The Impact of Taiwanese Clinical Practice Guidelines for Hemodialysis on Types of Treatments of the Creation and Maintenance of Vascular Access in End-Stage Renal Disease Patients

Autor: Yi-Chen Jiang, 姜鐿晨
Rok vydání: 2015
Druh dokumentu: 學位論文 ; thesis
Popis: 103
Background and Purpose The high incidence and prevalence of End Stage Renal disease (ESRD) in Taiwan has been a public issue. The expenditure of dialysis in uremic patient has become one of major burdens in health care insurance finance. Having a sustainable l hemodialysis access can not only provide a sufficient renal clearance but also decrease the complications and resulted in hospitalization. To better provide renal care, the Taiwan renal (Taiwan Society of Nephrology) issued clinical guidelines in 2004. To our best knowledge, no study revealed the changes of hemodialysis access model and associated costs after the introduction of the guideline. The purpose of this study is first to investigate the effect of occlusion treatment guidelines for ESRD on different disposition of vascular access (PTA or Shunt) by using national database. And further to explore the medical utilization and mortality by different access treatment models. Methods This study adopted retrospective cohort research design. The National Health Insurance Research Database was primary data source. Patients who t with ESRD (ICD-9-CM code: 585, 586) during 1997 to 2010. Patients were divided into Cohort I (1997- 1999) and Cohort II (2004- 2006) by the time Taiwanese Clinical Practice Guidelines 2004 was introduced. Each patient was followed up for 4 years since hemodialysis access (AVF or AVF) had been created. The access maintained method included access reconstruction surgery (Shunt) or percutaneous transluminal angioplasty (PTA). The SPSS 20.0 was used as statistical software. Chi-square test, T-test, mulitiple regression analysis, multiple linear regression and Cox regression were used to answer the hypotheses. Results The trend analysis indicated that the numbers of PTA over passed percutaneous angioplasty in 2004. Patients in Cohort II had 3.37 times (95% CI: 2.48- 4.58) likelihood to receive PTA as compared with cohort I. In terms of frequency of PTA, Cohort II received 1.48 PTAs than that of cohort I did. As compare with first AVF, first AVG had greater numbers of PTA Regarding to Fistula reconstruction frequency, no difference was found between Cohort I and Cohort II. At Fistula maintenance days, Cohort I appeared longer average days than that Cohort II in first Fistula (770 vs.694). With increasing frequency of PTA for the same fistula, the maintenance days were decreasing. For example, 418 day for first PTA, 147 for fifth PTA. Cohort II consumed more medical cost than that Cohort I over four year period. However, no difference in overall mortality between Cohorts I and II. Conclusions The study found that Cohort II received t more PTAs, higher vascular access maintenance costs than that of Cohort I., The results implied that the introduction of clinical guidelines might increase use of PTA. Many patients in Cohort II received PTA within 90 days which might implied over use of PTA However, further study with clinical parameters is suggested to validate the results.
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