糖尿病視網膜病變醫療資源耗用影響因素之研究－以某醫學中心為例

Factors Associated with Resource Utilization of Diabetic Retinopathy of a Medical Center

楊昌叔(Chang-Sue Yang) ； 張慧如(Huei-Ru Chang) ； 滕春祐(Chun-Yu Teng) ； 錢慶文(Ching-Wen Chien)

《醫務管理期刊》 6卷4期 (2005/12) Pp. 429-445

摘要

因糖尿病而導致的視網膜病變是常見的糖尿病合併症／併發症，根據國外的研究，由於糖尿病而導致的視網膜病變很難預防也無法根絕，故常造成一個國家醫療保健支出與國家社會福利上沉重的負擔。由於我國目前對糖尿病視網膜病變導致如失明等結果對健保財政負擔的研究缺乏，故本研究以北部某醫學中心民國92年1月至93年12月兩年中患有糖尿病之增殖性糖尿病視網膜病變（ICD-9-CM為362.02）263位病患進行回溯性研究，利用SPSS12.0套裝軟體和DTREG軟體進行資料整理及統計分析，以探討其術後一年醫療資源耗用量與其影響因素，期望以本研究之結果做為臨床處置、醫院經營管理及衛生制度制定的參考。
本研究結果顯示糖尿病視網膜病變若施以玻璃體切除術，在後續一年醫療費用的差異，其中最低一組和最高一組之間的差異達到6倍之多；又初次手術住院時次診斷含單純玻璃體出血(379.23)的術後一年內醫療費用低於牽引性視網膜剝離者。所以如果只以DRG來給付玻璃體切除術是只考慮到手術初次的住院費用，但卻未留意到術後的後續醫療服務費用的做法。換句話說所謂的「包裹式給付」並無法真正的「降低」醫療費用，只能「遞延」費用的發生。因此建議衛生主管機關應該適度修訂論病例計酬支付監瞥方式，應該對於整個DRG個案採取較長期的觀察，以避免醫療院所採取「刮脂」(Cream-skimming)策略，嚴重的影響病患的權益和醫療品質。
其次，本研究的結果建議修訂現行全民健保糖尿病論質計酬醫療給付改善方案中，為加強糖尿病思早期眼底篩檢，無論初診、複診或年度檢查之標準照護項均應轉介並限定由眼科專科醫師執行的眼底鏡檢查，以期確定診斷，防杜模稜兩可或誤診的結果。

關鍵字

糖尿病視網膜病變 ； 玻璃體切除術 ； 論病例計酬

並列摘要

Diabetic retinopathy (DR) is a usual co-morbidity/complication of diabetic mellitus (DM) patients. According to previous research, DR can become a heavy financial and social burden of a nation because of its difficulty in diagnosis, prevention and/or extinction. Since similar research can not be found in Taiwan, therefore this study aims at exploring how resources were consumed by DR patients one year after their first discharge from vitrectomy. What factors could affect their resource consumption? Results of the study will be used to make clinical guidelines, to set public policy and to assist hospital administration.
263 DM patients with DR of a medical center locating in Taipei during January 2002 to December 2004 were included in this study. Their resource utilization data were retrieved from hospital database and analyzed by using SPSS and DTREG software. Results show that the amount of resources consumed by DM patients, who had DR, one year after they received vitrectomy can be classified into six groups. The group which consumed most resources was six times more than the group which consumed fewer resources. Besides, DM patients with vitreous hemorrhage their resource consumption one year after receiving vitrectomy was much less than those DM patients who had retinal detachment. These findings suggest that DRG may not be an ideal reimbursement system for DM patients who received vitrectomy to cure DR because DRG cannot reduce health care expenditure; instead DRG just prolongs the occurrence of health care expenditure. Therefore, health policy makers should modify the DRG payment system so that it can include a better and longer monitoring mechanism in preventing a cream-skimming strategy adopted by hospitals and in protecting patient's rights and quality of services.
In addition, results of the study also suggest that NHIB should modify its existing pay-by-quality policy for DM patients to require all DM patients must receive a comprehensive examination of eyes by an ophomologist to protect their eyes.

並列關鍵字

Diabetic Retinopathy ； Vitrectomy ； Case Payment

參考文獻

林正清(2002)。台灣全民健康保險糖尿病資料庫有關之研究(碩士論文)。國立臺灣大學預防醫學研究所。

林璨(2003)。台灣糖尿病患預後因子與醫療費用之探討(博士論文)。國立陽明大學公共衛生研究所。

邱淑媞、林宏達、游能俊(2001)。整合是慢性病共同照護模式－蘭陽糖尿病照護網簡介。台灣醫界。44(3)，45-48。

周碧瑟()。,未出版。

黃三桂、王悅萍、錢慶文(2002)。疾病管理對糖尿病患醫療資源耗用之影響。醫務管理期刊。3(2)，35-48。