糖尿病整體照護－視網膜病變篩檢流程之評估

Managed Care for Diabetic Patients: Evaluation of Screening Pathway of Diabetic Retinopathy

謝瑞玟(Jui-Wen Hsieh) ； 陳立仁(Lee-Jen Chen) ； 韋熙(Shi Wei)

《中華民國眼科醫學會雜誌》 42卷4期 (2003/12) Pp. 404-414

https://doi.org/10.30048/ACTASOS.200312.0003

摘要

目的：希望藉由順暢便利的轉介管道及給予糖尿病患衛教，提高糖尿病視網膜病變的篩檢率，並建立標準化篩檢流程及糖尿病患者資料庫後再加以推廣，以降低因糖尿病視網膜病變失明的比率，提升國民的健康。
方法：自1998年9月至1999年7月，凡在本院新陳代謝科、糖尿病衛教室及家庭醫學科就診之一年內未接受眼底檢查的糖尿病患者，由門診護理人員將「糖尿病患眼科檢查時程表」貼在病歷封面內頁，並發給病患有關糖尿病視網膜病變與散瞳須知，請病患前往眼科看診；另外在眼科門診發現之此類糖尿病患者，也做相同的處理流程。糖尿病視網膜病變採用美國眼科醫學會建議之分類及標準追蹤時程模式，並稍作修飾。總共收集到446位符合條件的糖尿病患者，其中經由新陳代謝科轉介的有50位、糖尿病衛教室轉介的有91位、家庭醫學科轉介的有4位、眼科自行發現的有301位。
結果：眼科以外的科別轉介之糖尿病患145位當中，確實有到眼科看診的有131位，檢查率為91.0%；依據標準眼科追蹤檢查時程，需在1999年7月之前回診的153位病患當中，確實回診的有121位，回診率為79.0%，其中以眼科自行發現之病患回診率最高，為82.5%；糖尿病衛教室次之，為57.1%；新陳代謝科則為44.4%。
結論：此研究計劃設計之轉介流程，經由非眼科門診轉介的病例相對比眼科自行發現之糖尿病患來的少，可能因為負責新陳代謝科的醫師有許多位，並且每位醫師的門診都太忙碌，忽略了建議病患去眼科檢查，如果是在單一科別單一醫師的地區醫院、綜合醫院可能較適用；眼科自行發現之病患比糖尿病衛教室及新陳代謝科轉介之病患的回診率高出25%至40%，可能由於病患已在眼科看診，並且與醫師的關係已建立。病患資料庫之建立，由於電腦登錄系統尚在測試階段，有待一段時間改進才能推廣。眼科檢查時程表不能貼在病歷封面明顯處，也影響到門診護理人員及看診醫師發覺病患必須回診眼科。視網膜病變為糖尿病的慢性併發症之一，對於它的防治以及各相關醫療科別的轉介，需要醫療機構內各個團隊的共同努力合作才能達成。

並列摘要

Purpose: To evaluate the screening pathway of diabetic retinopathy in the managed care of diabetic patients.
Methods: Four hundred and forty-six diabetic patients who hadn't had clinical eye examination in the past one year were enrolled in this study. All these patients were referred from the departments of metabolism, family medicine, and the diabetes education center and from the department of ophthalmology. The guidelines for DM retinopathy were based on the classification and suggested follow-up interval guidelines by the American Academy of Ophthalmology, with some modifications. In order to notify doctors and nurses of the follow-up date of DM patients, an eye examination schedule was pasted on the inner side of the medical record's cover page. Patients were also given information pamphlets on DM retinopathy and pupil dilation examination and were advised to proceed to the ophthalmology clinic for examinations.
Results: One hundred and thirty-one out of 145 patients who were referred from the departments of metabolism (50 patients), family medicine (4 patients) and the diabetes education center (91 patients) completed the eye examination. The examination rate was 91.0%. Another 301 patients were diagnosed and examined from the department of ophthalmology. One hundred and twenty-one out of 153 patients (79.0%) who needed follow-up of DM retinopathy before July 1999 actually returned for the follow-up. Patients diagnosed at the department of ophthalmology had the highest follow-up rate of 82.5%; the rates for patients from the diabetes education center and the department of metabolism were 57.1% and 44.4%, respectively.
Conclusion: Patients diagnosed at the department of ophthalmology displayed more concern for follow-up treatment for their DM retinopathy. The clinically manifested eye problem and the pre-established doctor-patient relationship may have warned these patients to pay more attention to their DM retinopathy. The lower rate in the patients from the other three departments indicated that patients still lacked knowledge of possible eye complications from diabetes mellitus. Doctors from these departments may have been too busy to explain to patients the importance of additional eye examinations. Thus, an improved inter-department referral system and better cooperation amongst all hospital departments is necessary for the early detection and prevention of blindness from DM retinopathy.

並列關鍵字

Diabetic mellitus ； Non-proliferative diabetic retinopathy ； Proliferative diabetic retinopathy ； Macular edema