糖尿病醫療給付改善方案長期介入成效與影響因子之探討

The Long-term Effectiveness and its Determinants of Diabetes Shared-Care Program of an Area Hospital in Taiwan

葉素吟(Su-Yin Yeh)

指導教授 ： 蔡仲弘

亞洲大學/健康學院/長期照護研究所在職專班/碩士(2010年)

摘要

研究背景與目的：「糖尿病醫療給付改善方案」自2001至今已行之有年。研究顯示照護成效常因照護時間長而遞減。如何維持長期的照護成效為熱門且重要的議題。故本研究目的在瞭解地區醫院門診糖尿病患者接受「糖尿病醫療給付改善方案」介入後之長期照護成效，並探討影響血糖控制成效之因素。本研究的長期日標是研擬如何建立品質導向的衛教模式。
方法：本研究採立意取樣，以回溯病例方法分析中部某地區醫院2004年至2008年164位收案滿四年個案之資料。依初診斷(新案43人)與非新診斷(轉入案121人)兩類加以分析。以配對樣本t檢定分析各年間淨差異之顯著性；獨立樣本t檢定分析各年度個案生理及生化檢驗指標變化之關係；以二元邏輯迴歸分析影響個案糖化血色素改變之因素。
結果：糖化血色素第一年新案與轉入案分別下降0.9% (p<0.01)及0.3%；第二年增加0.3% (p<0.05)及0.2%第三年增加0.2%及下降0.1%；第四年下降0.7% (p<0.01)及0.1%。第四年兩組間之淨變值有顯著差異(p<0.01)。不吸菸、有自我監測血糖、身體質量指數≤24為介入第一年糖化血色素下降之影響因子(p<0.05)。無腹部肥胖及遵從醫囑則為四年之控制成效顯著影響因子(p=0.05)。新案與轉入案第一年收縮壓分別下降2.3及3.5 mmHg (p<0.05)；第四年下降3.4及3.3 mmHg (p<0.05)。第一年舒張壓分別下降3.0及3.1mmHg (p<0.01)；第
四年分別下降4.3 mmHg (p<0.05)及3.1 mmHg (p<0.01)。
結論：結果顯示糖尿病醫療給付改善方案之實施無論對新診斷的個案或轉入的續案的糖化血色素皆有顯著長期的成效。避免腹部肥胖及遵從醫囑為維持長期成效的主要因子。此研究顯示糖尿病醫療給付改善方案値得繼續推行。納入「糖尿病醫療給付改善方案」收案追蹤管理至少需執行三年以上得收較大的成效。

關鍵字

糖尿病 ； 糖化血色素 ； 糖尿病醫療給付改善方案

並列摘要

Background and objectives: "Diabetes shared-care program" has been implemented in Taiwan since 2001 but its effectiveness on glycemic control generally diminishes with time. How to maintain the effectiveness has become a pivotal issue in diabetes care. Hence, this study aimed to examine the long-term effectiveness of the shared-care program and the factors impacting the effectiveness of the program in diabetic patients.
Methods: The study analyzed the longitudinal data of 164 patients who enrolled in a diabetes shared-care program of an area hospital in Central Taiwan during 2004-2008. Subjects were classified according to whether one is a new diagnosis and a continuing (transferred) case. Blood glycated hemoglobin (HbA1C) was used as the major indicator of glycemic control. Regression analysis was performed to determine the factors associated with or that impact HbA1C or other parameters in these patients.
Results: HbA1C decreased 0.9% (p<0.01) and 0.3% from the baseline during the first year; and increased 0.3% (p<0.05) and 0.2% during the second year; increased 0.2% and 0.1% during the third year; and then decreased 0.7% (p<0/01) and 0.1% during the fourth year from the end of each prior year for new and transferred cases, respectively. Fasting blood glucose reduced 12.4 (p<0.05) and 10.0 mg/dL during the four-year period for new cases and transferred cases, respectively. Systolic blood pressure reduced 3.4 and 3.3 mmHg and diastolic reduced 4.3 and 3.1 mmHg for new and transferred cases, respectively. Non-smoking, self-monitoring of blood glucose levels and lower BMI (<24 kg/m2) were the factors associated with the decrease in HbA1C during the first year whereas no abdominal obesity and adhering to the treatment plan were the factors associated with the decrease during the fourth year.
Conclusion: Results indicate the diabetes shared-care program can reduce HbA1C 4 years after joining the program. However, the program can also prevent upward-rebound of HbA1C in transferred cases. Preventing central obesity and adhering to the treatment plans appear to be the major factors preventing the glycemic rebound. These results suggest that effective nutrition and lifestyle education is probably the key in extending the beneficial effects of the program.

並列關鍵字

Glycated hemoglobin ； Diabetes shared-care program ； Diabetes ； Nutrition education

參考文獻

賴美淑、邱淑媞(2002)：糖尿病共同照護之概念與內涵。台灣醫學，64(4)：560-568.

郭淑娟、陳重榮、梁深維(2005)：門診糖尿病病患個案管理照護之成效。

郝立智、趙海倫、簡崇仁、楊純宜、林興中、李振堃、奚明德、葛光中、柴國樑、鄭錦翔(2007)：某地區教學醫院糖尿病門診病患個案管理照護之成效探討。中華民國內分泌暨糖尿病學會刊，20(4)：11-33.

陳聲平、王德芳、余振興、蘇忠仁(2009).第二型糖尿病團隊照護的介入成效探討—以家醫科門診實施兩年為例。中華職業醫學雜誌 16(1)：55-64

翁瑞亨、徐瑞祥、謝玉娟(2002).台灣地區糖尿病共同照護網現況。台灣醫學，6(4)：569-573.