- 學位論文
探討影響台灣成人糖尿病照護臨床治療慣性（Therapeutic inertia）之醫療提供者影響因素分析
Therapeutic inertia among adult DM patients in Taiwan focusing on associated factors of health care provider
若您是本文的作者，可授權文章由華藝線上圖書館中協助推廣。
摘要
目的
針對慢性疾病糖尿病的治療，即使目前的實證或臨床指引指出積極的藥品治療可以減緩或預防併發症的發生，但部分醫師卻未給予適當的藥品治療，將疾病 (如血糖) 控制在理想的範圍內。此研究的目的首先為以糖尿病論質計酬方案 (Diabetes Pay-for-Performance Project, DM-P4P) 次級資料研究，根據病人糖化血色素檢驗值 (A1c)，進行處方箋降血糖藥品改變的分析，並針對「加強給藥 (intensify therapy)」作為台灣「臨床治療慣性 (therapeutic inertia)」的型態研究 (pattern analysis)。其次，針對醫療提供者之主要變量，分析未給予「加強給藥」之重要影響因素。並以多層次分析方法，檢視不同醫療機構之層級別是否與「臨床治療慣性」相關。第三為根據「臨床治療慣性」之不同型態追蹤與A1c之治療結果的相關性分析。
研究設計
第一部分為診療前後是否介入處方改變，研究設計為介入前後比較研究；第二部份為「加強給藥」與糖尿病之主要結果指標A1c的關係，研究設計為針對參加2006年至2008年糖尿病論質計酬方案之糖尿病個案之世代研究 (cohort study)。
資料來源
此研究主要聯結兩個大型的資料庫，包括2006至2008年全民健康保險申報總檔 (the regular NHI claims database) 及糖尿病論質計酬方案之VPN (Virtual Private Network) 資料檔案。
統計分析
使用描述性分析及羅吉斯迴歸分析個案特質與醫療提供者之主要變量對於「加強給藥」的影響及「加強給藥」與糖尿病之主要結果指標A1c的關係。並運用多層次分析法 (multi-level analysis)，探討在糖尿病照護中，檢驗不同醫院、醫師間的差異如何影響「加強給藥 (intensify treatment)」之因素。
結果
診療前後是否介入處方改變
在2006年至2008年加入糖尿病論質計酬方案，共215,679位糖尿病個案；1,527,539次的A1c數值，其中，僅25.98%的A1c數值低於7%的控制目標。針對A1c數值介於7%至11%，共有168,876位糖尿病個案，年齡為18至80歲者及899,135次的A1c數值。當該次A1c大於7%小於等於11%時，38.5% (346,221 處方箋數) 在診療後未獲得「加強給藥」。在藥品使用分類部分，42.0 %的藥品處方被歸為A1c值介入後新增加品項。在影響「加強給藥」之羅吉斯迴歸分析部分，年齡小於40歲之糖尿病個案處方箋較大於65歲之糖尿病個案處方箋數獲得「加強給藥」的發生比的1.26倍 (p< 0.001)，糖尿病嚴重度 (DCSI score) 低的個案處方箋數較DCSI高的個案處方箋數獲得「加強給藥」的發生比的0.46倍 (p<0.001)，糖尿病A1c為7%至8%的個案處方箋較A1c為10%至11% (10%
並列摘要
Background
Empirical evidence and clinical guidelines related to the treatment of diabetes have indicated that aggressive drug therapy can mitigate or prevent the occurrence of complications; however, many physicians fail to prescribe appropriate drug therapy for control of the disease (such as blood glucose levels). This study is divided into three stages. Initially, we present analysis of secondary data related to the Diabetes Pay-for-Performance Project (DM-P4P). We used hemoglobin A1c (A1c) test values to identify variations in the prescription of hypoglycemic drugs. We then conducted pattern analysis on intensive therapy to elucidate the issue of therapeutic inertia in Taiwan and examined the variables of healthcare providers to analyze the factors associated with intensive therapy. Multi-level analysis was performed to determine whether the level of the medical institutions was correlated with therapeutic inertia. In the third stage, we conducted correlation analysis on the patterns of therapeutic inertia and the outcome of A1c.
Research Design
The first stage involved identifying changes in prescription patterns and conducting a comparison of prescriptions before and after A1c intervention. In the second stage, we determined the relationship between intensive therapy and the primary index of A1c. This involved a cohort study on diabetes patients that participated in DM-P4P from 2006 to 2008.
Data Source
We accessed two major databases: the regular NHI claims database from 2006 to 2008 and the virtual private network (VPN) of DM-P4P.
Statistical Analysis
This study employed descriptive analysis and logistic regression to determine the influence of variables related to primary healthcare provider on intensive therapy and the relationship between intensive therapy and the primary index of diabetes, A1c. Multi-level analysis was also conducted to examine whether different hospitals or physicians influenced intensive diabetes therapy.
Results
A total of 215,679 diabetes patients participated in DM-P4P between 2006 and 2008. Among the 1,527,539 A1c test results, only 25.98 % were less than 7%. We focused on the 168,876 diabetes patients presenting A1c values between 7% and 11%. The age of the study population ranged between 18 and 80, and 899,135 A1c values were included. Among patients with A1c values greater than 7% and equal to or less than 11%, 38.5% (346,221 visits) did not receive intensive therapy. Of the total drug prescriptions, 42.0 % were categorized as newly added drugs following A1c value intervention. In multivariate analysis of the factors related to intensive therapy, the odds ratio of a diabetes patient under 40 years of age receiving intensive therapy was 1.26 times that of a diabetes patient over 65 years of age (p< 0.001), and the odds ratio of patients scoring zero on the Diabetes Complications Severity Index (DCSI) receiving intensive therapy was 0.46 times that of patients scoring 4 on the DCSI (p< 0.001). Diabetes patients with A1c of 7% to 8% were less likely to receive intensive therapy than patients with A1c values of 10% to 11% (10%
參考文獻
10.蕭淑華, 歐弘毅, 吳達仁. 增泌素(Incretin)類藥物治療第2型糖尿病之臨床實證. 內科學誌 2007; (18卷4期): 6.
107.溫福星, 邱皓政. 多層次模型方法論：階層線性模式的關鍵議題與試解. 臺大管理論叢 2009; 19(2): 263-293.
114.婁文信, 蘇聖珠, 王如鈺, 李政達. 顧客滿意與其前置變項之多層次分析. 顧客滿意學刊 2012; 8(2): 145-182.
120.Lin CC, Lai MS, Syu CY, et al. Accuracy of Diabetes Diagnosis in Health Insurance Claims Data in Taiwan. Journal of the Formosan Medical Association 2005; 104(3): 157-163. .
152.黃憶玫, 張慈桂. 糖尿病照護成效與影響因素之探討：以台東某區域醫院糖尿病共同照護網為例. 臺灣公共衛生雜誌 2011; 30(1): 19-28.