論質計酬對糖尿病患低血糖而急診就醫之影響

The Impact of Pay-For-Performance (P4P) Program on Emergent Department Visits for Diabetic Hypoglycemia

余鴻彰(Hung-Cheng Yu)

指導教授 ： 龔佩珍 ； 蔡文正

亞洲大學/健康學院/健康管理研究所/碩士(2011年)

摘要

背景與目的：在糖尿病疾病管理中，積極血糖控制成為減少併發症之要務，卻易產生低血糖風險，而嚴重低血糖需要急診處置。臺灣自2001年開始實施糖尿病論質計酬方案(P4P)，此方案結合支付與品質監控指標，期能達到糖尿病患之整體性照護，低血糖管理即為其中要項。本研究探討論質計酬方案實施對糖尿病低血糖發生後急診就醫之影響。
研究方法：利用全民健保資料庫糖尿病特定主題檔，以1998-2009年中曾於365天內門診3次以上或住院1次以上之糖尿病患為研究對象。依據傾向分數配對法，將加入P4P者與未加入P4P者以1：1配對，兩組病患各285,060人，最後以Cox對比涉險模式，分析有無加入P4P方案，對糖尿病患者因低血糖而至急診就醫之風險。
結果：從配對之兩組病患篩選出共6,433位糖尿病患因低血糖至急診就醫。加入P4P者有4,198(1.47%)人，未加入者2235(0.78%)人。由Cox對比涉險模式顯示，有加入P4P之HR為1.7 (95% CI: 1.63-1.80)，再與其他危險因子作調整後HR為1.5 (95% CI: 1.41-1.59)，風險仍較無加入者高。其他發生低血糖風險較高者為第1型糖尿病患，女性，年齡小於25歲或大於64歲，投保金額愈低，投保地區都市化程度愈低。CCI分數愈高風險愈高，5分以上之adjusted HR為2.11(95%CI: 1.92-2.33)；併發症嚴重度DSCI分數愈高風險愈高，3分以上之adjusted HR為2.09 (95%CI: 1.92-2.28)；主要就醫機構在醫學中心，發生低血糖而急診之風險較基層診所為大；就醫於非公立醫院，發生風險較公立高；糖尿病患主要就醫機構服務量高，或主要治療醫師服務量高，發生低血糖而急診之風險亦高。
結論與建議：根據上述結果建議應持續鼓勵P4P參與方案，加入後須注意低血糖風險，以避免急診就醫。

關鍵字

論質計酬 ； 糖尿病 ； 低血糖 ； 急診就醫

並列摘要

Background & objectives：In disease management of diabetes, intensive glycemic control aims to prevent or delay the diabetic complications. But the threat of diabetic hypoglycemia often increases with the intensive glycemic control, it becomes a barrier of glycemic control and management. The severe episodes may require the emergency care visits. Since 2001, Taiwan has begun the implementation of Diabetes Mellitus Pay-for-performance (P4P) program that rewarded providers based on outcome-based performance to achieve the total quality care of patients with diabetes. Prevention and education of hypoglycemia is one of key elements of the program. We explore the impact of pay-for-performance programs on diabetic hypoglycemia in this study.
Methods：The retrospective longitudinal study utilizes data from Taiwan National Health Insurance Research database focusing on diabetes mellitus collected during 1998-2009. If the subjects in database meet the criteria of at least one hospital admission with a diagnostic ICD-9-CM code of diabetes or three or more outpatient visits with a diabetes diagnostic ICD-9-CM code within 365 days, we included them as the study sample in the analysis. Using propensity score for 1:1 matching, we selected the P4P and non- P4P patients by matching their characteristics and covariates related to the probability of their participation in the program. Subsequently, we use Cox proportional hazard model to analyze the different risk of diabetic hypoglycemia with emergency department visit between the P4P and non- P4P patients.
Results：From the matched group included the P4P and non-P4P patients, we screened a total of 6,433 diabetic patients with severe hypoglycemia and ED visit. Of those, 4,198 (1.47%) were P4P patients and 2,235 (0.78%) were non-P4P patients. The results showed the hazard ratio of P4P patients was 1.7 (95% CI: 1.63-1.80), and after adjusted for other covariates, the hazard ratio was 1.5 (95% CI: 1.41-1.59). The risk of severe hypoglycemia with ED visits was higher in the P4P patients. Other variables such as patient characteristics including female, younger than 25 years old or more than 64 years old, lower premium-based salary, lower urbanization, and Type 1 diabetes have a significant hazard ratio for higher risk of severe hypoglycemia with ED visits. Besides, the Charlson comorbidity index could predict the risk of severe hypoglycemia. As the CCI > 5, the adjusted HR was 2.11 (95% CI: 1.92-2.33); the diabetes severity complication index also could predict the risk. As the DSCI>3, the adjusted HR was 2.09 (95% CI: 1.92-2.28); If the subjects were treated mostly in tertiary hospitals or non-public hospitals, the risk was significantly higher than clinics or public hospitals. Besides, if the subjects were treated mostly in the medical institution or physician with large of diabetes service volume, the risk was also higher than those in lower service volume.
Conclusions：We should encourage the non-P4P diabetic patient to participation in the program. After participation, the risk of severe hypoglycemia should be notified and avoided.

並列關鍵字

Pay-For-Performance ； Emergency Department visit ； Hypoglycemia ； Diabetes Mellitus

參考文獻

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