糖尿病醫療給付改善方案顯著改善基層診所糖尿病患者糖化血色素

The Diabetes Medical Benefit Improvement Project improves serum HbA1c concentrations of DM patients in primary health clinics

朱桂美(Kuei-Mei Chu)

指導教授 ： 蔡仲弘

亞洲大學/健康學院/長期照護研究所/碩士(2008年)

摘要

糖尿病共同照護模式(Shared-Care Model) 乃整合醫療資源以提供糖尿病患者疾病管理性照護。「糖尿病醫療給付改善方案」則以財務誘因落實共同照護的理念，將基層診所納入共同照護網，增進糖尿病患的醫療可近性及公平性，提升照護品質與效率。方案已實施數年，但診所或衛生所等基層醫療單位的實施成效仍少有探討，故本研究欲瞭解糖尿病患加入基層診所「糖尿病醫療給付改善方案」後之照護成效；並探討影響患者血糖控制之相關因素。
本研究以回溯性研究方法(Retrospective study)，立意選取台中縣某鄉鎮參與基層診所「醫療給付改善方案」滿12個月以上之第二型糖尿病患198人為對象，因個案參與方案之日期不同，其中收案滿三年者有79人，兩年者139人。從護理、營養衛教記錄及病歷記錄，收集個案基本資料、健康狀況、自我照顧行為及生理檢驗指標等資料，加以整理分析。
結果發現個案參與方案照護年數無論是一年、二年或三年，其第一年底平均糖化血色素皆有顯著下降；第二年底與第一年底相較，皆無顯著差異；第三年底與第二年底相較，則有顯著回升情形。影響第一年糖化血色素下降的正向因素最主要為護理衛教次數，其次依序為營養衛教次數、護照使用、回診率、男性；顯示「糖尿病醫療給付改善方案」增加護理和營養衛教照護，對個案之血糖控制有明顯助益。負向因素則有家族史、視網膜病變、年齡、高血壓及抽菸；隨著病人年齡老化、併發之疾病以及抽菸等，皆會增加糖尿病治療的困難並影響治療之成效。第三年糖化血色素回升之預測因素則依序為高血壓、年齡、抽菸。除了年齡之外，積極控制血壓與戒菸成為治療糖尿病重要之一環。
個案參與基層診所「醫療給付改善方案」後，至少在前兩年有顯著控制血糖之效果，第三年則成效減低，如何加強及延續其成效將成為日後研究之重要議題。

關鍵字

糖尿病 ； 糖化血色素 ； 血糖控制 ； 共同照護模式 ； 醫療給付改善方案

並列摘要

Background and objective: The Diabetes Medical Benefit Improvement Project is an incentive mechanism of the Shared-Care Model promoted by the Universal Healthcare Insurance of Taiwan for diabetics aiming at improving the efficiency of diabetic care, especially at the primary local health clinics. Although the potential benefit of the Shared-Care Model at teaching or area hospitals has been demonstrated, such observation has not been made at the level of primary health clinics. Thus, this study was aimed to make such an observation.
Method: The study purposively sampled diabetics in three primary health clinics in Taichung County. A total of 198 subjects was enrolled in this study and all participants who have joined the program for >12 months. Among them, 139 have joined the program for two years and 79 for three years. Each subject's health and nutrition education, clinic visits, self-care behaviors, biomarkers, health indicators and personal data were retrospectively extracted from the record. Data were then analyzed with SPSS/Windows 10.0 Statistical Package.
Results: The program was effective in reducing serum level of HbA1c, a biomarker of blood glucose control, and the average reduction was 1% during the first year of the program. Serum HbA1c was kept at the same reduced level during the second year but it increased to nearly the baseline (initial) level at the end of the third year. Regression analysis showed that health and nutrition education, frequency of clinic visit, hypertension control and family history were the major factors associated with the effectiveness of the program whereas hypertension and cigarette-smoking were two major factors associated with the increase in HbA1c.
Conclusion: Results of this study suggest that the Diabetes Medical Benefit Improvement Project of the Shared-Care Model is effective in improving diabetic control at least during the first two years of the program. It can help to delay the development of diabetic complications. Health education and hypertension & smoking control appear to be the major factors impacting the effectiveness of the program. Future studies should be concentrated on finding ways to improve or extend the effectiveness of the program.

並列關鍵字

Diabetes ； HbA1c ； diabetic control ； Shared-Care Model ； Diabetes Medical Benefit Improvement Project

參考文獻

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