論質計酬制度對第二型糖尿病患發生髖關節骨折之影響及相關因素探討

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题名:	論質計酬制度對第二型糖尿病患發生髖關節骨折之影響及相關因素探討 The effect of pay for performance on risk incidence of hip fracture in type II diabetic patients
作者:	李永恆;Yung-Heng Lee
贡献者:	醫務管理學系碩士在職專班
关键词:	第二型糖尿病;髖關節骨折;論質計酬;Type II diabetes;hip fracture;pay for performance
日期:	2015-07-22
上传时间:	2015-11-04 17:05:04 (UTC+8)
出版者:	中國醫藥大學
摘要:	目的：糖尿病患者會受糖尿病病變的影響而增加髖關節骨折的風險。目前很少有文獻探討第二型糖尿病患者加入論質計酬後，對其發生髖關節骨折是否具有顯著的影響。本研究探討第二型糖尿病患者加入論質計酬後對發生髖關節骨折的影響。方法：研究資料取自國家衛生研究院全民健康保險學術研究資料庫，研究設計採用回溯性的世代研究，以2001年至2008年45歲以上的糖尿病患者為研究母群體。為減少選擇性的偏誤，將有無加入?質計酬的??病患者?族群，使用傾向分?配對法（Propensity Score Matching），以1:1的方式配對，探討影響糖尿病髖關節骨折之相關因素。除計算各變項的次數與百分比外，並以對數等級檢定（Log-rank test）檢定有無統計之顯著差異。利用COX 比例風險模式（Cox proportional hazards model）計算風險危害比率（Hazard Ratio, HR），以探討有無加入論質計酬對發生髖關節骨折的相對風險。結果： 2002年至2008年共有751,552位45歲以上的糖尿病患者，加入P4P共有73386人（占9.8%）。加入論質計酬且規律就醫者較未加入論質計酬者有較低的髖部骨折風險（HR＝0.80），而加入論質計酬但未規律就醫與未加入論質計酬者發生髖部骨折的風險則無統計上明顯差異(P>0.05)。糖尿病患者發生髖關節骨折相關因素方面，女性、年齡較大者、低收入戶、糖尿病併發症嚴重度(Diabetes Complications Severity Index，DCSI) 2分、長期使用類固醇有顯著較高的髖部骨折風險，而長期使用利尿劑及醫師高服務量則有較低的髖部骨折風險（P<0.05）。男性糖尿病患加入論質計酬且規律就醫者較未加入論質計酬者有較低的髖部骨折風險（HR＝0.70）。當併發症嚴重度≧2分，加入論質計酬且規律就醫較未加入論質計酬者，有較低的髖部骨折風險（HR＝0.45）。結論：本研究可以發現第二型糖尿病患加入論質計酬且規律就醫者可降低發生髖關節骨折的風險。尤其對於男性及糖尿病併發症嚴重度(DCSI) ≧2分者降低發生髖關節骨折風險的效果更加顯著。因此建議擴大醫師與病人加入糖尿病論質計酬的比例，排除貧窮、老人、糖尿病嚴重度高的弱勢病人加入糖尿病論質計酬計畫的阻礙，並建議政府應將有限的健保資源多用於糖尿病併發症嚴重度較高的病人。 Objective: Patients with diabetes mellitus are at an increased risk of hip fractures. Currently, research is lacking on the effect of Taiwanese National Health Insurance “Pay for Performance” (P4P) program on hip fracture risk in type II diabetic patients. In this study, we investigated whether the P4P program has a significant impact on hip fracture risk in this population. Materials and Methods: We conducted a retrospective cohort study using the Taiwanese National Health Research Institute’s (NHRI) National Health Insurance Research Database (NHIRD). Type II diabetic patients age ?45 were identified between 2001 and 2008. To reduce selection bias, propensity score matching was used to match P4P and non-P4P patients on a 1-to-1 basis, and correlation factors between these two populations with respect to hip fracture risk were analyzed. The frequency and proportion of these factors were determined, and statistical significance was established using the log-rank test. We also employed the Cox proportional hazards model to calculate the hazard ratio at a confidence interval of 95%, which allowed us to determine a relative risk for hip fractures in P4P and non-P4P diabetic patients. Results: A total of 751,552 Type II diabetic patients age ?45 between 2002 and 2008 were identified, of whom 73,386 (9.8%) were enrolled in P4P. We found that P4P-enrolled patients who received regular treatment had a lower risk of hip fracture (HR = 0.80) compared to the non-P4P cohort. In contrast, there was no significant difference (p>0.05) in risk between P4P-patients who failed to follow through with regular treatment, and non-P4P patients. Factors that correlated with an increased risk of hip fractures in Type II diabetic patients include female sex, older age, lower socioeconomic status, diabetes complications severity index(DCSI )score of 2, and long-term use of steroids. Conversely, long-term diuretic use and high physician volumes were correlated with lower risk (p<0.05). When comparing the P4P-enrolled cohort who received regular treatment and the non-P4P cohort, there was a greater decrease in hip fracture risk among males (HR = 0.70) and those who have a DCSI score of ?2 (HR = 0.45). Conclusion: These results suggest that P4P enrollment (and following through with regular treatment) may lower the risk of hip fractures in patients with type II diabetes. This benefit may be more significant in those who are male and those with a DCSI score of ?2.
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