家醫科與內分泌科糖尿病照護品質之比較

施培艾

doi:10.6342/NTU201702571

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家医科与内分泌科糖尿病照护品质之比较

Comparison of Quality of Care for Patients with Type 2 Diabetes by Departments of Family Medicine and Endocrinology

施培艾 , 硕士　　导师：季玮珠　　

英文 DOI： 10.6342/NTU201702571

家医科；内分泌科；第二型糖尿病；照顾品质；共照网； type 2 diabetes mellitus ； Department of Family Medicine ； Department of Endocrinology ； quality of care ； pay-for-performance (P4P) program

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摘要 │ 参考文献 (38) │ 国际计量

摘要〈TOP〉

背景：糖尿病及其相关疾病占国人十大死因前几位，影响国人健康甚钜；於2014年，台湾糖尿病患者约有176万人，相关医疗花费达新台币226亿。其并发症影响全身，相关科别均有可能收治糖尿病患者，但国内目前少有比较不同科别糖尿病照护之相关研究；国外文献则显示不同的比较结果。    
目的：探讨家医科及新陈代谢科於第二型糖尿病病人的照顾品质，分析病人特性及照顾品质不同的可能原因。
方法：此为一回溯性世代研究，分析新北市某医学中心电子病历，研究对象为2011至2015年间於家医科或新陈代谢科接受照顾的第二型糖尿病病人。若於此期间至两科别就诊的病人则予以排除。照顾品质指标包含尽责度（年度血液、尿液检查及视网膜筛检的达成率）及血糖控制，并分析急诊、住院次数，及疫苗施打、戒菸谘询、癌症筛检的使用情形。以血糖控制状况为主要结果。统计方法以卡方检定、费歇确率检定和t检定比较两科尽责度，并使用广义估计方程式（Generalized estimating equations）分析家医科及新陈代谢科在2011至2015年间，於第二型糖尿病病人血糖控制的影响因素，变项有病人的年纪、性别、共病、胰岛素施打与否，并设虚拟变项来同时比较新陈代谢科是否加入共照网与家医科於血糖控制之影响。
结果：於2011年，共有12813人於家医科或新陈代谢科接受照顾，其中於家医科追踪者为1591人，於新陈代谢科则有11222人。尽责度以新陈代谢科病人达成率较高，尤其是接受共照网照护的病人。在调整了年纪、性别、共病、胰岛素施打及基线血糖值後，新代科没有加入共照网病人血糖控制不好相对家医科病人血糖控制不好（糖化血色素> 9.5%）的风险为0.91倍，统计上没有显着差异；新代科有加入共照网病人血糖控制不好相对家医科病人血糖控制不好的风险为1.55倍，统计上达显着差异。在调整了年纪、性别、共病及基线血糖值後，新代科没有加入共照网病人血糖控制良好（糖化血色素< 7%）相对家医科病人血糖控制良好的风险为1.01倍，统计上没有显着差异；新代科有加入共照网病人血糖控制良好相对家医科病人血糖控制良好的风险为0.61倍，统计上达显着差异。急诊及住院次数以新陈代谢科病人较高；家医科病人在疫苗施打、戒菸谘询及癌症筛检的实行比例较高。
结论：家医科及新陈代谢科於第二型糖尿病病人的照顾品质，尽责度以新陈代谢科较佳；在调整可能之干扰变项後，加入共照网的病人血糖控制不理想的风险较高。未来的研究应进一步讨论整体医疗花费及生活品质，以期能更完整的评估不同科别及共照网的照顾品质。

并列摘要〈TOP〉

Background:
Diabetes mellitus has become one of the major causes of death and has great impact on people’s health in Taiwan. The complications of diabetes involve the whole body, and patients may be treated by any of the associated departments. Few studies compared the quality of care in type 2 diabetes provided by different departments in Taiwan, and conflicting outcomes were reported in previous studies in other countries.
Objectives:
    This study aims to compare the quality of care in patients with type 2 diabetes provided by Departments of Family Medicine and Endocrinology.
Methods:
    This is a retrospective cohort study. Data were collected from electronic medical records in one medical center in New Taipei City. Records of all patients diagnosed as type 2 diabetes and followed up at Departments of Endocrinology or Family medicine during 2011-2015 were retrieved. Patients visited 2 departments at any time during this period were excluded. Quality of care was assessed included accountability, glycemic control, adverse outcomes and the use of preventive services. The primary outcome is annual glycemic control. As for inferential analysis, Chi-square test and Fisher exact test were used for categorical variables, and continuous variables were analyzed by using t-test. Generalized estimating equations (GEEs) were used to evaluate the effects of factors associated with annual glycemic control, defined as good (HbA1c <7%) and poor (>9.5%), respectively. 
Results: 
    In 2011, there were 12813 patients diagnosed with type 2 diabetes with at least once HbA1c measurement followed up at Departments of Endocrinology or Family Medicine. Accountability indicators, including the percentage of HbA1c examination more than 2 times per year, fasting lipid test once per year, urinary test for nephropathy screen and ophthalmoscopy examination per year, were better in patients followed at Endocrinology, especially those under the Pay for Performance (P4P) program. 
    After adjusting age, gender, comorbid conditions, insulin treatment and the baseline HbA1c, the odds ratio of poor glycemic control (HbA1c >9.5 %) of non-P4P Endocrinology versus Family Medicine was 0.91 (95% CI 0.59 to 1.32; p=0.55); that of P4P Endocrinology versus Family Medicine was 1.55 (95% CI 1.09 to 2.45; p=0.02). On the other hand, after adjusting age, gender, comorbid conditions and the baseline HbA1c, the odds ratio of good glycemic control (HbA1c <7 %) of non-P4P Endocrinology versus Family Medicine was 1.01 (95% CI 0.95 to 1.51; p=0.12); that of P4P Endocrinology versus Family Medicine was 0.61 (95% CI 0.60 to 0.96; p=0.02).
    The number of emergency visits and hospitalizations were more frequent in patients followed at Endocrinology. Preventive service were generally more frequent in patients followed at Family Medicine, including vaccination for influenza or pneumococcus, smoking cessation consultation and cancer screening.
Conclusions:
    Accountability was generally better in patients followed at endocrinology department, especially those under P4P program, while after adjusting age, gender, comorbid conditions, insulin treatment and the baseline HbA1c data, patients enrolled in P4P program by endocrinologists versus those under family physicians’ care had poorer glycemic control. On the other hand, Family Medicine performed better in preventive services. To further analyze the performance of the different department and the P4P program, a longer follow up duration and overall medical expenses should be included in future analysis.

参考文献 ( 38 ) 〈TOP〉

1. Ogurtsova, K., et al., IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract, 2017. 128: p. 40-50.
连结：
2. Standards of Medical Care in Diabetes-2016: Summary of Revisions. Diabetes Care, 2016. 39 Suppl 1: p. S4-5.
连结：
4. 宋铭展, 全民健康保险糖尿病医疗给付改善方案五年影响评估, in 预防保健与卫生学. 2009, 台湾大学. p. 1-148.
连结：
5. 李待弟, 全民健康保险糖尿病医疗给付改善方案初步影响评估, in 预防保健与卫生学. 2007, 台湾大学. p. 1-138.
连结：
6. 林文德, et al., 以倾向分数配对法评估糖尿病论质计酬方案之成效. 台湾公共卫生杂志, 2010. 29(1): p. 54-63.
连结：

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