Clinical Follow-Up Study on Diabetes Patients Participating in a Health Management Plan

糖尿病患參加健康管理計畫之臨床追蹤研究

唐佩玲(Pei-Ling Tang)；袁婉玲(Wan-Ling Yuan)；曾弘富(Hung-Fu Tseng)

糖尿病 ； 健康管理計劃 ； 整合性護理照護 ； diabetes ； health management plan ； integrated nursing care

The Journal of Nursing Research

13卷4期（2005 / 12 / 01）

253 - 262

英文

糖尿病對人們健康與國家經濟的負擔有重大的影響，透過健康管理計劃的運作，健保局希望能將有限的醫療資源，作最有效的利用。本研究的目的為介紹護理專業人員在醫師規劃指導下，執行的糖尿病健康管理計劃，並分析影響計畫成效的相關因素。研究對象為某醫學中心糖尿病門診病患，全程參與照護計畫且次數達五次以上之個案，共計136名。病患在參與糖尿病照護計畫後，有效改善糖化血色素者有22人(16.2%)，維持組101人(74.3%)。有規律運動習慣的病患獲得有效改善的機率是無運動習慣者的2.8倍（95%信賴區間：0.9-8.7）；目前有合併症的糖尿病病患獲得有效改善的機率是有合併症糖尿病患的0.3倍（95%信賴區間：0.1-1.0）。特別訓練的護理人員與醫療團隊的共同合作中，能執行標準化的診療追蹤與衛教工作，提供糖尿病患全面性的照護品質。

The ”Health Management Plan” (HMP) for caring diabetic patient was begun by the National Health Insurance (NHI) in Taiwan in order to maximize the effectiveness of limited medical resources. This study describes the clinical experience of the nurse-directed diabetic HMP program and analyzes factors associated with the outcome. One hundred and thirty-six patients, all of whom had participated in the diabetic HMP program at least 5 times, were enrolled in the study. The effect of the HMP was evaluated by comparing hemoglobin A1C status before and after program participation. In this study, 22 patients (16.2%) improved and 101 patients (74.3%) maintained their hemoglobin A1C status over the course of HMP participation. Diabetic patients with regular exercise habits showed a 2.8-fold increased chance of outcome improvement compared with those who did not exercise regularly. The chance of outcome improvement in patients with complications was found to be one-third that of patients who had no complications (Odds ratio: 0.3, 95% CI: 0.1-1.0). This study found that specially trained nurses, following agreed upon protocols and algorithms and collaborating with medical team members, can effectively concentrate on providing comprehensive and effective diabetes care.

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