現行衛教與醫療給付制度對透析模式選擇之衝擊

Patient Education and Reimbursement Policy: Impact on the Choice of Renal Replacement Therapy Modality

台灣自民國84年實施全民健康保險制度起，全體國民都能獲得更完善及全方位的醫療照顧。隨著國人平均壽命逐年延長，加上國人生活型態與飲食習慣的改變，慢性疾病日益增加，而慢性腎臟疾病(chronic kidney disease, CKD)人口亦與日俱增。依據美國腎臟資料系統(US Renal Data System, USRDS)統計顯示，我國末期腎臟病，其發生率及盛行率均高居世界第一位(USRDS, 2008)。雖然末期腎臟病病患人口僅佔全體健康保險人口約0.15%，但每年卻耗用超過7.2%（約302億）之全民健康保險費用，對醫療系統帶來極大的衝擊，對社會與經濟各層面莫不造成沉重負擔。衛生署國民健康局於93年提出腎臟防治保健計畫，鼓勵醫療院所加入腎臟病健康促進機構並成立慢性腎臟疾病衛教門診，依腎臟疾病不同分期而給予護理指導及營養師的飲食衛教，並定期追蹤病患疾病進展，以提昇病患對疾病認知，使病患行為改善同時也增加病患自我照顧能力，以期有效地防治慢性腎臟疾病惡化。近來許多研究指出，給予慢性腎臟病病患衛教後，病患會傾向選擇自主性較高的透析治療模式。目前末期腎臟病患者透析模式主要有血液透析(hemodialysis, HD)或腹膜透析(peritoneal dialysis, PD)。然而病患選擇血液透析或腹膜透析這個問題應考量病患的自主性、個人需求喜好與醫師的專業判斷，共同來協助病患針對個別狀況選擇最適合的治療模式。爾後定期的透析品質監測，才是提升病患生活品質與健康狀況的不二法門。但現今政策忽略病患就醫自主性以及選擇透析模式的自由，並以「推廣腹膜透析」為主軸，醫護人員對現行政策的了解與否？現行衛教對病患透析模式選擇發揮影響力為何？如何讓末期腎臟病患者有更好的透析品質並提升生活品質，醫護人員責無旁貸。本文內容探討的重點，包括全球透析現況、台灣醫療給付現況、現行臨床衛教及影響透析模式選擇因素。希望透過對此議題背景的認識，醫護人員能自我審視一番，俾對末期腎臟病患者之衛教更具說服力。因此，專業的醫護人員有責任提供慢性腎臟病患正確的衛教資訊及幫助他們選擇最有利於自己的透析模式，也為有限的健保醫療資源而努力。

Since 1995, when Taiwan established a comprehensive and egalitarian health care system for its citizens, the incidence and prevalence of chronic diseases (particularly cardiovascular disease, hypertension, diabetes mellitus and chronic kidney disease) have steadily increased. The 2008 USRDS data reports that Taiwan has the highest incidence and prevalence of patients with end-stage renal disease (ESRD) worldwide. Although the population of patients with ESRD accounts for only about 0.15% of the total health insurance population, health care costs for this population account for about 7.2% (approximately NT$ 30.2 billion) of the total NHI budget. Clearly, the cost of managing ESRD represents a leading threat to public health and healthcare resources not merely locally but rather on a worldwide scale. In 2004, the Bureau of National Health Insurance (BNHI) launched the pre-ESRD education program with the ultimate goal of achieving positive and long-lasting changes in patient behavior by empowering them with the knowledge required to enable them to make autonomous decisions regarding their own health care as much as possible, as well as to help improve their own outcome. Substantive research has been carried out regarding the benefits of such a pre-ESRD educational program on all renal replacement therapy (RRT) modalities. Recent studies from a variety of countries have shown that patients given pre-ESRD education tended to opt for self-care RRT. It is a challenge for renal health care providers to offer and deliver the best options in regard to all of the aspects of dialysis and transplant therapies to patients with ESRD, while keeping costs in line with health care budgets. Renal care professionals and health care authorities have to work together to formulate an optimal modality selection strategy. As professional renal nurse practitioners, it is our duty to properly inform and educate patients with chronic kidney disease (CKD) and help them to make the best choices regarding the mode of RRT which they should choose.