基層診所實施論質計酬疾病管理之整體效應:以糖尿病管理照護為例

The effect of the pay-for-performance program in clinics: Example of diabetic mellitus management care.

莊鵬舉(Peng-Chu Chuang)

指導教授 ： 邱亨嘉

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(2013年)

https://doi.org/10.6832/KMU.2013.00141

摘要

研究背景
由於人口年齡老化，生活方式的改變，糖尿病人總數從2000年的1億7,100人預計到2030年將會上升到3億6,600人，糖尿病患者增加了54％(Wild, Roglic et al. 2004)。中央健康保險局自2001年，實施「糖尿病醫療給付改善方案試辦計畫」，更於2006年實施論質計酬方案計畫模式，期望藉由支付方式，鼓勵醫療人員，提供具效益與完整性的服務項目，使糖尿病人之病情得到良好控制，以降低糖尿病患的併發症和減少醫療資源利用。過去文獻多著重在初期試辦的論質計酬試辦計畫(P4P)成效評估，未就合併任一種疾病及病患自覺照護能力評估和滿意度之完整性研究。本研究目的 要瞭解基層診所對糖尿病論質計酬試辦計畫(P4P)與未參與論質計酬試辦計畫(Non-P4P)成效評估及自我照護能力評估，就醫滿意度的研究。
研究方法
本研究以高屏5家診所共收集300位，糖尿病病人為研究對象，進行參與論質計酬(P4P:210人)與非論質計酬(Non-P4P:90人)的臨床生化指標、過程指標，自我慢性疾病照護(Patient Assessment Of Chronic Illness Care.PACIC)，病患滿意度調查(Patient Satisfaction Questionnair.PSQ-18)兩組的比較，使用描述性統計、卡方檢定、t test.簡單線性迴歸分析、複線性迴歸分析。
研究結果
本研究呈現患者平均年齡為62.8歲，女性162人，男性138人，已婚者有253人(84.3%)未婚病患25人，分居離婚病患22人，語言以閩南語佔大部份217人，自我血糖監測0次/週的病患174人，眼底檢查病患198人(66%)，無做眼底檢查病患102人(34%)，有足部檢查病患262人(87%)，無足部檢查病患38人，體重/身高比(BMI)：BMI>27(肥胖)有114人(38%)；參加P4P：85人， Non-P4P：29人；有執行眼底檢查者198人(66%)；有執行足部檢查者有262人(87.3%)；HbA1c<7% 有98人(32.9%)，P4P：74人(35.4%)，Non-P4P：24人(27.0%)，P值=0.001.LDL<100 mg/dl：124人，P4P：97人，Non-P4P：27人所以控制LDL仍是以P4P控制較好。A院診所比其他診所在PACIC自我照護估及病患滿意度較好。
結論與建議
藉由臨床生化指標(HbA1C、LDL、ACR(微蛋白尿)、眼睛視網膜檢查次數、足部檢查次數、自我慢性疾病照護能力及就醫病患滿意度，都顯示參與論質計酬(P4P)比非論質計酬(Non-P4P)有較好的情形。此結果顯示糖尿病參加論質計酬有正向的效果，未來可以建議成政策參考。

關鍵字

糖尿病 ； 論質計酬 ； 臨床效果 ； 自我照護能力 ； 就醫滿意度

並列摘要

Background
As population aging, lifestyle changes, the total number of people with diabetes from 7,100 in 2000 to 100 million people by 2030 will rise to 300 million 6,600 people with diabetes increased by 54% . National Health Insurance Bureau since 2001, the implementation of "Diabetes Medical Benefits demonstration program", but in 2006 the implementation of P4P program planning model, expect to pay by way of encouraging medical staff to provide with efficiency and integrity of services, so that the disease diabetes is well controlled, in order to reduce the complications of diabetes and reduce medical resource utilization. Previous studies such emphasis in the initial pilot P4P pilot program (P4P) effectiveness evaluation, not a disease of the merger either consciously care and patient satisfaction, competency assessment and the integrity of research. This study aims to understand the primary care clinics for diabetes P4P pilot program (P4P) and did not participate in P4P pilot project (Non-P4P) Effectiveness evaluation and self-care capacity assessment, medical satisfaction study.
Research Methods
In this study, Pingtung five clinics to collect 300 diabetes patients for the study, carried out in P4P (P4P: 210 people) and non-P4P (Non-P4P: 90 people) clinical and biochemical indicators, process indicators self-care of chronic diseases (Patient Assessment Of Chronic Illness Care.PACIC), patient satisfaction surveys (Patient Satisfaction Questionnair.PSQ-18) compared the two groups using descriptive statistics, chi-square test, t test. simple linear regression analysis, multiple linear regression analysis.
Results
This study presents patients with an average age of 62.8 years, 162 women, 138 men, 253 married people (84.3%) patients 25 were unmarried, separated divorced patients, 22 were Hokkien language to represent a large part of the 217 person, self-monitoring of blood glucose 0 times / week 174 patients, 198 patients with fundus examination (66%), fundus examination without doing 102 patients (34%), 262 patients with foot examination (87% ), 38 patients without foot examination, weight / height ratio (BMI): BMI> 27 (obese) and 114 (38%); participate P4P: 85 people, Non-P4P: 29 people; has performed fundus examination in 198 people (66%); has executed 262 people who foot examination (87.3%); HbA1c <7%, 98 people (32.9%), P4P: 74 people (35.4%),Non-P4P: 24 people (27.0%), P value = 0.001.LDL <100 mg / dl: 124 people, P4P: 97 people, Non-P4P: 27 people so the control is still based P4P well controlled LDL. A hospital clinics than any other self-care clinics in PACIC estimates and better patient satisfaction.
Conclusions and recommendations
With clinical biochemical parameters (HbA1C, LDL, ACR (microalbuminuria), the number of checks retina of the eye, foot inspection frequency, chronic illness self-care abilities and medical patient satisfaction, are shown in P4P (P4P) than non-P4P (Non-P4P) has a good situation. this showed diabetes participated in P4P has a positive effect in the future can suggest a policy reference.

並列關鍵字

diabetes ； P4P ； clinical effects ； self-care abilities ； medical Satisfaction

參考文獻

英文文獻

Bonomi, A. E., et al. (2002). "Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement." Health Serv Res 37(3): 791-820.

Chang, R.-E., et al. (2012). "A pay-for-performance program in Taiwan improved care for some diabetes patients, but doctors may have excluded sicker ones." Health Affairs 31(1): 93-102.

Ericson, D., et al. (1999). "Clinical evaluation of efficacy and safety of a new method for chemo–mechanical removal of caries." Caries Research 33(3): 171-177.

Escarce, J. J., et al. (2003). "Practice characteristics and HMO enrollee satisfaction with specialty care: an analysis of patients with glaucoma and diabetic retinopathy." Health services research 38(4): 1135-1155.