糖尿病衛教整合效益評價－某區域教學醫院經驗

The Clinical Effectiveness of Combined Educational and Self-Care Interventions in Diabetes Health Care: Experiences of a Regional Teaching Hospital in Central Taiwan

10.3966/168232812016092603002

張富勝(Fu-Sheng Chang)；吳南緯(Nan-Wei Wu)；洪禎澤(Chen-Tse Hung)；陳國寶(Kuo-Pao Chen)；張倩淇(Cian-Ci Jhang)；孫嘉成(Chia-Cheng Sun)

慢性疾病 ； 糖尿病 ； 健康教育為基礎的醫療照護 ； chronic illness ； diabetes mellitus ； health education-based medical care ； hyperglycemia

台灣家庭醫學雜誌

26卷3期（2016 / 09 / 01）

135 - 146

繁體中文

目的：心臟血管疾病高居國人十大死因前三名，而糖尿病為其主要危險因子之一；本研究透過醫師、護理師、營養師、藥師的共同團隊提供高品質衛教醫療照護，分析血糖控制不佳之第二型糖尿病人經衛教後的實質效益以提供慢性疾病照護之參考。方法：以中臺灣彰化一個區域級教學醫院門診的血糖控制不良病人，由系統篩選收案，分析經糖尿病衛教六個月後，糖尿病自我管理評量與胰島素認知評量、使用糖尿病藥物組成及血糖控制成效等指標的前後差異。結果：收案132位病人，依衛教醫療團隊規則追蹤及衛教，療程完整且完成前後測問卷者，共有120位病人(90.9%)。血糖控制成效包括糖化血色素及飯前血糖於介入前後皆有顯著差異。糖尿病自我管理評量於介入前後除了健康調適項目沒有顯著差異外，其餘指標皆有顯著差異。胰島素認知評量於介入前後皆有顯著差異。糖尿病藥物組成於介入前後，配方中含有胰島素之患者由73人(60.8%)上升至87人(72.5%)。結論：在此研究中，透過醫護團隊衛教模式對第二型糖尿病控制不佳的病人做積極的介入，提供高品質的衛教和適當的治療，能有效改善病人的血糖控制，藉由在衛教過程中建立的積極觀念使有需要的病人能更易於接受胰島素治療。衛教醫療照護的介入使患者在日常生活自我管理上有明顯改善，唯在健康調適項目上沒有顯著差異，顯示糖尿病患者衛教重點除了醫療照護面外，儘可能的心理支持與建設或許是糖尿病衛教更需要加強介入的區塊，以求提供糖尿病患更優質的照護。

Background: Cardiovascular diseases as one of top three leading causes of death in Taiwan find a major risk factor in diabetes mellitus. However, poor compliance and self-care often interferes with the blood sugar control of type 2 DM patients and results in unsatisfactory outcomes. In this study, by providing quality health care education through team works from clinical physicians, nurses, nutritionists and pharmacists, we aimed to analyze the clinical effectiveness of combined educational and self-care interventions for DM patients with poorly controlled blood sugar with the hope to obtain insights applicable to chronic disease care in general. Methods: Totally, 132 type 2 DM outpatients with poor recorded blood sugar (HbA1c＞8%), either with insulin injection or at least two kinds of oral antidiabetic (OAD) combination therapy, from a regional hospital in Changhua were enrolled. Analyses on indexes including blood sugar control (HbA1c and fasting blood sugar), the self-assessment of diabetes management scale (SADMS), the insulin treatment appraisal scale (ITAS), combinations of OAD agents, and dose adjustments of insulin preparations were performed six months after the interventions. Results: Study results showed improvement in blood sugar control (HbA1c and fasting blood sugar) after the interventions. With the only exception of psychological self-adjustment, statistically significant improvement was also observed in the remaining SADMS subscales on healthy diet, medication use, blood sugar monitoring, exercising, risk mitigation, and problem solving. Similar improvement further appeared in all ITAS subscales on benefits of insulin, selfblaming and health, daily life interference, social problems, and injection related problems and side effects. The insulin injection therapy rate increased from 60.8 to 72.5%. Conclusion: Through teamwork-based quality combined educational and self-care interventions, affirmative benefits were observed in nearly all clinical aspects of major indexes for assessing type 2 DM patients with poorly controlled blood sugar. Development of positive perceptions about insulin use through health education is crucial for early insulin treatment of patients with poorly controlled DM. Lack of improvement in psychological self-adjustment indicates the need to pay attention to the mental states of patients in addition to the provision of medical care. psychological evaluation and support are crucial in caring DM patients, as well as patients with chronic conditions, comprehensive health care.

1. 糖尿病對話網。2015年8月，取自http://www.dawnstudy.tw/index.asp.
2. Abu Hassan, H,Tohid H,Mohd Amin, R,Long Bidin, MB,Muthupalaniappen, L,Omar, K(2013).Factors influencing insulin acceptance among type 2 diabetes mellitus patients in a primary care clinic: a qualitative exploration.BMC Fam Pract,14,164.
3. American Diabetes Association(2010).Standards of medical care in diabetes.Diabetes Care,33(Suppl 1),S4-10.
4. Boren, SA(2007).AADE7TM Self-care Behaviors: systematic reviews.Diabetes Educ,33,866-71.
5. Brown, SA(1988).Effects of educational interventions in diabetes care: a meta-analysis of findings.Nurs Res,37,223-30.
6. Chang, MP,Huang, CY,Li, TC,Liao, LN,Chen, CC(2010).Validation of the Chinese-version of the insulin treatment appraisal scale.J Diabetes Invest,1(Suppl 1),88.
7. Glasgow, RE,Fisher, L,Skaff, M,Mullan, J,Toobert, DJ(2007).Problem solving and diabetes self-management: Investigation in a large, multiracial sample.Diabetes Care,30,33-7.
8. Gois, CJ,Ferro, AC,Santos, AL(2012).Psychological adjustment to diabetes mellitus: highlighting self-integration and selfregulation.Acta Diabetol,49(Suppl 1),S33-40.
9. Greenberg, ME(2000).Telephone nursing: Evidence of client and organization benefits.Nurs Econ,18,117-23.
10. Lai, CL,Hou, YH(2013).The association of clinical guideline adherence and pay-for-performance among patients with diabetes.J Chin Med,76,102-7.
11. Loveman, E,Frampton, GK,Clegg, AJ(2008).The clinical effectiveness of diabetes education models for Type 2 diabetes: a systematic review.Health Technol Assess,12(9),1-116.
12. McSharry, J,Moss-Morris, R,Kendrick, T(2011).Illness perceptions and glycaemic control in diabetes: a systematic review with metaanalysis.Diabet Med,28,1300-10.
13. Mudaliar, S,Edelman, SV(2001).Insulin therapy in type 2 diabetes.Endocrinol Metabol Clin North Am,30,935-82.
14. Peyrot, M,Rubin, RR,Lauritz, T(2005).Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitude, Wishes and Needs (DAWN) Study.Diabet Med,22,1379-85.
15. Philip, C(2003).Nurses on call.Nurs B C,35,8-12.
16. Piette, JD,Weinberger, M,McPhee, SJ,Mah, CA,Kraemer, FB,Crapo, LM(2000).Do automated calls with nurse follow-up improve selfcare and glycemic control among vulnerable patients with diabetes?.Am J Med,108,20-7.
17. Snoek, FJ,Skovlund, SE,Pouwer, F(2007).Development and validation of the insulin treatment appraisal scale (ITAS) in patients with type 2 diabetes.Health Qual Life Outcomes,5,69-74.
18. Stratton, M,Adler, AI,Neil, HA(2000).Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study.BMJ,321,405-12.
19. The Diabetes Control and Complications Trial Research Group(1993).The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.N Engl J Med,329,977-86.
20. Yang, YS,Wu, YC,Lu, YL(2015).Adherence to self-care behavior and glycemic effects using structured education.J Diabetes Invest,6,662-9.
21. 中華民國糖尿病學會(2015)。2015糖尿病臨床照護指引。台北:中華民國糖尿病學會。
22. 高佳霙、丁紀台、葉明珍、張彩秀(2008)。全面性照護計畫之成效探討。實證護理，4，233-42。
23. 樓美玲、李怡娟、葉明珍、張彩秀(2004)。社區非胰島素依賴型糖尿病患者家庭功能與自我照顧行為。長期照護雜誌，8，195-212。
24. 謝麗鳳、莊紫雲、劉淑珍、蔡欣玲、陳美碧(2011)。癌症病人化療期間居家護理指導及電話諮詢成效。腫瘤護理雜誌，11，23-35。

1. 蔡盈玫,陳佩英,徐敏芳(2021)。運用個案管理協助一位車禍截肢後初次診斷糖尿病患者自我照護經驗。彰化護理，28(4)，68-80。
2. 簡順添,廖翎聿,陳芬如,陳玫君,梁素綺,林雅慧(2021)。探討糖尿病共同照護於慢性阻塞肺病合併第二型糖尿病人之代謝指標成效。醫學與健康期刊，10(1)，73-87。
3. 鍾明憲,黃美娟,陳榮福,陳淑娟(2018)。門診強化照護對血糖控制成效之初探。領導護理，19(4)，41-56。