糖尿病照護品質測量與預後評估相關性研究:
第一型與第二型糖尿病

曾芬郁

doi:10.6342/NTU.2006.01486

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糖尿病照护品质测量与预後评估相关性研究: 第一型与第二型糖尿病

Outcome evaluation associated with quality measures of diabetes care: Type 1 and type 2 diabetes

曾芬郁 , 博士　　导师：赖美淑;陈秀熙　　

英文 DOI： 10.6342/NTU.2006.01486

第一型糖尿病；第二型糖尿病；照护品质；专业尽责度；病人特徵；医院特徵；医师特徵；检验结果认知；自我血糖监测；血糖控制；血压控制；血脂控制；糖尿病肾病变； Type 1 diabetes ； Type 2 diabetes ； Quality of diabetes care ； adherence to diabetes care measures ； patient case-mix ； hospital characteristics ； physician specialty ； awareness of test results ； self-management ； glycemic control ； blood pressure control ； lipid control ； diabetic nephropathy

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摘要〈TOP〉

背景及研究目的：
    台湾地区糖尿病盛行率约为百分之四，估计糖尿病人口超过100万人。糖尿病是台湾第四大死因，糖尿病之医疗花费每年超过三亿美元，不论着眼於民众健康或是卫生经济，提升糖尿病照护品质均是重要的课题。本论文对於台湾的糖尿病照护品质做多面向的分析。

研究对象及方法：
    本研究之第一部分以中央健康保险局台北分局2001年的申报资料分析，计算糖尿病人实际接受的检验次数并与糖尿病照护准则所建议的检验做比较，以评估糖尿病照护的专业尽责度，并且探讨病人特徵与医院特徵对於尽责度的影响。本研究之第二部分以十分之一随机抽样2002年於台大医院就诊四次以上的糖尿病人，其中固定於内科、家庭医学科、内分泌科接受治疗的875位糖尿病人为研究对象。以病人之病历资料作回溯性分析，使用Chi-square、logistic regression、linear regression 等统计方法探讨医师及病人特徵对於相关检验执行、以及血糖、血压、血脂控制之影响。本研究之第三部分以十分之一随机抽样2002年在台大医院就诊四次以上且2003年曾经回诊的糖尿病人。以邮寄方式做问卷调查，512位回覆者为研究对象。利用回溯性病历资料分析以及问卷答覆，以logistic regression、Chi-square等统计方法，分析糖尿病人对於他们自己的检验值或临床状况的了解程度，并探讨临床状况认知与自我监测血糖的相关。本研究之第四部份回溯研究自1995年至2005年在台大医院就诊的第一型糖尿病人的病历，撷取各项临床资料以及检验数据，纪录糖尿病慢性并发症的发生率。估算自糖尿病发病以至产生视网膜病变、神经病变、末期肾衰竭或死亡之期间，并分析导致肾病变的危险因子。

结果：
   以收录的2259位糖尿病人健保申报资料分析，一年当中约有76.3%、42.7%、40.2%、59.7%、59.2%、53.2%、16.8%的病人曾经接受至少一次血糖、糖化血色素、尿液、肾功能、血脂、肝功能以及视网膜病变的检查。约有19.2%的糖尿病人一年当中未曾接受上述任何一项检查。使用降血糖、抗高血压或降血脂药物、曾经住院、曾经急诊、就诊次数多的病人，接受检验的比率较高。医院层级、所在地、权属、是否为糖尿病照护机构等特徵会影响糖尿病照护专业尽责度。
    在台大医院就诊的第二型糖尿病人一年当中曾经接受至少一次血糖、糖化血色素、尿液、肾功能、血脂、肝功能以及视网膜病变检查的百分比为89.7%、82.5%、48%、53.6%、69%、45.9%、18.0%。内分泌科医师比内科医师或家庭医学科医师注重对於糖尿病人血糖、糖化血色素、以及尿液检查的监测。在台大医院就诊的第二型糖尿病人的平均糖化血色素值为7.3 ± 1.5%。与内科或家庭医学科病人相较，在内分泌科门诊追踪治疗的病人有较低的血糖值。
    约有73%、17.9%的糖尿病知道自己的血糖值、糖化血色素值及其意义。有33.3%、66.7%、65.5%、70.6%的病人知道自己有蛋白尿、肾功能异常、肝功能异常或是高血脂等临床状况。年老、低教育程度、低收入、就诊次数较少的病人对於自己的检验值或临床状况认知较不足。以胰岛素治疗、医师年纪较大、或是糖尿病专科医师的病人临床认知较足够。年青、糖尿病得病期间较久、收入较多、使用胰岛素治疗、有较多并发症或合并症、糖尿病专科医师的病人比较会执行自我血糖监测。对於血糖值以及糖化血色素的认知与自我血糖监测有正相关。
    以病历上记载的最後一次数据分析，台大医院第一型糖尿病患者的平均糖化血色素值为8.9 ± 1.5%。这些病人在长期追踪後产生视网膜病变、神经病变、肾病变、脑血管疾病、冠状动脉疾病、周边血管疾病之比例分别为23.1%、15.1%、25.7%、1.1%、4.0% 以及5.5%。共有5位(1.1%)病人死亡。女性病人、血糖控制不良、血脂异常是微白蛋白尿的风险因子。高血压、高血脂、抽菸是产生蛋白尿的危险因子。发病年龄大於15岁、糖尿病发病期间长以及高血压会增加末期肾衰竭的风险。多数合并有高血压、肾病变、血脂异常的病人并没有被投予糖尿病照护准则所建议的相关用药。

结论: 
    医院、医师、以及病人特徵均会影响糖尿病照护品质。台湾地区对於糖化血色素、尿液、视网膜等检查之专业尽责度较低，尤其是基层医疗院所。不同专科医师对於检验监测的执行有所不同，他们照护的病人的血糖控制程度也有不同。糖尿病人的临床认知可以增加他们的自我照护，但并不是所有的糖尿病人都了解他们的检验结果或是临床状况。与其他国家相较，台湾第一型糖尿病患者的肾病变有较早期、进展较快速的特徵。台湾地区糖尿病患者所接受的检验监测以及相关用药与照护准则所建议的相较，均有所不足。我们希望提昇糖尿病照护品质，可以由定期检验追踪、针对病情需要用药、加强对於病人的沟通教育等着手，希望可以让我们的糖尿病人有好的血糖、血压、血脂控制，并减少糖尿病肾病变等慢性并发症的发生。

并列摘要〈TOP〉

Aims: 
The diabetic population in Taiwan is estimated to be over 1,000,000. Diabetes is the fourth leading cause of death in Taiwan. Improvement in the quality of diabetes care is critical, both for patients and health care costs. The main purpose of this study is to evaluate the quality of diabetes care in Taiwan.
Study design and methods:  
Four study populations were recruited for evaluating quality of diabetes care in different domains. Study population I (NHI-DM population) enrolled diabetic patients randomly sampled from year 2001 National Health Insurance Bureau Taipei Branch claims data. Effects of patient factors or hospital factors on adherence to diabetes care measures were analyzed by logistic regression. Study population II (NTUH-T2DM patients) recruited 875 type 2 diabetic patients who were regularly cared for by endocrinologists (EN), internists (IM) and family medicine physicians (FM) at National Taiwan University Hospital (NTUH) in the year 2002. Adherence to laboratory exams and quality improvement measures (glycemic, blood pressure, and lipid control) of diabetic patients were evaluated. Effects of physician specialty on professional performance or patient health status indicators were analyzed by logistic regression or linear regression, accordingly. Study population III (NTUH-T2DM-Q patients) recruited 512 type 2 diabetic patients who were regularly treated at NTUH and responded to our questionnaire. Awareness of test results and self-management in diabetic patients were assessed. Effects of patient characteristics or physician factors on the clinical awareness, and self-monitoring of blood glucose (SMBG) were evaluated by logistic regression. Study population IV (NTUH-T1DM patients) recruited 471 type 1 diabetic patients who were treated at NTUH in the period between 1995 and 2005. Adherence to diabetes care measures, glycemic control, blood pressure control, lipid control, and long-term clinical outcomes of the study cohort were evaluated. Risk factors for developing diabetic nephropathy were analyzed by logistic regression and Cox regression. 
Results: 
Adherence rates to plasma glucose, glycated hemoglobin A1C (A1C), urinalysis, renal function test (RFT), lipid profile, liver function test (LFT), and eye ground exam (eye) in the NHI-DM population was 76.3%, 42.7%, 40.2%, 59.7%, 59.2%, 53.2%, and 16.8%, respectively. Patients with hypoglycemic medications, anti-hypertensive drugs, lipid-lowering agents, hospitalization, emergency service visit and frequent visits were more likely to receive exams. Hospitals with different levels, ownerships, locales or qualifications as diabetes care institutions presented different accountability for diabetes care measures. After regression, counts of visits and levels of hospitals persistently affected all the measures. 
The adherence rates to annual measures in NTUH-T2DM patients for glucose, A1C, urinalysis, RFT, lipid profile, LFT, and eye exam were 89.7%, 82.5%, 48%, 53.6%, 69%, 45.9%, and 18%, respectively. EN patients showed a significantly better adherence to glucose checkup, A1C measure and urinalysis than IM patients. EN patients also had better adherence to glucose checkup and urinalysis than FM patients. The mean A1C for NTUH-T2DM patients was 7.3 ± 1.5%. About 49.3% patients had an A1C level < 7.0%. EN patients had the lowest mean fasting plasma glucose (FPG) and lowest mean postprandial plasma glucose (PPG). The difference in PPG between EN and IM patients, and the difference in FPG between EN and FM patients were persistently significant following adjustment by patient and physician characteristics. 
Percentages of patients who knew their test results were: glucose level 73%, A1C level and meaning 17.9%, proteinuria 33.3%, impaired renal function test 66.7%, liver disease 65.5%, dyslipidemia 70.6%. Unawareness of clinical conditions was remarkable in patients with older age, lower education level, lower income, or less frequent visits. Patients treated with insulin, under the care of older physicians or diabetologists had better awareness of test results. About 49.3% patients performed SMBG. Patients with younger age, longer diabetes duration, higher income, insulin therapy, more comorbidities/complications, under the care of diabetologists were more likely to perform SMBG. Clinical awareness of glucose level or A1C meaning had significant correlations with SMBG. 
The NTUH-T1DM patients had a mean latest A1C of 8.9 ± 1.5%. The percentages of NTUH-T1DM patients with retinopathy, neuropathy, nephropathy, cerebral vascular disease, coronary artery disease, and peripheral vascular disease were 23.1%, 15.1%, 25.7%, 1.1%, 4.0%, and 5.5%, respectively. Female, poor glycemic control, and dyslipidemia are risk factors for microalbuminuria. Hypertension, dyslipidemia, and smoking are risk factors for proteinuria. Older age at diagnosis, longer diabetes duration, and hypertension significantly increased risks for end stage renal disease (ESRD). The mean interval between DM diagnosis and ESRD was 13.3 ± 7.7 years. Five patients (1.1%) died. Medications for blood pressure control, renal protection, and lipid control were not prescribed as recommended by practice guideline for diabetes care. 
Conclusions: 
Hospital-, physician-, and patient- characteristics influence quality of diabetes care. Adherence to A1C measure, urinalysis, and eye ground exam is sub-optimal, especially in primary health care units. Physician specialty had significant effects on adherence to diabetes care measures and outcomes of diabetes care. Clinical awareness and self-care of diabetic patients should be further enhanced. Taiwanese type 1 diabetic patients had a tendency of early onset and rapid progress to develop microvascular complications. However, screening and follow-up exams were inadequate. Medications for preventing and slowing diabetic complications were not promptly prescribed. To improve quality of diabetes care in Taiwan, we should establish Taiwanese diabetes database, enhance adherence to diabetes care measures, encourage effective physician-patient communication, and reinforce fulfillment of the practice guideline.

被引用文献 (1) 〈TOP〉

蔡茜如(2014)。糖尿病医疗给付改善方案、照护过程品质与可避免住院之相关性探讨。国立台湾大学健康政策与管理研究所学位论文。2014。1-98。

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DOI可强化引用精确性、增强学术圈连结，并给予使用者跨平台的良好使用经验，目前在全世界已有超过五千万个对象申请DOI。如想对DOI的使用与概念有进一步了解，请参考（）。