背景：台灣末期腎臟病的發生率與盛行率名列世界前茅，如何藉有效的醫療、適切的衛教，延緩 疾病慢性腎臟病的惡化成為照護的首要目標。過去已知透過慢性腎臟病整體照護計畫以病 人為中心的照護，可以提升病人自我照顧行為之能力及遵從度。 目的：本研究在比較慢性腎臟病病人參加慢性腎臟病整體照護計畫對自我照顧行為與腎功能的影 響。 方法：本研究為橫斷式研究設計，將有無加入慢性腎臟病整體照護計畫之病人分為有參與照護計 畫組(n=118) 與未參與照護計畫組(n=117)。有參與照護計畫組為有接受慢性腎臟病整體照 護計畫一年以上，未參與照護計畫組僅接受常規回診治療。測量工具包括：病人基本屬性 量表、慢性腎臟病自我照顧行為量表、年度腎絲球過濾率變化速率。 結果：在自我照顧行為方面，有參與照護計畫組的規律服藥、飲食控制、規律運動、整體自我照 顧行為平均分數顯著高於未參與照護計畫組(p < .05)。有參與照護計畫組對於腎功能下降速 率慢的機會為未參與照護計畫組的2.83 倍(Odds ratio: 2.83, 95% CI：1.59-5.04, p < .001)。 結論／實務應用：本研究證實慢性腎臟病整體照護計畫可以讓腎臟病病人有較佳的自我照顧行為， 緩慢的腎功能下降速率，建議未來透過整體照護加強自我照顧行為，以延緩腎臟病病程的 進展。

Background: Taiwan has of the highest incidence and prevalence of end-stage renal disease. A care model to prevent disease progression is necessary. Chronic Kidney Disease Integrated Care Program (CKDICP) is a multi-disciplinary, multi-teams, and patient-centered program that has been carried on nearly fifteen years. However, the effectiveness of this program on self-management behavior and renal function is still unclear. Purpose: The aim of the study was to explore the association between CKDICP and self-care behavior and renal function progression. Methods: We conducted a cross-sectional study in one medical center. A total of 117 patients who did not enroll in the CKDICP and 118 patients who enrolled in the program over one year with a similar CKD stage were randomly selected. Clinical characteristics and self-care information were obtained using structured questionnaires. Slop of estimated glomerular filtration rate (eGFR) in one-year was calculated. Results: The average scores of regular medicine, diet-control, regular exercise, and overall selfmanagement were significantly higher in the CKDICP group than in the Non-CKDICP group. The CKDICP group was significantly more likely to have slow renal function decline rate compared with the patients in the Non-CKDICP group (Odds ratio: 2.83, 95% CI: 1.59-5.04, p < .001). Conclusions / Implications for Practice: CKDICP was associated with improved self-care behavior and slower renal function decline. Application of CKDICP to enhance self-care behavior and retard renal progression is recommended.