住院糖尿病個案管理試驗長期成效追蹤

The Long-term Effectiveness of Inpatients Case Management of Diabetes

葉秀真(Hsiu-Chen Yeh) ； 游雪峰(Shene-Fong You) ； 章淑娟(Shu-Chuan Chang)

《健康促進研究與實務》 1卷1期 (2018/07) Pp. 29-37

https://doi.org/10.29442/HPRP.201807_1(1).0004

摘要

目的：探討建立住院糖尿病個案管理模式長期成效並持續追蹤此模式對糖化血色素（HbA1C）之影響，以及提供機構發展慢性病照護個案管理模式之參考。方法：2007－2008年先採用研究試驗方法於骨外科進行，爾後延續其管理模式擴展全院。再以人群為基礎研究法探討2009－2012年及2013－2016年兩階段擴展成效與維持狀況。結果：收案對象以外科患者佔約4成為最多，高危險因素以血糖控制不佳HbA1C≧9%為最多，其次為糖尿病初診斷。研究試驗期設定骨外科高危險群之需求，先驅試驗研究成效顯示住院糖尿病個案管理模式能有效降低HbA1C數值0.8%。全面擴展期以及成效追蹤期的出院4個月內，HbA1C改善成效、HbA1C不良率（HbA1C＞9.5%）、HbA1C控制良好率（HbA1C＜7.0%），均較住院期間有明顯改善。收案之個案HbA1C愈趨嚴重，全面擴展期平均HbA1C自10.6%降至出院後四個月內之8.2%，以及成效追蹤期平均11.8%降到8.0%。結論：經長期追蹤顯示住院中介入糖尿病管理照護之必要性，此模式有助於HbA1C之改善以及提高照顧品質。建議未來健保卡能建立雲端檢驗報告，以持續監控HbA1C，並增加獎勵措施落實共同照護網個案之追蹤，以提高慢性病照護品質之效益。

關鍵字

糖尿病 ； 個案管理

並列摘要

Purpose: The purpose of this study was to trace the long-term effectiveness of hospitalized diabetes case management. These results will provide the government or other institutions to develop a management model for chronic disease care. Method: From 2007-2008, we collected several cases of diabetes from orthopedics unit by using clinical control study. Then we used population-based studies to analyze the extended stage and effectiveness of the management model on 2009-2012 and 2013-2016, respectively. Results: 40% of the participants was surgical patients. Among the risk factors, HbA1C≧9% has the highest percentage. Followed by patient with first time diabetic diagnosis. While conducting clinical control study, the results showed that the case management model could decrease HbA1C 0.8% effectively. After follow-up monitoring of extended stage and maintainace effectiveness stage, the results showed a dramatic improvement than hospitalization, include HbA1C data, poor control rate(HbA1C≧9.5%), and good control rate(HbA1C＜7%). We finded the participants with diabetes getting more serious during hospitalization. In the extended stage, the average of HbA1C data decreased from 10.6 % to 8.2%. And the maintainace effectiveness stage, the average of HbA1C data decreased from 11% to 8%. Conclusion: Long-term results showed the necessity of hospitalized diabetes model, and it helps to improve HbA1C and care quality. We suggested that The Health Insurance Card can be added to the cloud inspection report to improve the effectiveness of quality of monitoring chronic disease and follow-up the diabetes of share-care network.

並列關鍵字

Diabetes ； Case Management