全民健康保險糖尿病醫療給付改善方案之果效研究與糖尿病患生活品質評估

An Outcome Research of Diabetic Pay-For-Performance Program and Evaluation on Health-Related Quality of Life in Taiwanese Type 2 Diabetes Outpatients

黃齡慧(Ling-Hui Huang)

指導教授 ： 黃耀斌

共同指導教授 ： 黃尚志(Shang-Jyh Hwang)

高雄醫學大學/藥學院/臨床藥學研究所/碩士(2011年)

https://doi.org/10.6832/KMU.2011.00117

摘要

研究背景：近年來，國人糖尿病的盛行率快速增加，而糖尿病的許多嚴重併發症，不但惡化病患生活品質更造成醫療花費支出的負擔。為建立以病患為中心的照護模式，我國行政院衛生署中央健康保險局於2001年11月起實施「全民健康保險糖尿病醫療給付改善方案試辦計畫」，提供一項以照護品質為導向，論質計酬的支付制度。自糖尿病醫療給付改善方案實施至今，尚未有針對此改善方案是否影響糖尿病各項併發症發生率以及病患生活品質之評估。故本研究目標為評估此改善方案對糖尿病患醫療利用、處方型態及長期預後之影響，同時探討糖尿病患生活品質之測量方法，作為未來進行經濟學評估的初探。
研究方法：本研究分為三部分，第一部分為橫斷性研究（cross-sectional study），以2004到2008年之「糖尿病照護診療資料檔」，連結健保申報資料檔，探討納入改善方案糖尿病患之族群特性及醫療利用模式。第二部分為回溯性世代研究追蹤（retrospective cohort study），採用具全國抽樣代表性的「全民健康保險研究資料庫2005年百萬抽樣歸人檔」，比較納入改善方案之病患族群與未納改善方案糖尿病患之醫療利用、並以存活分析方式追蹤兩組發生大小血管併發症之比率。第三部分為橫斷性研究，以半結構化訪談南部某區域醫院之門診糖尿病患，探討各種影響因素與糖尿病患生活品質的關係。並以歐洲生活品質量表五面向問卷（EQ-5D）、視覺類比尺度法（EQ-VAS）及時間交換法（time-trade-off，TTO）測量受訪者的生活品質。
研究結果：在2004年至2008年間，共有297103位糖尿病患納入糖尿病醫療給付改善方案，病患納入改善方案期間長度在1年以下者佔最多數（26.62%）。研究期間整體糖尿病門診醫療利用次數並無變化；但以醫療層級分層後，醫學中心及地區醫院門診申報就醫次數為顯著減少，基層診所則有顯著增加之趨勢。門診醫療費用在基層診所與特約藥局為顯著增加，醫學中心則顯著降低。糖尿病藥物處方佔率以sulfonylureas（36.94%）最高、biguanides（34.69%）類次之。
針對長期預後之研究發現，納入改善方案的糖尿病患每人每年之門診醫療利用次數與費用皆較未納入改善方案病患高，但其整體糖尿病慢性大小血管併發症之發生率則顯著低於未納入改善方案之糖尿病患。而生活品質之研究共有100位糖尿病患完成訪談與EQ-5D，98位完成EQ-VAS，96位完成TTO。半結構化質性訪談結果可分為：受訪者如何發現罹患糖尿病、本次就診原因及平均回診間隔期間、因糖尿病造成生理或心理不適之情形、糖尿病對日常生活的影響、藥物使用情形及影響病患面對疾病態度之因素等六大面向作探討。以EQ-5D測出之效用值為0.93±0.11，EQ-VAS為0.70±0.16，而TTO則為0.69±0.22，三種測量工具所得之效用值分別受不同因素所影響。
結論：納入改善方案之病患其醫療利用情形在不同層級之醫療院所亦不相同，須要同時多方面評估門診醫療利用次數、費用、處方型態與相關政策規定，才得以探討糖尿病醫療給付改善方案對不同醫療層級之影響。相較於未納入改善方案之病患，有納入之病患其糖尿病大小血管併發症發生率較低。糖尿病患健康相關生活品質研究中訪談結果顯示，可能影響糖尿病患生活品質的因素十分多樣，對不同生活品質問卷之影響因素亦不同。後續研究可朝糖尿病醫療給付改善方案之成本效益分析（cost-effectiveness analysis）或成本效用分析（cost-utility analysis），以提供健保局作為政策上之依據。

關鍵字

糖尿病 ； 糖尿病醫療給付改善方案 ； 論質計酬 ； 糖尿病併發症 ； 健康相關生活品質

並列摘要

Background: With the increasing diabetic prevalence, cost of diabetic treatment and complications management has been substantially increased. The Diabetic Pay-for-performance Program was implemented in 2010 by the Bureau of National Health Insurance (BNHI) that provided financial incentives to healthcare providers to improve the quality of diabetic care, yet its impacts on long-term medical utilization and anti-diabetic usage remain unclear. Therefore, this study aims to evlaute the current medical and drug utilizations related to this program, assess the impacts of this Program on long-term diabetics-related outcomes, and explore the feasibility of quality of life measures on diabetic patients in order to inform future cost-effectiveness studies on this Program.
Method: A cross-sectional study was conducted from 2004 to 2008. Adult diabetic patients who were enrolled in the Pay-for-performance Registry were identified, and connected to the National Health Insurance reimbursement dataset to extract medical claim data. Data of medical utilization and drug usage were analyzed in descriptive statistic. We also conducted a cohort study by using Longitudinal Health Insurance Database 2005. Descriptive analysis and survival analysis were used to compare medical utilization and long-term complication rate between PFP and non-PFP patients. In the third part, a cross-sectional study was conducted from June to December 2010 at a regional hospital in southern Taiwan. Outpatients with type II diabetes were invited for measuring quality of life (QoL). Semi-structured interviews followed with 3 different QoL questionnaires were conducted. Interviews were recorded, transcribed verbatim and analyzed by constant comparison approach to saturation. Simple and multiple regressions were used to evaluate the realtionship between patient characteristics and utility value.
Result: During study period, 297103 patients were included; most of the participants (26.62%) were enrolled in the PFP program for less than 1 year. The overall diabetic outpatient visit times were no significantly variation. However, it varied from different tiers of hospitals; medical center and local hospital were significantly decreased while clinics were significantly increased. The diabetic outpatient medical costs were significantly increased in regional hospital, clinics and contracted pharmacy while it decreased in medical center. Among the antidiabetic prescriptions, sulfonylureas (36.94%) and biguanides (34.69%) were the most frequently prescribed categories. We also found that although PFP patients had a higher medical utilization per patient per year compared to non-PFP patients, they had a lower complication incidence rate.
There were 100 participants finished the QoL interview and EQ-5D, 98% finished EQ-VAS and 96% finished TTO. The results of semi-structured interview could be divided into 6 aspects: How did participants get to know they had diabetes, the average visit interval, physical or emotional illness due to diabetes, how did diabetes affect particpants’ daily life, medications and factors which impacted participants’ altitude toward diabetes. The utility which transformed from EQ-5D questionnaire was 0.93±0.11, EQ-VAS utility was 0.70±0.16, TTO score was 0.69±0.22.
Conclusion: PFP program might be a costly policy with potential good outcomes, NHI shall enrolled more patient in different disease status into the program and evaluate these years’ medical utilization trend to allocate resourses more efficiently. Diabetes patients’ QoL might be influenced by many different factors when using different measuring tool. For future study, a cost-effectiveness analysis or a cost-utility analysis will be necessary for BNHI to make decision or upgrade the program.

並列關鍵字

Diabetes mellitus ； pay-for-performance program ； diabetes complications ； quality of life

參考文獻

參考文獻

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