| 摘要: | 摘 要 本研究之目的為描述糖尿病論質計酬改善方案實施前後，糖尿 病病患醫療資源利用及照護結果改變之情形，及探討有無接受糖尿病論質計酬改善方案之糖尿病病患，在醫療資源利用與照護結果之差異。本研究採類實驗性研究設計（Quasi-experimental design）之雙組前後測比較（nonequivalent comparison group，pretest-posttest design）。研究對象來源係以西元2002年至西元2004年在中部某醫學中心門診就醫，疾病診斷碼為ICD-9CM前三碼250之糖尿病病患，實驗組344人，對照組1968人，收集其在該醫學中心的門診、急診、住院利用及檢驗檢查資料檔進行回溯性分析。 研究結果顯示參加計劃組糖尿病病患在接受論質計酬改善方 案後，其醫療資源利用情形在門診就診次數，平均每次門診檢驗 費用、住院利用（包含住院次數、住院天數、住院藥費、檢驗檢查費用、住院總費用）、急診利用（包含每次急診藥費、檢驗費用、急診總費用）及平均每次住院病人自付總費用等，皆比實施前有顯著的降低。而在各項篩檢如糖化血色素、總膽固醇、高密度脂蛋白膽固醇、低密度脂蛋白膽固醇、三酸甘油脂、尿素氮及視網膜檢查等實施前無篩檢變有之比率顯著增加。有關照護結果僅在三酸甘油脂及尿素氮比實施前有顯著的改善。 糖尿病論質計酬改善方案施行對醫療資源利用之成效研究結果顯示，參與糖尿病論質計酬改善方案者僅在參與計劃前後的每人六個月門診就診次數、平均每次門診檢驗費用之變化量顯著比對照組少，其餘的如平均每次門診藥費、平均每次門診檢查費用、平均每次門診總費用、每人住院次數、平均每次住院天數、平均住院檢驗檢查費用、平均每次住院總費用、平均每次急診檢驗費用、健保支付總醫療費用、總醫療費用之變化量顯著比對照組多，達統計之顯著差異。 糖尿病論質計酬改善方案施行對各項檢驗檢查篩檢利用之成效研究結果顯示，糖尿病論質計酬改善方案對糖化血色素、空腹血糖、總膽固醇、高密度脂蛋白膽固醇、低密度脂蛋白膽固醇、三酸甘油脂、尿蛋白、肌酸酐、尿素氮、視網膜檢查等篩檢率的增加有影響。 糖尿病論質計酬改善方案施行對照護結果之成效研究結果顯 示，參與糖尿病論質計酬改善方案者在參與計劃前、後在糖化血色素、空腹血糖、總膽固醇、高密度脂蛋白膽固醇、低密度脂蛋白膽固醇、三酸甘油脂、肌酸酐、尿素氮的照護結果沒有影響。 本研究結果顯示，健保局現所推行的糖尿病論質計酬改善方案實屬於鼓勵醫療院所加入方案的推展，對於資源的利用沒有限制，並不具有控制財務的機制，針對糖尿病的照護費用呈現上升的趨勢，若要有效的控制醫療費用的成長，應可考慮採論人計酬的支付方式，控制醫療費用的成長，且糖尿病論質計酬改善方案現今僅著重於照護標準的執行，並沒有訂定照護結果需要達到的目標，故建議應訂定所需達到照護品質指標，並與支付制度相扣連，始有助於照護結果的提昇。; Abstract The purposes of this study are check-up, and outcomes in patients with diabetes after participating in Diabetes Mellitus (DM) Promotion Improvement Program and to compare the differences among diabetic patients who participate and don’t participate in the program. This study adopted Quasi-experimental design – non-randomized comparison group - pretest-posttest design. The study sample consisted of outpatients withICD-9-CM primary diagnosis code 250 from outpatient clinics of a Medical Center in Mid-Taiwan during the period from 2002 to 2004. There are 344 DM patients in study group and 1968 DM patients in control group. Type of medical care utilization included outpatient, inpatient, and emergency room use. Our results indicates that the study group significantly decreases in medical service utilization of the outpatient visits, mean exam expenditure per outpatient visit, hospitalized utilization (number inpatient admissions, mean length of stay per visit, mean inpatient pharmacy expenditure, mean laboratory exam expenditure, and total inpatient expenditure), emergency utilization (mean emergency pharmacy expenditure per visit, exam expenditure, and total emergency expenditure), and mean inpatient co-payment per visit. However, the completion of laboratory exams increases significantly after participating the program and these items included glycated hemoglobin, total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, triglyceride, blood urea nitrogen, retina test. For the medical outcome, only triglyceride and blood urea nitrogen significantly improved. The results regarding the effectiveness of Diabetes Mellitus Promotion Improvement Program on the use of medical resource shows that the changes in number of outpatient visits in six months and the fee per outpatient visit in the study group is significantly less than control group during study period. While the changes in mean outpatient pharmacy expenditure per visit, mean outpatient exam expenditure per visit, mean total outpatient expenditure, mean inpatient admission, mean length of sty per admission, mean laboratory exam expenditure, total inpatient expenditure, mean emergency exam expenditure per admission, the total expenditure covered by National Health Insurance, and total medical expenditure are significantly higher in control group than study group. The results regarding the effect of Diabetes Mellitus Promotion Improvement Program on screening tests indicates that the program significantly increases the completion of HbA1c, fasting plasma glucose, total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, triglyceride, urine albumin, creatinine, blood urea nitrogen, and retina examine. The |
