探討台灣第二型糖尿病病人的眼科醫療服務未被滿足的需求-以糖尿病視網膜病變為例

背景：第2型糖尿病發生率逐年在增加，控制不良的糖尿病病人易併發視網膜病變，包括初期的非增殖性糖尿病視網膜病變和危及視力的增殖性糖尿病視網膜病變、黃斑部水腫、甚或衍生出具破壞性的併發症如玻璃體出血、牽引性視網膜剝離，最後可能到末期的新生血管性青光眼及眼盲。糖尿病視網膜病變已成為成年人失明的首要原因。然而透過早期檢查、早期治療可以降低50%以上的失明率，因此糖尿病病人未定期檢查、未早期治療網膜病變以致於進展成視力喪失或眼盲被視為是未被滿足的需求。每年眼底篩檢為照護品質指標之一，但最容易被忽略，根據健保署醫療品資訊公開的資料，至2012年為止，相較於其他指標，糖尿病病人眼底檢查率仍未達1/3，且近十年執行率增加幅度不若其他指標。文獻上，年度眼底篩檢遵從度與糖尿病視網膜病變及視力喪失的大型資料庫研究仍相當缺乏，相關因素仍無清楚的評估。另外，發生增殖性糖尿病視網膜病變或玻璃體出血等併發症後，全網膜雷射光凝固或玻璃體切除術可能預防疾病進展成眼盲，但是這種治療上的需求，仍可能未能及時提供，因此本研究亦包括這些未被滿足的需求和其相關性研究。目的：探討台灣第2型糖尿病用藥之病人，每年眼底篩檢遵從度、及時全網膜雷射光凝固施行率、玻璃體切除術與糖尿病視網膜病變程度、眼盲的相關性，從而了解這類病人未被滿足的眼科醫療服務的需求狀況。材料與方法: 本研究為世代長期追蹤研究，資料來源為國家衛生研究院全民健保資料庫2000-2013年百萬抽樣歸人檔，以2002-2007年新診斷的糖尿病病人，且為20-80歲的第2型糖尿病用藥之病人為研究對象。群體一為初發第2型糖尿病用藥之病人，研究重點是年度眼底篩檢遵從度;群體二為初發增殖性糖尿病視網膜病變的第2型糖尿病病人，研究重點是全網膜雷射光凝固施行率;群體三為初發玻璃體出血或牽引性網膜剝離的第2型糖尿病病人，研究重點是玻璃體切除術施行率。追蹤至2013年，主要結果為眼盲，群體一另有次要結果,為非增殖性糖尿病視網膜病變、增殖性糖尿病視網膜病變、黃斑部水腫及併發症。分析方法為Kaplan-Meier方法與Cox比例風險模型和羅吉斯迴歸。結果: 群體一、二、三各有28,087、2,423、1,782位病人，平均年齡為55.1 (+- 12.1)、56.6 (+- 10.3)、54.4 (+- 11.9)歲，中位追蹤時間為108.8、106.5、106.1個月。在追蹤時間內，百分之36初發第2型糖尿病用藥病人從未接受眼底檢查;百分之23的病人也只曾接受過一個年度的眼底檢查;有百分之22的初發增殖性糖尿病視網膜病變的第2型糖尿病病人未曾接受全網膜雷射治療;有百分之36的初發玻璃體出血或牽引性網膜剝離的第2型糖尿病病人曾接受玻璃體切除術治療。初發增殖性糖尿病視網膜病變的第2型糖尿病病人接受全網膜雷射治療會降低百分之42失明低視力風險[風險比(hazard ratio, HR): 0.58, 95%信賴區間(confidence interval, CI): 0.42 - 0.79, P < 0.001]。玻璃體切除術降低失明低視力的風險不顯著(風險比: 0.76, 95%信賴區間: 0.52 - 1.12, P = 0.169)。在群體一，初發第2型糖尿病病人診斷後，每年年度眼底檢查率越高，被診斷出糖尿病視網膜病變及失明或低視力的機率越高，從未接受眼底檢查的顯著危險因子為年齡大於60歲(邊際顯著)、高血壓、糖尿病併發症嚴重程度指數(Diabetes Complications Severity Index, DCSI)分數較低者、(糖尿病主要治療院所)區域醫院、地區醫院/診所、私立醫院、(糖尿病主要治療院所)在南台灣、少用口服降血糖藥者、沒有用或少用口服降血脂藥者。相反地，較晚診斷糖尿病者、低收入者、(糖尿病主要治療院所)在中或東台灣、併有其他眼睛狀態(如在眼科追蹤的青光眼、高度近視、白內障手術後)者、加入糖尿病論質計酬方案一年以上者、屬於山地離島地區計劃、使用胰島素注射者會比較容易接受眼底檢查。在群體二，年紀大於60歲的人，併有青光眼，沒有用降血脂藥物的人，較少接受全網膜雷射治療;低收入者(邊際顯著)、眼科主要治療院所在南台灣或東台灣、使用胰島素者、接受過玻璃體內注射/Lucentis@者，較多接受全網膜雷射治療。另外，在群體一、二、三的男性病人，及在群體二、三的二十到四十歲病人，其失明低視力風險皆增高。結論: 初發第2型糖尿病病人眼底檢查明顯不足，不利糖尿病視網膜病變的診斷。雖然全網膜雷射可以明顯降低失明低視力比率，患有增殖性糖尿病視網膜病變的第2型糖尿病病人應接受全網膜雷射治療而未接受的比率仍高，眼底檢查及全網膜雷射的眼科醫療服務需求，有地理上的差異，應設法改善。年輕的病人需依建議，適時檢查和早期治療，避免工作能力降低。建議: 鼓勵醫師與其病人參與糖尿病論質計酬方案，可以有效改善眼底檢查不足情形。

關鍵字

糖尿病視網膜病變；玻璃體出血；視網膜剝離；年度眼底檢查；全網膜雷射光凝固；玻璃體切除術；眼盲

並列摘要

Background: Diabetic retinopathy remains the leading cause of legal blindness in adults as incidence of type 2 diabetes is increasing over time. Patients with uncontrolled blood sugar frequently suffer from complications of diabetic retinopathy, such as early stage non-proliferative diabetic retinopathy (NPDR), vision-threatening proliferative diabetic retinopathy (PDR), diabetic macular edema (DME) and more devastating PDR complications as vitreous hemorrhage (VH), tractional retinal detachment (tRD), to end-stage neovascular glaucoma and even blindness. Nevertheless, through early screening and early treatment of diabetic retinopathy, it is probable to reduce the risk of visual loss by more than 50 %. Unmet ophthalmic needs ensue when such care not be delivered to diabetic patients and may lead to vision loss or blindness. Annual ocular fundus examination is considered as one of the indicators of diabetic care but is the one most easily be ignored. According to administrative report, ocular fundus examination rate was less than 1/3 as of 2012 compared to other indicators, and the increasing trend was lower than those of other indicators in the recent decade. In addition, once PDR or PDR complications occur, panretinal photocoagulation (PRP) or vitrectomy may prevent disease progression to blindness/low vision, but such kind of need of treatment may not be provided. Thus, we investigated these aspects of unmet ophthalmic needs and evaluated the risk factors. Objective: The study aimed to evaluate adherence of annual fundus examination, timely PRP rate, vitrectomy and their associations with blindness/low vision in type 2 diabetic patients with medication and to investigate risk factors of unmet ophthalmic needs (i.e. non-receipt of fundus examination, non-receipt of PRP). Materials and methods: This design was a longitudinal cohort study. Study subjects were diabetic patients and information of their healthcare utilization was derived from the longitudinal claims data (2000 – 2013) of the National Health Insurance Research Database, which included a random sample of 1 million people from all insured beneficiaries. From outpatient and inpatient claims of the Research Database, we identified patients who were newly diagnosed with diabetes between January, 2002 and December, 2007. Inclusion criteria included type 2 diabetes and aged between 20 and 80 years. Cohort 1 referred to newly diagnosed type 2 diabetic patients with medication and focused on adherence of annual fundus examination; cohort 2 referred to newly diagnosed PDR in type 2 diabetic patients regarding PRP; cohort 3 referred to newly diagnosed VH, tRD in type 2 diabetic patients regarding vitrectomy. The outcomes were followed till the end of 2013.The primary end point was blindness/low vision in cohorts 1 - 3. Secondary end points were NPDR, PDR, DME and PDR complications in cohort 1. Statistical analyses were conducted via Kaplan-Meier method, Cox proportional hazards model and multivariate logistic regression. Results: There were 28,087 (cohort 1), 2,423 (cohort 2) and 1,782 (cohort 3) patients who fulfilled the inclusion criteria and were eligible for this study. Mean age was 55.1 (+- 12.1), 56.6 (+- 10.3) and 54.4 (+- 11.9) years for cohorts 1, 2 and 3, respectively. Median follow-up was 108.8, 106.5 and 106.1 months for cohorts 1, 2 and 3, respectively. In cohort 1, 36% of newly diagnosed type 2 diabetic patients never received annual fundus examination. Besides, 23% of cohort 1 received annual fundus examination for only once. In cohort 2, 22% of patients with newly diagnosed PDR never underwent PRP. There were 36% (cohort 3) of patients with newly diagnosed VH/tRD underwent vitrectomy. Multivariate Cox proportional hazards model showed PRP was a significant prognostic factor [hazard ratio (HR): 0.58, 95% confidence interval (CI): 0.42 - 0.79, P < 0.001], while vitrectomy was insignificant prognostic factor (HR: 0.76, 95% CI: 0.52 - 1.12, P = 0.169) for blindness/low vision in cohorts 2 and 3, respectively. For patients of cohort 1, annual fundus examination did not reveal its protective role in multivariate Cox proportional hazards model. Significant risk factors for non-receipt of fundus examination after diabetic diagnosis in patients with newly diagnosed type 2 diabetes were aged over 60 years (marginal), hypertension, lower Diabetes Complications Severity Index (DCSI) score, diabetic care facilities belonged to regional hospital, district hospital/clinics, proprietary hospital, diabetic care facilities located in southern Taiwan, less use of oral hypoglycemic agent, less or no use of statin/fibrate. Conversely, factors including recent diabetic diagnostic year, lower income, diabetic care facilities located in central/eastern Taiwan, coexisted with ophthalmic conditions, diabetes mellitus – pay-for-performance (DM-P4P) participation >= 1 year, user of integrated delivery system (IDS) program, and insulin use were at lower risk for never receiving fundus examination after diabetic diagnosis. Significant factors associated with non-receipt of PRP in newly diagnosed PDR patients with type 2 diabetes in cohort 2 were aged >= 60 years, glaucoma, non-user of statin/fibrate. Factors as low income (marginal), eye care facilities located in southern or eastern Taiwan, use of insulin and intravitreal injection/Lucentis® were associated with lower risk of non-receipt of PRP. Male patients in cohorts 1, 2 and 3, younger patients (< 40 years) in cohorts 2 and 3 were associated with higher risk of blindness/low vision. Conclusions: Rate of annual fundus examination was still low in patients with newly diagnosed type 2 diabetes. Although PRP might reduce risk of blindness/low vision, there was considerable proportion of non-receipt of PRP in patients with newly diagnosed PDR. Existence of geographic differences in the provision of ophthalmic needs of ocular fundus examination and PRP treatment should be ameliorated. Younger patients with type 2 diabetes should undergo appropriate examination and treatment if necessary, to avoid loss of vision and working ability. Suggestion: Encouraging patients and related physicians to participate DM-P4P program may decrease this unmet ophthalmic need.

並列關鍵字

diabetic retinopathy ； vitreous hemorrhage ； retinal detachment ； annual fundus examination ； panretinal photocoagulation ； vitrectomy ； blindness

參考文獻

Hsu YJ, Hsieh YT, Yeh PT, Huang JY, Yang CM (2014) Combined tractional and rhegmatogenous retinal detachment in proliferative diabetic retinopathy in the anti-VEGF era. J Ophthalmol 2014:917375 doi:10.1155/2014/917375

Park YG, Kim EY, Roh YJ (2014) Laser-based strategies to treat diabetic macular edema: history and new promising therapies. J Ophthalmol 2014:769213 doi:10.1155/2014/769213

Kimoto K, Kubota T (2012) Anti-VEGF agents for ocular angiogenesis and vascular permeability. J Ophthalmol 2012:852183 doi:10.1155/2012/852183

Kovach JL, Schwartz SG, Flynn HW, Jr., Scott IU (2012) Anti-VEGF treatment strategies for wet AMD. J Ophthalmol 2012:786870 doi:10.1155/2012/786870

Pollreisz A, Schmidt-Erfurth U (2010) Diabetic cataract-pathogenesis, epidemiology and treatment. J Ophthalmol 2010:608751 doi:10.1155/2010/608751

國際替代計量

探討台灣第二型糖尿病病人的眼科醫療服務未被滿足的需求-以糖尿病視網膜病變為例

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