| 摘要: | 隨著國人飲食習慣及生活型態等因素的改變，高成本、高醫療資源利用之糖尿病已成為國人盛行的慢性病。衛生署有鑑於此，於2001年11月推行疾病管理制度的健保給付方式，即「全民健康保險糖尿病醫療給付改善方案試辦計劃 」(亦稱論質計酬計劃)來提高照護品質。對糖尿病的病患而言，良好的醫療照護，仍需要病患落實遵醫性以達良好療效。本研究之目的，希望藉由健保次級資料庫，建立糖尿病病患遵醫性監測指標(包括服用藥物、照護指引、醫病溝通指標)，並探討病患之遵醫性與醫療照護結果間之相關性。
本研究以國家衛生研究院全民健康保險研究資料庫(2001年11月至2002年6月)及糖尿病個案管理子系統之糖尿病照護診療資料檔，進行單一族群回顧性研究，診斷代碼以ICD-9-CM碼為250，以有加入論質計酬計劃病患為研究對象，考量資料取得可分析時間，符合研究計劃收案期間病患有10,624人，未符合有54,135人，加入後一年半有完成追蹤病患為5,049人為本研究對象，進行回溯性分析。
研究結果顯示病患加入論質計酬後，在醫療資源利用上，有完成追蹤之病患，西醫門診次數及門診總費用隨加入計劃時間愈久而增加；全部門診次數、住院天數及住院次數會隨加入計劃時間愈久而減少。病患特質與照護指引指標分析中，結果顯示「醫療機構權屬別」與「投保地區」、「治療方式」達統計上顯著；醫療利用與遵醫性多變項迴歸顯示，加入論質計酬計劃後延遲回診率上升、眼底檢查遵循指引好、尿液檢查遵循指引差，會增加門診次數；加入論質計酬計劃後延遲回診率上升、血液檢查遵循指引好，住院天數會下降；尿液檢查遵循指引好、加入論質計酬計劃後看診醫師數增加、就醫場所家數及主要就醫場所就醫率減少，門診總費用會下降；在糖化血色素之羅吉斯迴歸發現，尿液檢查遵循指引好、主要醫療提供者照護率及看診醫師數增加，糖化血色素控制不良率呈現上升狀態。
本研究結果顯示病患加入論計酬計劃後在醫療利用率呈現上升，病患有遵醫性，門診次數及住院天數下降，但糖化血色素卻反而控制不良，故建議後續研究可建立評估計劃，可了解論質計酬計劃中長期成效，另糖尿病病患照護應著重衛教相關行為，應將衛教列入申報，以監控病患照護情形，進而提昇照護品質。
Diabetes mellitus, high cost and high medical resources utilization disease, has become common chronic disease in Taiwan due to diet and lifestyle change. So Bureau of National Health Insurance implemented a Share Care Disease Management Program for the Diabetes on November 2001 to enhance quality of care. In requires diabetes, patients to adhere treatment regimens to achieve maximum regimen effect. The purpose of this study was to establish compliance indicators (including taking medicine、care guideline adherence、Physician-Patient communication ) by analyzing health insurance datasets and to investigate the relationship between compliance and outcome of diabetes care.
Datasets used in this study were from National Health Insurance of National Health Research Institute and system of Share Care Disease Management Program for the Diabetes. Dataset from November, 2001 to June, 2002 with the diagnosis code ICD-9-CM 250. There were 10,624 who were eligible for study inclusion criteria, and 54,135 who were not. Among those, who were eligible, 5,049 patients completed one and half year of follow-up.
The study results show that number of Western Medicine outpatient visits and total outpatient expenditure increases as duration for patients, Participation in program increases；and number of total outpatient visits、 length of stay, and number of inpatient decreases. For relationship between patient characteristics and care quideline adherence, type of hospital, areas for insurance, type of hospital , areas for insurance registration and type of treatment were significant factors. For relationship between medical outcome and compliance , outpatient visit increases as delay appointment rate, and eyeground and urine examination compliance is good ; length of stay decreases as delay appointment rate, decreases, and blood examination compliances is better ; total inpatient expenditure decreases as urine examination is good , number of physicians that patient visit increases, number of clinical settings that patient visit decreases, and proportion of visits at the major clinical settings decreases ; good urine examination compliance , proportion of urine by the major physicians, and of physicians are associated with the increased adds of poor glucose control.
This study indicates that after patients participating Disease Management program, medical service utilization increases, patient have better compliance and partial medical service utilization has improved, but HbA1c control is worse, suggesting that we need to to an evaluation plan to monitor effect of the Disease Management program in the future . Moreover, education behavior need to been emphasized on diabetic patients and to declared for monitor the situation of diabetic care to enhance quality of care. |
