis treatment per week, and characteristics of healthcare facility. Logistic regression, multiple regression, generalized estimating equations (GEE), Mixed model, and Cox proportional hazards model were carefully chosen and applied in this investigation according to the different type of dependent variables. The numbers of incident dialysis patents included in this investigation in 2002 through 2005 were 7472, 7456, 7402 and 8204 respectively. Forty-five percent of the population was above the age of 65. And 51.9% of the subjects were diabetic. 42.5% of the all-cause admissions during their first year of dialysis treatment were dialysis access related. And 58.5% of the expenditures on hospitalization were dialysis access related. AVF comprised of 76.7% of the first time access construction of those incident patients in our investigation. During our investigation years, however, a downward trend of the AVF construction rate were observed . There were only 38% of new dialysis patients had their access constructed before the start of their dialysis treatment. Regarding the type of access, influential factors were gender, age, timing of access construction, and comorbidities, given dosage of EPO per month, type of healthcare institute and calendar year. The access related inpatient expenditure was the highest during the first year after initiation of dialysis therapy. The access-related inpatient expenditure of AVG patients was significant higher than those of AVF patients. For both the AVF and AVG patients, the incidence of infection and thrombosis of access did not reach the standard recommanded by our guideline. The secondary patency of AVF and AVG in this study was 1240 days and 859 days respectively. Both reached the recommandation by the the guideline. The AVF patients did have lower short term access infection and thrombosis rate and higher reconstruction rate in 3 months. The access reconstruction rate in 6 months were similar between two groups of patients. After well control of other variables, the AVF patients do perform better on free from access infection, primary patency of access, secondary patency of access and patient survival. Access-related problems were the main cause of hospitalizations of the long term dialysis patients within their first year after initiation of dialysis. We have found that the incidence of AVF construction were higher than most of other countries. However, the referral time for access construction was late. We have also found that the type of access correlates significantly to the expenditure on hospitalization and index on health care. Improvement on access related problem may impose positive impact on quality of care. We suggested that the access related problems should be paid with more attention. Continuous monitoring and efforts on caring of the access related problems such as infection, admission, thrombosis and patency is mandatory.