個人及區域社經地位對血液透析病人早期轉介腎臟科之影響

The effects of individual and neighborhood socioeconomic status on early nephrology referral for hemodialysis patients

目標：健康不平等是公共衛生研究的重要議題，台灣在全民健保開辦後，大幅降低民眾就醫的財務障礙，早期轉介腎臟科是否存在個人及區域社經地位之差異，是值得探討的議題。方法：採回溯性世代研究法，以2009年慢性血液透析成人新個案為對象，資料來源包括全國健保門住診及相關次級資料；以病人透析前二年內首筆出現腎臟科門診之日計算，若落在透析前90日以上定義為早期轉介。以逐步邏輯斯迴歸探討個人（被保險人收入、教育程度、工作狀態）及區域（平均每戶全年經常性收入、15歲以上人口高等教育率）社經地位對早期轉介之影響，並控制人口學、共病症與轉介前最常就醫院所特質。結果：2009年慢性血液透析成人新個案有7,687位，早期轉介率為70.9％；控制其他因素後，被保險人收入較低者、無工作者早期轉介率顯著較低（OR=0.81，95％CI=0.70－0.93；OR=0.84，95％CI=0.73－0.95），區域社經地位則與早期轉介率無顯著相關。結論：我國在全民健保實施後，透析患者之早期轉介仍存在個人社經地位之差異，產生此現象之原因有待未來研究作進一步探討。

Objectives: Tackling health inequalities is a key concern of public health policy makers. The major purpose of Taiwan's National Health Insurance (NHI) is to reduce the financial barriers to care. It is worth ascertaining if individual and neighborhood socioeconomic inequalities exist in early nephrology referral for hemodialysis patients. Methods: This population-based retrospective cohort study examined the incidence of new hemodialysis patients in 2009 as identified from the Taiwan National Health Insurance database and relevant secondary data. Early referral was defined as patients meeting with a nephrologist more than 90 days before initial hemodialysis. Stepwise binomial logistic regression models were performed to examine the effect of individual socioeconomic status (SES) (premium-based monthly salary (NT$), level of education, and employment status) and neighborhood SES ('average family income and expenditure per household' and 'educational attainment of the population aged 15 and over - junior college and above') on early nephrology referral after controlling for demographic characteristics, co-morbid conditions, and characteristics of major health care organizations before referral. Results: A total of 7,687 consecutive adult incident hemodialysis patients were identified, and 70.9% of them were referred early. Unemployed patients and those with a lower premium-based monthly salary had significantly lower early referral rates after controlling for other factors (OR=0.81, 95%CI=0.70- 0.93; OR=0.84, 95%CI=0.73-0.95). No significant associations were found between neighborhood SES and referral pattern. Conclusions: Individual socioeconomic inequalities exist in early nephrology referral for hemodialysis patients despite universal health coverage. The causes of this finding require further investigation.