醫療給付改善方案與照護過程對糖尿病病人健康結果之影響

The Effects of Pay-for-Performance and Process of Care on Health Outcomes of Diabetic Patients

譚家惠(Chia-Hui Tan)

指導教授 ： 楊銘欽

國立臺灣大學/公共衛生學院/健康政策與管理研究所/博士(2013年)

https://doi.org/10.6342/NTU.2013.01947

摘要

背景：目前已有許多文獻探討論質計酬方案對於照護品質的影響，然而論質計酬方案對於照護結果的影響，卻少有著墨。
目的：本研究目的為探討第二型糖尿病病人是否參加論質計酬方案對於其糖尿病相關併發症發生情形之影響。
材料與方法：本研究為固定世代長期追蹤研究，平均追蹤期間為五年，資料來源為國家衛生研究院提供之2005年承保抽樣歸人檔，以2004-2006年新診斷的糖尿病病人世代(以門診出現三次以上糖尿病診斷(ICD-9-CM: 250.xx)或住院主診斷出現一次糖尿病診斷，並排除前一年門、住診記錄有糖尿病診斷者)為研究對象。研究組定義為於追蹤期間(2004-2010年)加入論質計酬方案，且至少接受完整照護一年以上者，而對照組為追蹤期間內，從未加入該方案者；由於病人是否加入論質計酬並非隨機分派(randomization)的情形，為了增加兩組間的可比較性，因此採用傾向分數配對法(propensity score matching)，分析六大類糖尿病相關併發症(包括眼睛病變、神經病變、腎臟病變、腦血管病變、心血管疾病與周邊血管病變等)之發生情形，並透過不同傾向分數法與存活分析，估計糖尿病病人是否參加論質計酬方案對於糖尿病人心血管併發症發生的影響；整體資料以SAS 9.3版套裝軟體進行資料處理與統計分析。
結果：新診斷且無併發症的糖尿病人，參與論質計酬方案超過12月可降低其發生心血管併發症的危險，依據不同傾向分數法估計之風險值為0.60至0.62之間；此外，參與論質計酬方案可顯著降低糖尿病人發生心臟衰竭、心肌梗塞與中風的風險(HR=0.53-0.65)。在不同的傾向分數法中，使用傾向分數配對與傾向分數加權法，可大幅降低兩組樣本間的系統性誤差。
結論：新診斷且無併發症的糖尿病人參加論質計酬方案，可有效降低其發生心血管併發症的危險；此外，當估計介入的相對風險時，使用傾向分數配對與傾向分數加權法，可有效降低兩組樣本間的系統性誤差。

關鍵字

糖尿病 ； 論質計酬 ； 併發症 ； 心血管疾病 ； 傾向分數法

並列摘要

Objective: A number of studies have examined the impacts of pay-for-performance programs on quality of care, but little is known about long-term effects of these programs on the health care outcomes.
Objective: The study aimed to examine the effects of the pay-for-performance program for type 2 diabetes patients on diabetes-related complications.
Materials and methods: A longitudinal cohort study with 5-year follow-up was used to evaluate the impact of pay-for-performance program on diabetes-related complications. Research materials came from claims files of the Longitudinal Health Insurance Database (LHID) 2005 released from the Nation Health Research Institute. Patients newly diagnosed as diabetes (with more than 3 times of ambulatory visits diagnosed as diabetes [ICD-9-CM: 250.xx] or 1 time hospitalization with major diagnosis of diabetes) in 2004-2006 were included in the study. The case group were defined as joined the pay-for-performance program and received the comprehensive care over 12 months during 2004 to 2010. The control group were defined as never joined the pay-for-performance program during follow-up period. Patients who involved the pay-for-performance program or not is not randomization, we applied the propensity score matching (PSM) as a mean to increase the comparatives between these two groups. The incidences of six diabetes-related complications, including retinopathy, neuropathy, nephropathy, cerebrovascular, cardiovascular, peripheral vascular disease and metabolic disease) were analysed.
Different propensity score methods and survival analysis were use to estimate whether involved in the pay-for-performance program was able to decrease the risk of cardiovascular events for diabetes patients. The SAS v9.3 package software was used the database process and statistical analyses.
Results: Patients with newly diagnosed diabetes who participated in the pay-for-performance program for over 12 months experienced cardiovascular event significantly later than non-participants. The marginal hazard ratios of different propensity score method ranged from 0.60 to 0.63. There were significantly different risk of heart failure, myocardial infarction and stroke between those participated in the pay-for-performance program for over 12 months and those did not. Of these propensity score methods, propensity score matching and inverse probability of treatment weighting (IPTW) using propensity score resulted in the estimate with lower standardized difference of means between participant and non-participant groups.
Conclusions: Cardiovascular events were significantly reduced over 5-year period among patients newly diagnosed with diabetes who participated in the pay-for-performance program for over 12 months. When estimating relative effects of interventions, propensity score matching and IPTW using the propensity score were recommended to apply to reduce the systematic bias between groups.

並列關鍵字

diabetes ； pay-for-performance ； complication ； cardiovascular disease ； propensity score method

參考文獻

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