縱貫性探討糖尿病對社區老人醫療服務利用之影響

本研究主要目的在於瞭解社區老人有無罹患糖尿病之人口學特質、經濟資源、精神健康及身體健康狀態之差異，並比較醫療服務利用縱貫性變化情形，進一步探討影響社區老人糖尿病患者醫療服務利用之相關因素。本研究主要以居住在高雄市三民區65歲以上社區老人為研究樣本，以中文版老人多元功能評估問卷所收集1998年受訪資料，將研究樣本區分為糖尿組（143位）與非糖尿病組（731位），配合其長期醫療服務利用資料，分析罹患糖尿病是否為顯著影響醫療服務利用之因素，並依據Andersen醫療服務利用行為模式，探討社區老人糖尿病患者醫療服務利用情形之相關因素。研究結果顯示，在門診醫療服務利用方面，除1997年門診費用外，糖尿病組自1995年至2000年之年平均門診次數、費用皆顯著高於非糖尿病組；住院醫療服務利用方面，糖尿病組僅在1999年住院次數、日數顯著高於非糖尿病組。進一步經迴歸分析，罹患糖尿病確實為顯著影響門診費用、住院日數及費用重要因素之一。針對糖尿病組，研究結果發現影響糖尿病患者1998年門診費用顯著因素為傾向因素中的婚姻狀況、能力因素中的有餘錢買喜歡的東西、需要因素中的老人常見慢性病數及前一年門診次數（R2=29.6%）；影響住院日數顯著因素皆為需要因素，依序為日常活動能力、當年度併發症種類數、合併症種類及前一年門診、住院次數（R2=61.6%）；影響住院費用顯著因素則為當年度併發症種類數、合併症種類數及前一年門診次數（R2=51.4%）。利用相同迴歸模式分析，以1998年收集之傾向、能力及需要因素對於後續2年之門診費用、住院日數及費用之解釋力則是呈現下降趨勢，而婚姻狀況、是否有餘錢買喜歡的東西，常見慢性病數及前一年門診次數為長期影響門診費用之重要因素，合併症種類數為長期影響住院日數、費用之重要因素。若各年度醫療服務利用迴歸模式將併發症及合併症種類數以該年度資料置換，長期影響門診費用之重要因素仍為婚姻狀況、是否有餘錢買喜歡的東西，常見慢性病數及前一年門診次數，而併發症、合併症種類數仍為住院日數、費用之重要因素。整體而言，社區老年人口罹患糖尿病者其醫療服務利用顯著高於非糖尿病者。在門診醫療服務利用方面，婚姻狀況、是否有餘錢買喜歡的東西、慢性病數及前一年門診次數是重要影響因素，而住院醫療服務利用方面，則多為需要因素之併發症、合併症種類數及前一年門診次數為重要因素，因此未來健康照護計畫規畫糖尿病之門、住診醫療服務時應全面整合患者傾向、能力及需要因素，以達成最有效率之健康管理。

關鍵字

醫療服務利用；糖尿病；中文版老人多元功能評估

並列摘要

Objective—The major purpose of this study is three-fold: 1) to compare demographic characteristics, economic resources, mental and health status of elderly people with and without diabetes; 2) to describe long-term medical utilization among elderly people with and without diabetes; 3) to examine effective factors associated with medical utilization among elderly people with diabetes residing on community over three years. Research Design and Methods—These over 65 elderly people was separated into diabetes group (143) and non-diabetes group (874) from San-Min, Kaohsioung. The survey data were collected by the CMFAQ in 1998 and the medical utilization was obtained from Bureau of National Health Insurance. Using Andersen’s behavioral model assessed the predictable factors of medical utilization for individuals with diabetes over 65 years from San-Min community. Results—The utilization of outpatient for individuals with diabetes was higher than those without diabetes. The utilization of inpatient for individuals with diabetes also was higher than those without diabetes. Generally, the diabetes was an important effective factor that affected outpatient charges, length of stay, and inpatient charges. Marital status, having extra money for shopping, numbers of chronic diseases and previous medical utilization of outpatient services were significant associated with the health care expenditures of outpatient. The activities of daily living, numbers of complications and co-morbidities and previous medical utilization were significant associated with the length of stay. The numbers of complications and co-morbidities and previous medical utilization were significant associated with the health care expenditures of inpatient. Using the same model, we were able to explain more variation in medical utilization in 1998, and marital status, having extra money for shopping, numbers of chronic diseases and previous medical utilization of outpatient services were long-term predictable factors of health care expenditures of outpatient; the numbers of complications and co-morbidities were the long-term predictable factors for health care expenditures of inpatient. According to the medical utilization, after a replacement for numbers of complications and co-morbidities, having extra money for shopping, numbers of chronic diseases, and previous clinical visiting were associated with health expenditures of outpatient; on the other hand, numbers of complications and co-morbidities also were associated with length of stay and health expenditures of inpatient. Conclusion— Overall, medical utilization of elderly people with diabetes was higher than non-diabetes. Marital status, having extra money for shopping, numbers of chronic diseases and previous medical utilization of outpatient services were significantly associated with the health care expenditures of outpatient; the numbers of complications and co-morbidities were significantly associated with the medical utilization of inpatient. Therefore, health care program should obtain the predisposibling, enabling, and need factors in order to picture a comprehensive medical service for diabetes.