糖尿病醫療給付改善方案之醫療盡責度與照護結果之相關性

The relationship between medical accountability and clinical outcome of diabetes care

張祺玩(chi-wan chang)

指導教授 ： 陳金淵

長榮大學/健康科學學院/醫務管理學研究所/碩士(2010年)

https://doi.org/10.6833/CJCU.2010.00005

摘要

目的 健保局於2001年11月開始推行「糖尿病醫療給付改善方案試辦計畫」，並於2006年8月修訂時增加品質獎勵措施，朝向「提昇糖尿病治療指引遵循率、建立品質導向之支付制度」的照護目標邁進。惟在諸多相關研究中，仍以病患之遵循度為主，鮮少針對醫師在專業責任的部份進行探討。因此，本研究將分析比較醫師在糖尿病醫療改善方案之醫療盡責度及初步照護結果生理指標有無差異，並進一步探討兩者間之相關性，以提供主管部門或醫療提供者作為相關方案推行與改進時之參考。
方法 蒐集雲嘉南地區2006年1月至2009年4月期間參加該方案之新收案且完成第一次年度評估並符合歸屬主要照護醫師之病患為研究對象，合計醫師124位、病患6,148位。擷取門診醫療費用申報檔和糖尿病患VPN個案登錄系統之數值為資料來源，進行次級資料分析。所得資料使用SPSS統計軟體進行變異數分析及相關性檢測，另使用複迴歸及羅吉斯迴歸等分析模式探討照護結果生理指標之影響因素。
結果 病患在新收案及完成第一次年度評估時生理指標前後之變化，舒張壓、三酸甘油脂、醣化血色素及低密度脂蛋白皆呈現下降改善量（p＜0.05）。醫師歸戶後，醫師不同屬性在盡責度有顯著差異者（p＜0.05），在看診次數方面，地區醫院大於基層診所及區域醫院；在衛教追蹤次數方面，基層診所大於地區醫院；在醣化血色素檢驗次數方面，內科大於其他專科及同時具有內科、家醫科者，年齡與其呈現負相關。舒張壓前後平均變化量與醫師執行膽固醇、三酸甘油脂、高或低密度脂蛋白檢驗次數呈現正相關且達顯著性，低密度脂蛋白平均變化量以及血壓、低密度脂蛋白改善率與完成年度評估時間呈現正相關。複迴歸模式顯示，不論在前後變化量或改善率方面，只有低密度脂蛋白值整體的解釋力達到統計上顯著性；醣化血色素不良改善率整體解釋力達到統計顯著水準。羅吉斯迴歸模式得知，生理指標改善與否大多受到機構層級、醫師及病患因素等影響。
結論與建議 「糖尿病醫療給付改善方案」參與醫師之醫療盡責度在看診次數、衛教追蹤次數、醣化血色素檢驗次數項目存在顯著差異性；其次，醫療盡責度與生理指標變化也存在顯著相關。醫學之專業知識日益發展，建議參加方案之醫療人員執行繼續教育學分及訓練，以促進照護之醫療品質。論質計酬看的是長期的影響，對未來研究者建議蒐集更長期的資料及指標使研究更臻完善。

關鍵字

糖尿病 ； 糖尿病醫療給付改善方案 ； 盡責度

並列摘要

The relationship between medical accountability and clinical outcome of diabetes care

Objective The Bureau of National Health Insurance (BNHI) initiated Diabetes Quality-based Payment Initiative (DQBPI) in November, 2001, and included incentive plans in the amendment released in August, 2006, with the objectives of enhancing physicians’ accountability for diabetes care, and of establishing a performance-based payment system. However, relevant research still largely focused on patients’ compliance rather than physicians’ professional accountability. This study aims to examine the relationship between physicians’ accountability and patients’ outcome indicators of diabetes care. The results will be expected to serve as reference for the authorities or healthcare providers in future development of relevant programs.

Methods This study used secondary data extracted from the BNHI database for analysis. New enrollees in the project who have completed their first annual assessment in the BNHI South Division from January 2006 to April 2009 were selected as research subjects; in total there were 6,148 patients and 124 physicians retained in this study. We collected data from outpatients’ claims files and the diabetics’ VPN case management system. Statistical software SPSS was used for analysis of variance and correlation and multiple regression analyses and logistic regression modeling were conducted to test the predictive power of factors associated with clinical outcome.

Results The results show that significant improvement occurred in patients’ clinical outcomes of diastolic blood pressure, triglycerides, HbA1c, and LDL between the onset and the completion of first annual assessment (p<0.05). Physicians with different attributes demonstrated significant differences in the level of medical accountability (p <0.05). As for the number of visit, district hospitals had larger number than clinics and regional hospitals; on the frequency of health education, clinics were larger than district hospitals; on the frequency of HbA1c test, internal medicine physicians conducted more times than other specialists. While age was negatively correlated with HbA1c, patients’ average differentials in diastolic blood pressure showed a significant positive correlation with physicians’ frequency of cholesterol, triglycerides, and high- or low-density lipoprotein examinations. Positive correlations were also found between patients’ average change of LDL as well as improvement rates in BP and LDL, and their completion time of first annual assessment. Multiple regression models showed that in terms of quantity variations or improvement rates, only LDL model reached statistical significance while the improvement rate of poor HbA1c reached statistical significance. The logistic regression model suggested that the improvement of clinical outcomes were significantly predicted by the level of hospital, physicians’ and patients’ characteristics. In the meantime, the degree of HbA1c improvement was found higher for metabolic specialist than internal medicine or family practice physicians.

Discussion and Conclusion Physicians who participated in DQBPI project revealed significant variations on the number of visit, follow-up of health education and frequency of HbA1c test; the degree of variation differs between variables. In addition, a significant correlation was found between physicians’ medical accountability and clinical outcome. We suggest that further professional education and training with regards to diabetes care should be provided for physicians other than metabolic specialists so to improve patients’ HbA1c values.

並列關鍵字

diabetes ； diabetic quality-based payment initiative (DQBPI) ； accountability

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