糖尿病病人合併憂鬱症或焦慮症長期趨勢、醫療資源耗用與醫療療效之探討

Temporal Trends, Medical Resources Utilization and Medical Outcomes among Diabetic Patients Comorbid Anxity or Depression

孫金梅(Chin-Mei Sun)

指導教授 ： 許弘毅

高雄醫學大學/健康科學院/醫務管理暨醫療資訊學系碩士在職專班/碩士(2017年)

摘要

研究目的
糖尿病照護是不易的，同時又必須長期面對病程及治療過程中疾病變化，因此在諸多合併症中憂鬱或焦慮患者日益增加，進而間接增加醫療資源耗用及社會成本，但目前探討糖尿病患者合併憂鬱症或焦慮症之直接及間接成本相關文獻較少。因此本研究目的為探討糖尿病患者合併憂鬱症或焦慮症之盛行率、醫療資源使用情形、醫療療效與其相關影響因子。
研究方法
本研究採回朔性長期縱貫性世代研究分析之研究設計，以2003年至2013年間的全民健保學術資料庫為研究主體，研究對象選取糖尿病患者，總共為143,127人納入研究。依照研究對象再區分為有合併憂鬱症或焦慮症組樣本數3,396人和無合併憂鬱症與焦慮症組樣本數139,731人，利用線性複回歸以及Cox回歸模式研究其人口特性、臨床特性、醫療機構特性以及時間特性與醫療資源耗用以及醫療療效之相關影響因子。
研究結果
研究結果發現糖尿病病人合併憂鬱症或焦慮症其盛行率，在2004年至2012年有顯著性下降盛行率為每十萬人口3.58下降至2.80，但在2013年值得關切的是盛行率上升為每十萬人口3.17；其中女性2145人(63.2%)高出男性1251(36.8%)，平均年齡為58.55±14.01歲。糖尿病病患合併憂鬱症或焦慮症之相關影響因素，不論是在人口學特性、臨床特性、醫療機構特性等皆有達顯著性的相關(P<0.001)。糖尿病病患合併憂鬱症或焦慮症醫療耗用(門診次數、門診費用、住院天數、住院費用、總醫療費用)皆有達顯著性的差異(P<0.001)，糖尿病病患合併憂鬱症或焦慮症平均每年門診次數是26.1次，較無合併憂鬱症或焦慮症之糖尿病病患平均每年門診次數(14.6次)多；平均每次住院天數7.1天，較無合併憂鬱症或焦慮症之糖尿病病患平均每次住院天數(6.2天)多；平均每年門診費用1,326.1元，較無合併憂鬱症或焦慮症之糖尿病病患平均每年門診費用(107.7元)高；平均每次住院費用52,781.8元較無合併憂鬱症或焦慮症之糖尿病病患平均每次住院費用(42,433.4元)高；總費用54,107.9元較無合併憂鬱症或焦慮症之糖尿病病患總醫療費用(43,588.3元)高。糖尿病有合併憂鬱症或焦慮症病患發生併發症(高血壓、冠心病及慢性腎臟病)、90天再入院風險相較於無合併合併憂鬱症或焦慮症之病患達顯著性增加(P<0.001)。
結論與建議
本研究期間發現糖尿病合併憂鬱症或焦慮症在醫療資源耗用較無合併憂鬱或焦慮為高。糖尿病合併憂鬱症或焦慮症在併發症及90天再入院風險性較無合併憂鬱症或焦慮症為高。臨床醫護團隊對於糖尿病病患罹患憂鬱症或焦慮症時，應給予適當介入措施，以降低病患長期受憂鬱症或焦慮症等精神疾病所困擾，讓病患獲得更好的醫療照護，以利有效降低醫療資源耗用，進而使病患與家屬有更好的生活品質。

關鍵字

糖尿病 ； 憂鬱或焦慮症 ； 醫療資源耗用 ； 盛行率 ； 存活率

並列摘要

Objective
Caring for diabetes is no easy task; the patient is faced with changes in the disease process and course of treatment throughout the long span of the illness. This leads to an increase in the number of patients with diabetes with combined symptoms of depressive or anxiety disorder, which results in the indirect increase of medical resource consumption and social cost. However, few pieces of research focus on the direct and indirect cost of patients with diabetes combined with depressive or anxiety disorder. Therefore, this study aims to explore the prevalence, use of medical resources, medical efficacy, and other related influence factors of patients with diabetes combined with depressive or anxiety disorder.
Methods
This study applies retrospective study, long-term longitudinal research, and cohort study analysis based on data from the National Health Insurance Research Database between 2003 and 2013, which includes a total of 143,127 patients with diabetes. The patients are further separated into 3,396 patients with diabetes combined with depressive and anxiety disorder and 139,731 without depressive and anxiety disorder. Using linear regression and Cox regression, related impact factors including demographic characteristics, clinical features, characteristics of medical institutions, time characteristics, the consumption of medical resources, and medical efficacy are studied.

Results
Results of this study indicate that the prevalence of patients with diabetes who have depressive and anxiety disorder showed a significant decrease from 3.58 to 2.80 every one hundred thousand people between 2004 and 2014. However, in 2013, the prevalence increased to 3.17 every one hundred thousand people, among which the number of female patients was 2145 (63.2%), higher than the 1251(36.8%) male patients, the average age being 58.55±14.01. The influencing factors related to patients with diabetes combined with depressive of anxiety disorder, such as demographic characteristic, clinical features, and characteristics of medical institutions, all reached significant correlation (P<0.001). The utilization of medical resources of patients with diabetes combined with depressive of anxiety disorder (clinic visits, clinic fee, days of hospitalization, hospitalization fee, and total medical fee) all reached significant difference (P<0.001). On average, the number of clinic visits of patients with diabetes combined with depressive of anxiety disorder is 26.1 times each year, higher than the clinic visits of patients with diabetes without depressive or anxiety disorder (14.6 visits each year). The average of length of hospitalization is 7.1 days, longer than that of patients with diabetes without depressive or anxiety disorder (6.2 days). The average annual clinic fee is 1,326.1 NT dollars, higher than patients with diabetes without depressive or anxiety disorder (107.7 NT dollars). The average hospitalization fee per stay is 52,781.8 NT dollars, higher than patients with diabetes without depressive or anxiety disorder (42,433.4 NT dollars). The total fee is 54,107.9 NT dollars, higher than patients with diabetes without depressive or anxiety disorder (43,588.3 NT dollars). The likelihood for complications (hypertension, coronary heart disease, and chronic kidney disease) to occur in patients with diabetes combined with depressive and anxiety disorder and risk of rehospitalization within 90 days shows a significant increase (P<0.001) compared with patients with diabetes without depressive or anxiety disorder.
Discussion and suggestion
This study has discovered that patients with diabetes combined with depressive and anxiety disorder consume more medical resources than patients with diabetes without depressive and anxiety disorder. Patients with diabetes combined with depressive and anxiety disorder are more likely to be admitted back to the hospital within 90 days compared with patients without depressive and anxiety disorder. Therefore, clinical health care teams should provide adequate intervention measures to patients with diabetes combined with depressive or anxiety disorder to lighten the burden of long-term mental issues such as depressive or anxiety disorder, and provided better medical care to lower the consumption of medical resources and furthermore promote better quality of life for patients and family.

並列關鍵字

Diabetes ； Anxiety or depressive disorders ； Medical Resource Utilization ； Prevalence Rates

參考文獻

Fu, T. S., Lee, C. S., Gunnell, D., Lee, W. C., & Cheng, A. T. (2013). Changing trends in the prevalence of common mental disorders in Taiwan: a 20-year repeated cross-sectional survey. Lancet, 381(9862), 235-241. doi: 10.1016/s0140-6736(12)61264-1

む英文文獻め

Association, A. D. (2010). Standards of medical care in diabetes--2010. Diabetes Care, 33 Suppl 1, S11-61. doi: 10.2337/dc10-S011

Association, A. P. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub.

Bruce, D. G., Casey, G., Davis, W. A., Starkstein, S. E., Clarnette, R. C., Foster, J. K., . . . Davis, T. M. (2006). Vascular depression in older people with diabetes. Diabetologia, 49(12), 2828-2836. doi: 10.1007/s00125-006-0478-y