台灣國人末期腎臟疾病(ESRD)之患者逐年增加，每年新增洗腎患者達八千人，根據台灣腎臟學會統計表示，台灣洗腎病患於2002年首度超越美國，成為世界第一。另外，根據台灣每年死因報告中顯示，腎炎、腎徵候群及腎變性病是國人十大死因第八名，健保支出更是年年高升，根據中央健康保險局之統計數字，健保局一年約需花費300億元台幣於洗腎治療上，此數據為健保局支付單項醫療項目中最大的花費，甚至遠超過於第一死因癌症病患之60億元台幣。雖然ESRD病患人數僅占健保中之0.15%，其所花費之費用竟占健保之7.2%，高居重大傷病第一位，是健保單一給付最高的疾病。由此可知，末期腎臟疾病所需之資源和金錢為社會之極大負擔。
因此，於此篇研究中便探討並研究現在台灣所面臨洗腎狀況之相關議題，提出一馬可夫模式以描述ESRD病況的行進，並分析兩種洗腎方式：血液透析(HD)和腹膜透析(PD)之成本效益，之後，再提出一數學模式以有效分配有限之資金於ESRD病患，並使他們獲得最佳之生命品質調整壽命年(QALYs)，而此模式之目標為將推廣計劃之投資滿足政府所訂定之增加腹膜透析病患比例之目標，並最大化其效益，經由案例分析和敏感度分析之方式，提供政府一未來醫療政策之參考。

End stage renal disease (ESRD) has been a widespread disease in many countries, especially in Taiwan. According to statistics from the Taiwan Society of Nephrology in 2002, Taiwan ranks second globally in the prevalence and also has the highest incidence of ESRD. In addition, although ESRD patients occupy only 0.15% in the whole health insurance in Taiwan, it costs 7.2% (the highest of whole diseases) of the expense of health insurance. In other words, it is known that the resources and money spent in this disease become a huge burden in the society. Hence, this paper examined the cost-effectiveness of ESRD treatment for patients to make them treated with better cost-effectiveness treatment modalities.
The Markov-chain model was used to study the influence of substitutive policies on the overall cost-effectiveness of the ESRD treatment program. After analyzing the cost-effectiveness of the treatments, a mathematical model was constructed to allocate the patients to maximize the effectiveness under the limited funds and to achieve their best QALYs (quality-adjusted life-years). The result shows that Peritoneal Dialysis is the treatment with better cost-effectiveness; therefore, various policies in the budget allocation model are constructed to analyze how the policy will change under different parameters by using sensitivity analysis. The method provides the government a reference for promoting popularization program to change patient proportions in the specific treatment.

[1] 中央健康保險局。取自http://www.nhi.gov.tw/
[2] 台灣腎臟醫學會。取自http://www.tsn.org.tw/
[3] 自由電子新聞網。取自http://www.libertytimes.com.tw/
[4] 行政院衛生署衛生統計資訊網。取自http://www.doh.gov.tw/statistic/
[5] 財團法人中華民國腎臟基金會。取自http://www.kidney.org.tw/
[6] 器官捐贈移植登錄中心。取自http://www.torsc.org.tw/about/about.jsp
[7] 腹膜透析專業諮詢網。取自http://www.capd.com.tw/main.html
[8] Abellan J.J., Panades J.P., Conesa C.A.D., “Predicting the behaviour of the renal transplant waiting list in the Pais Velencia (Spain) using simulation modeling,” Proceeding of the 2004 winter Simulation Conference.
[9] Ahn J.H., Hornberger J.C., “Involving Patients in the Cadaveric Kidney Transplant Allocation Process: A Decision-theoretic Perspective,” Management Science, 42, 629-641(1996).
[10] Albright S.C. and Derman C., “Asymptotic optimal policies for the stochastic sequential assignment problem,” Management Science, 18, 349-335(1972).
[11] Al M.J., Feenstra T., Brouwer W.B.F., “Decision makers’ views on health care objectives and budget constraints: results from a pilot study,” Health Policy, 70, 33-48(2004).
[12] Bayoumi A.M. and Redelmeier D.A., “Preventing Mycobacterium avium complex in patients who are using protease inhibitors: a cost-effectiveness analysis,” AIDS, 12, 1503-1512(1998).
[13] Croxson B.C. and Ashton, T. “A cost effectiveness analysis of the treatment of end stage renal failure.” New Zealand Medical Journal, 103, 171-174(1990).
[14] David, Yechiali I. and U., “A time-dependent stopping problem with application to live organ transplant,” Operations Research, 33, 491-504(1985).
[15] Epstein D., Chalabi Z., Claxton K., Sculpher M., “Mathematical programming for the optimal allocation of health care resources,” Center for Health Eonomics, (2005)
[16] G. Ardine de Wit, Paul G. Ramsteijn, Frank Th. De Charro. “Economic evaluation of end stage renal disease treatment,” Health Policy, 44, 215-232(1998).
[17] Kusoom V, Lapjaroengwong N. “Quality of life of patients with end-stage renal disease and receiving renal replacement therapy,” Vajira Med J 2004; 48:107–15.
[18] Ludbrook A., “A cost-effectiveness analysis of the treatment of chronic renal failure.” Applied Economics, 13, 337-350(1981).
[19] Maharatanavirosn W. “Quality of life of patients with end stage renal disease on hemodialysis and continuous ambulatory peritoneal dialysis,” [Master’s Thesis]. Salaya: Mahidol, 1999.
[20] Pukpobsuk N. {Determination of quality of life in end stage renal disease patients on hemodialysis and continuous ambulatory peritoneal dialysis,” [Master’s thesis]. Salaya: Mahidol, 2001.
[21] Richter A., “Duct tape for decision makers: the use of OR models in pharmacoeconomics,” Operations Research and Health Care, 275-296(2004).
[22] Roderick P., Davies R., Jones C., Feest T., Smith S. and Farrington K., “Simulation model of renal replacement therapy: predicting future demand in England” Nephrology Dialysis Transplantation, 19, 692-701(2004).
[23] Sriwajana P. “Comparative survival of patients with chronic renal failure on hemodialysis and continuous ambulatory peritoneal dialysis,” Pramongkutklao Hospital [Master’s thesis]. Salaya: Mahidol, 1997.
[24] Tisayathikom K, Patcharanalumol W, Mukem S, et al. “Cost and Efficiency of Public and Private Hemodialysis Centers in 2001,” Nonthaburi: International Health Policy Program, 2003.
[25] Vestergaard P. and L□kkegaard H., “Predicting future trends in the number of patients on renal replacement therapy in Denmark,” Nephrology Dialysis Transplantation, 12, 2117–2123(1997).
[26] Wit G.A., Ramsteijn P.G.., Charro F.T., “Economic evaluation of end stage renal disease treatment,” Health Policy, 44, 215-232(1998).
[27] Yot Teerawattananon, MD, Miranda Mugford, DPhil, and Viroj Tangcharoensathien, “Economic Evaluation of Palliative Management versus Peritoneal Dialysis and Hemodialysis for End-Stage Renal Disease: Evidence for Coverage Decisions in Thailand,” Value in Health, (2006)
[28] Zenios S.A., “Models for kidney allocation,” Operations Research and Health Care, 537-554(2004).
[29] Zenios S.A., Chertow G.M. and Wein L.M., “Dynamic allocation of kidneys to candidates on the transplant waiting list.” Operations Research, 48, 549-569(2000).
[30] Bureau of Health Promotion. Epidemiological Study of End-Stage Renal Disease Patients in Taiwan: Ten years survey. Retrieved November 22, 2006, from http://www.bhp.doh.gov.tw/english/category.php?table=publications&page=detail&id=17&pid=88
[31] National Kidney Foundation. From http://www.kidney.org/