糖尿病論質計酬對醫療利用與照護成效之影響

The effect of the pay-for-performance program on diabetes patients’ medical utilization and disease outcome

冼裕程(Yu-Cheng Sheng)

指導教授 ： 陳美美

長榮大學/健康科學學院/醫務管理學系(所)/碩士(2011年)

https://doi.org/10.6833/CJCU.2011.00051

摘要

研究背景：
糖尿病為一種全球性的慢性疾病。在國內，糖尿病於2009年十大死因中高居第五位，也是常見的慢性疾病之一。有鑑於糖尿病照護不僅需藥物控制，更需飲食和運動的配合，因此健保局於2001年11月起推出以「糖尿病共同照護網」為基礎的「糖尿病論質計酬計劃」，期望藉由以病人為中心的疾病照護方式來提升我國糖尿病的照護品質。
研究目的：
本研究之目的有二。(一)探討參加與未參加論質計酬計畫的糖尿病患之醫療利用差異情況。(二)分析糖尿病論質計酬計畫對糖尿病患發生相關慢性併發症的影響，尤其是心血管併發症與腎臟併發症。
研究方法：
本研究採類實驗研究法，實驗組為參加糖尿病論質計酬之病患，對照組為未參加計畫的糖尿病患。研究架構採用Andersen的醫療服務利用模式。資料來源為國衛院全民健保研究資料庫之2005年承保抽樣歸人檔的2組資料。擇取2003~2007年間，可連續觀察，在地區醫院層級以上就醫，且有固定就醫地點之糖尿病患為研究對象。經篩選後實驗組有421人，對照組有1,123人。統計方法有t檢定、卡方檢定、複迴歸分析、羅吉斯迴歸分析、存活分析。
研究結果：
一、在控制各項因素下發現，參加糖尿病論質計酬者的年平均總醫療費用、門診費用、門診次數皆顯著的比未參加者高。年平均急診費用、急診次數、住院費用、住院次數雖比未參加者低，但無顯著差異。但參加者的年平均住院天數比未參加者低，且有顯著差異。此外，隨著觀察年數增加未參加者的年總醫療費用出現顯著成長，但參加者則沒有。
二、參加糖尿病論質計酬者比未參加者出現新的併發症的機率，出現的時間也顯著較晚。在開始觀察時為無合併症的糖尿病患者，參加論質計酬出現心血管併發症的時間顯著比未參加者晚；另外，出現腎臟併發症的時間也較未參加者晚，但無顯著差異。在開始觀察時已有心血管或腎臟合併症的糖尿病患，參加論質計酬後新出現腎臟併發症或新出現心血管併發症的時間會較未參加者來的晚，並達顯著差異。
結論：
參加論質計酬的糖尿病患雖會使用比較多的門診資源，有比較高的總醫療費用，但不會像未參加者隨著時間增加而增加年總醫療費用。從參加糖尿病論質計酬計畫者較不會出現併發症且出現時間也較晚的結果來看，糖尿病論質計酬所提供的照護方式帶來的效果比一般的照護方式來的好。

關鍵字

糖尿病 ； 論質計酬 ； 糖尿病醫療給付改善方案 ； 照護成效 ； 醫療利用

並列摘要

Background:
Diabetes is a global chronicle disease. In Taiwan, diabetes was found as the fifth common death cause in 2009, as well as a common chronicle disease. Given that diabetes care requires not only regular medication, but also the combination of diet and exercise, the Bureau of National Health Insurance (NHI) introduced the “Payment-For-Performance Program for Diabetes” based on the concept of “Diabetes Shared-Care System” in November, 2001, expecting to improve the quality of diabetes care in Taiwan through patient centered medical care.
Purpose:
This study contains two purposes: (1) to explore participation in the pay for performance program for diabetes on medical utilization of differences in diabetes patients and (2) to analyze the effect of pay for performance program for diabetes on diabetes patients' complications of diabetes occur. In particular cardiovascular and kidney complications.
Method:
This was a quasi-experimental study, in which the experimental group consisted of patients participating in the payment-for-performance program for diabetes while the control group of patients who did not. The research structure adopted Anderson’s behavior model of health service utilization. The data was extracted from the two groups of insured samples in 2005 in the database of the National Health Research Institute. The data between 2003 and 2007 was extracted for a continuous observation. Diabetes patients who sought medical services in a regular location of district hospitals or district hospitals upward were the research subjects. After selection, there were a total of 421 people in the experimental group and 1,123 people in the control group. The statistic methods included t-test, chi-square test, multiple regression analysis, logistic regression analysis and survival analysis.
Result:
1. When controlling various factors, it was found that the annual average total medical expense, expenditure on outpatient services and number of outpatient visits of patients participating in the payment-for-performance program for diabetes were significantly higher than patients who did not participate in the program. Their annual average expense for emergency treatments, number of visits of emergency treatments, expenditure on admission, and number of admission visits were lower than patients outside of the program but no significant difference was found. But the inpatient length of stay were significantly fewer in the participant than patients who did not participate. In addition, as the number of years of observation extended, the annual total medical expense significantly increased among patients who did not participate in the program.
2. Patients who participated in the payment-for-performance Program for diabetes were less likely to encounter new complications. If complications did occur, they often occur in a later period. Among patients who did not present any co-morbidity at the beginning of observation, individuals who participated in the program suffered from cardiovascular complications significantly later than individuals who did not. Furthermore, the former also experienced kidney complications later than the latter, even though no significant difference was found. Among diabetes patients who already experience cardiovascular or kidney co-morbidity, individuals in the program were likely to present a new kidney or cardiovascular complication later than individuals not in the program. The difference was significant.
Conclusion:
Although patients who participate in the payment-for-performance program for diabetes care utilize more resources of outpatient services and higher total medical expense, unlike patients who did not participate in the program, they do not increase the annual total medical expense by time. Concerning that patients who participate in the program are less likely to occurrence complications and only experience them in a later period if they do, the healthcare provided by the payment-for-performance program for diabetes indeed results in better effectiveness than other general healthcare methods.

並列關鍵字

diabetes ； pay-for-performance program for diabetes ； medical utilization ； disease outcome

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