不同疾病管理照護模式之探討
─以糖尿病及痛風個案為例

中文摘要背景動機：山地鄉及澎湖地區以整合醫療資源方式實施疾病管理計畫，分別以不同照護模式實施，在山地鄉為共同照護模式，在澎湖地區為個案管理師照護模式，本研究以高發生率之糖尿病及山地離島高盛行率之痛風為例，探討不同照護模式之對臨床照護成效及醫療利用之影響。研究目的：本研究之目的為瞭解不同疾病管理照護模式下，同一疾病之照護個案，於疾病管理介入前、後之臨床照護成效及醫療利用情形，並比較不同疾病管理照護模式下，照護門診複診率、臨床照護成效及醫療利用之差異情形。研究方法：採回溯性之研究，研究資料為2004年1月至2005年12月屏東縣霧台等三個山地鄉及澎湖社區醫療群，登錄且持續接受照護滿一年之糖尿病及痛風個案，探討項目分為臨床照護及醫療利用；以STATA 8.0統計軟體之GEE (Generalized Estimating Equations)分析臨床照護改善趨勢，糖尿病臨床指標變項為身體肥胖指數、糖化血色素、收縮壓、舒張壓、低密度脂蛋白膽固醇、高密度密度脂蛋白膽固醇，痛風臨床指標變項為血清尿酸、血清肌酸酐、痛風三個月內發作次數；醫療利用係分析計畫介入前、後一年之差異情形。研究結果：一、山地鄉共同照護模式：複診執行率為糖尿病個案平均79.23%、痛風個案平均91.44%；臨床照護有顯著成效之項目在糖尿病個案為收縮壓(P=0.003)及身體肥胖指數(P=0.034)，痛風個案為血清尿酸(P=0.000)；疾病管理介入後門診醫療利用，以總醫療費用、就醫次數及診療費之增加最明顯(P=0.000)。二、澎湖地區個案管理師照護模式：複診執行率為糖尿病個案平均47.10%、痛風個案平均48.34%；臨床照護有顯著成效之項目在糖尿病個案為糖化血色素(P=0.037)、收縮壓(P=0.000)、舒張壓(P=0.002)及身體肥胖指數(P=0.018)，痛風個案為血清尿酸(P=0.000)；疾病管理介入後門診醫療利用，以總醫療費用、就醫次數及診療費之增加最明顯(P=0.000)。三、不同疾病管理照護模式之比較：複診執行率以山地鄉較高；山地鄉個案照護成效之改善差異比澎湖地區個案顯著之項目，糖尿病為舒張壓及身體肥胖指數、痛風為血清肌酸酐及三個月痛風發作次數；澎湖地區個案照護成效之改善差異比山地鄉個案顯著之項目為糖尿病之糖化血色素及低密度脂蛋白膽固醇。結論：照護複診執行率以山地鄉共同照護模式較高；臨床照護成效在不同疾病管理照護模式下，顯著性改善之項目不同，隨照護時間之延長，均呈現持續改善之趨勢；門診醫療利用在疾病管理介入後明顯增加。建議：山地鄉疾病管理共同照護模式，因結合當地衛生所公共衛生人力，個案有較高之複診執行率，應可持續推動；澎湖地區個案管理師照護模式，應考量個案管理師照護人數，建議結合衛生所共同推動增加照護人力；對於特定疾病盛行率高之地區實行區域性疾病管理之方式，應可擴大推廣至其他地區實施。關鍵詞：疾病管理、糖尿病、痛風、照護成效、醫療利用

關鍵字

疾病管理；糖尿病；痛風；照護成效；醫療利用

並列摘要

Abstract Introduction：Mountain township and Penghu region used integrated medical resource method for Differential Disease Management Care Model (DDMCM). This research set high incident disease like diabetes and the prevalence of gout in mountain township and Penghu region as example. The purpose of this study is to explore the variation under DDMCM program before and after medical treatment for the same disease. This study also compares the difference after DDMCM, re-visit rate, medical care and medical utilization. Method：This study is based on community medical group from Ping Tong’s three mountain township and Penghu region . Diabetes and Gout cases that had been under medical care at least one full year from January to December, 2005 were eligible as data base, and divided into two categories as medical care and medical utilization. The GEE (Generalized Estimating Equations) model was employed to analyze improvements under medical care. Diabetes clinic index are Body Mass Index、Hemoglobin A1C、systolic pressure、diastolic pressure、LDL-Cholesterol、HDL-Cholesterol. Gout clinic index are Serum uric acid、Serum creatinine and how many times gout occurred within three month. This study also analyzed one year before and after medical utilization. Result：1. Under joined care mode from mountain region counties：subsequent consultation ratio for diabetes patients are, on average, 79.23%、gout patients 91.44%；medical care have great impact on diabetes patient in systolic pressure (P=0.003) and Body Mass Index (P=0.034). gout cases are Serum uric acid (P=0.000)；after Disease Management Care-Mode. intervene medical utilization there are significant increases for total medical expense、 medical treatment attendance and clinic fee (P=0.000). 2. Penghu region under case manager mode：subsequent consultation ratio for diabetes patients are, on average, 47.10%、gout patients 48.34%；medical care have great impact on diabetes patients in Hemoglobin A1C (P=0.037) 、systolic pressure (P=0.000)、diastolic pressure(P=0.002) and Body Mass Index (P=0.018). gout cases are Serum uric acid (P=0.000)；after Disease Management Care-Mode intervene medical utilization there are significant increases for total medical expense、 medical treatment attendance and clinic fee (P=0.000). 3. The comparison for Differential Disease Management Care-Mode：mountain region counties have higher subsequent consultation ratio；mountain region counties compare to Penghu region have the following higher efficiency categories, diabetes cases are diastolic pressure and Body Mass Index、gout cases are Serum creatintine and how many times gout occurred within three month.；Penghu region compare to mountain region counties have the following higher efficiency categories, diabetes cases are Hemoglobin A1C and LDL-Cholesterol. Conclusion：Re-visit rates are higher in mountain township than the other；under DDMCM the medical care efficiency are different. For the long-term observation, these improvements for the diabetes and the gout will increase. Clinic medical utilization eminently increased after DDMCM intervention. Mountain region joined disease DDMCM with local health station had higher re-visit rates and it is recommended. Penghu region case manager mode should consider the limit of its man power. Perhaps case manager should work with local health station to increase medical staff. Joined diseases Management Care-Mode can be introduced and applied to the prevalence of disease area. Key word：Disease Management、Diabetes、Gout、Care Effect、Medical Utilization