臺灣博碩士論文加值系統

近年來健康差異議題逐漸受到注意，社經位置地位及種族在健康照護品質上的差異也大量被指出，消除社經位置與族群在健康照護的差異已成為各國政策推動的焦點。
糖尿病是全球的健康問題，全世界將近6%％的成人有糖尿病，回顧過去研究發現低社經位置地位的糖尿病人獲得較差的照護品質及健康結果。在過去探討個人或區域社經位置與健康之關係，僅在同一層次分析，較少同時探討個體與區域效果，且沒有處理資料具階層結構問題。
近年來使用多層次分析探討社經位置與健康研究有增多趨勢，使用多層次分析可以同時處理個人層次與區域層次在健康結果上的效果，也可以處理跨層次交互效果。但尚未有研究探討過不同層次社經位置的糖尿病人在健康照護品質及健康結果之差異，也尚未探討過區域醫療資源對不同社經位置糖尿病人與健康照護品質及健康結果之影響。
為了改善照護品質，越來越多國家健康照護系統採行論質計酬，即以財務誘因提供給醫療照護服務提供者，使其達到預先訂定品質目標，提供高品質之照護服務。而中央健保局在2001年11月開始實施五大疾病論質支付的醫療服務改善方案試辦計畫，糖尿病亦在其中。國內外研究大多證實論質計酬能提升品質，但有關論質計酬對健康不平等的影響，大多探討種族間的不平等，但結果尚無定論。然而，有效果的政策是否能使全民都提升達相同的照護品質，而提升照護品質後，是否能使全民的健康結果都變好？還是會因不同社經位置而有差異？或者是否會使不同社經位置糖尿病人的健康照護品質或健康結果的差距會變小呢？
本研究以多層次分析採回溯性縱貫研究，使用國衛院2005年健保歸人檔，研究對象針對1999-2004年糖尿病人進行追蹤，瞭解不同層次社經位置糖尿病人在健康照護品質與健康結果的差異，並探討區域醫療資源對不同社經位置糖尿病人與健康照護品質與健康結果關係之影響。另一研究對象針對2000-2005年新發生糖尿病人進行追蹤，探討論質計酬政策對不同層次社經位置糖尿病人與健康照護品質與健康結果關係之影響。研究設計為準實驗設計的僅為後測控制設計，觀察實驗組與控制組在糖尿病論質計酬方案介入後一年時間。
本研究樣本篩選每年至少2次門診主次診斷為糖尿病、或1次因糖尿病住院的為確診的糖尿病人，且有固定門診照護機構之病人。社經位置，包含區域社經位置，如所得與教育，與個人社經位置，如收入與職業，健康照護品質為照護過程品質盡責度，包含10項糖尿病必要之生理檢查，健康結果為照護結果，包括急診、及可避免住院。實驗組定義為2001年11月到2005年12月期間申報過三種論質計酬，且在同一機構完整照護一年以上。而在相同期間從來沒有申報過論質計酬個案即為控制組。由於論質計酬方案並非隨機分配，為了增加實驗組跟控制組的可比較性並減少選擇偏誤，控制組的選取係使用傾向分數配對。資料以SAS 9.13套裝軟體進行處理與除錯後進行統計分析，再使用HLM軟體進行多層次分析模型。
本研究發現有以下三點：
1.糖尿病人在個人社經位置的健康照護品質及健康結果存在不平等，區域社經位置則僅在糖尿病可避免住院結果有影響，存在區域社經位置之不平等。整體來看，個人社經位置在健康照護品質及健康結果不平等的效果較區域社經位置顯著，收入高的人其健康照護及健康結果較佳，而地區人口及低收入者的健康照護與健康結果較差。
2.區域醫療資源除了糖尿病可避免住院結果外，對於個人社經位置與健康照護品質或健康結果有跨層次的調節作用，醫療資源可用性有縮減不同職業糖尿病人在健康照護品質及健康結果之差距，但區域醫療人力與醫療設施的作用不同，醫療設施減弱地區人口及低收入者其獲得較低的照護盡責度，而醫療人力減弱地區人口者其較低可能發生糖尿病急診。
3.論質計酬僅對健康照護品質有正向影響，而論質對個人社經位置與健康照護品質及健康結果有影響，論質會縮減不同職業及收入糖尿病人在健康照護品質及健康結果之差距。
根據上述研究發現提出以下建議：
一、對政策的建議
1.建議政府仍應持續透過政策介入，來改善不同社經位置糖尿病人在健康照護及健康結果之不平等，如不同職業類別的糖尿病人，特別是軍榮民、地區人口、低收入者其健康較差，應設法了解其照護的需要。
2.建議強化糖尿病共同照護網的功能，特別是在糖尿病醫師數多、大型醫院數多的區域，透過基層醫師與醫院間的合作，來形成病人的照護網路，以病人為中心提供照護，減少病人發生急診的情形。
3.建議持續推動糖尿病論質計酬，並對於不同社經位置之糖尿病人特別是社經位置弱勢者，應監測其健康照護品質及健康結果，並將負向的健康結果如急診或可避免住院發生納入評估的指標。
二、對未來研究的建議
1.建議後續研究者進一步探討，不同職業類別糖尿病人其健康照護及健康結果較差的原因。
2.建議後續研究者可採用不同醫療資源變項，如新陳代謝專科醫師數與一般醫師數比、或每人口專科醫師數，來釐清醫療人力與個人社經位置與健康交互作用。
3.建議後續研究者進行長期追蹤研究，採用其他健康結果作為測量指標，如失明、洗腎或者死亡，進一步了解論質計酬對於長期健康的影響。

Diabetes is a global health problem, there are nearly 6%% of adults have diabetes in the world. Past studies found that low socio-economic position of people with diabetes obtain the poor quality of care and health outcomes. However, no study explored the different levels of socio-economic position simultaneously with diabetes patients in healthcare quality and health outcomes disparities, and there was no study had explored the impact of the regional health care resources on these disparities. The purpose of this article is to assess the inequities on healthcare quality and health outcomes for patients with diabetes mellitus with different levels of socio-economic position and to assess the impact of the regional health care resources on those inequities by using multi-level analysis.
The reform of payment policies by using quality and performance as the incentive mechanism to improve the quality of health care, also referred to as Pay-for-Performance (P4P), has become increasingly popular in the world. In 2001, the Bureau of National Health Insurance in Taiwan implemented a quality-based payment system or P4P program for five diseases, one of which was diabetes mellitus. Previous studies reported that positive results through improved performance and better outcomes. Some studies had explored the impacts of P4P on racial or ethnical disparities, but there was no study explored the impacts of P4P on socio-economic disparities. This article is the first one to assess the impact of P4P on socio-economic position inequities in healthcare quality and health outcomes for patients with diabetes mellitus.
This study used the Longitudinal Health Insurance Database 2005 (LHID2005), with a population–representative cohort of 1 million out of the 22.72 million National Health Insurance enrollees. The study had two population consisted of patients having a regular place of care diagnosed with DM between 1999 and 2004, and with new DM case between 2000 and 2005. The socio-economic position included two parts: one is neighborhood level incluing the average discretionary income each person of one year and the proportion of residents with a university degree, and the other is individual level including income and occupation. The healthcare quality is measuring process quality of care for diabetes mellitus patients. The P4P requestes 10 types of regular examinations for diabetes patients, such as HbA1c, lipid, and ophthalmoscopic etc. The healthcare outcomes constituted binary variables are measuring the utilization of an emergency or a preventable hospitalization.
The patients were divided into two groups: (1) the P4P group, who had received comprehensive care for at least one year between 2001 and 2005, (2) the control group, who were never enrolled in the diabetes mellitus pay-for-performance programs. Because the diabetes P4P program is voluntary for the health care providers, and providers are given the freedom to decide which patients to enroll in the program, we adopted the propensity score matching in this study. The P4P and the non-P4P groups were 1:4 matched using the greedy matching algorithm from an initial 8-digit to 1-digit. Statistical analyses were conducted using SAS statistical software, version 9.1 and HLM 6.08, and P < 0.05 was considered statistically significant.
There were three findings in this study:
1. There are individual socio-economics position inequities on healthcare quality and health outcomes of patients with diabetes mellitus. The inequitiesof neighborhood socio-economics position was only on health outcome of preventable hospitalization.
2. The regional health care resources had impacts on socio-economics position inequities in healthcare quality and health outcomes, except on emergency utilization.
3. The DM P4P can reduce the inequalities of socio-economics position on healthcare quality and health outcomes.
Based on the above findings, we have three recommendations:
1. The govement should have policies to improve the socio-economics position inequities, especially for the low socio-economics position patients with diabetes.
2. Continually promote the diabetes shared-care network, through cooperations between the physicians and hospitals to form a network to provide care for the diabetes patient and reduce the increase of emergency situations.
3. Continually execute the P4P program, and monitor the healthcare inequities for the low socio-economics position patients. The assess indicator should including negative health outcome such as emergency or preventable hospitalization.
We also have three suggestions for future research:
1.To explore the reasons why different occupation of patients have worse health outcome.
2.To use different medical resources, such as the number of metabolic specialist physician, to clarify the regional medical resources interaction effect between socio-economic position and health.
3.To conduct a long-term follow-up study using other health outcome indicators, such as blindness, kidney dialysis or death, to explore the long-term health outcome of the P4P program.

誌謝 I
中文摘要 II
ABSTRACT V
目錄 VIII
圖目錄 X
表目錄 XI
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第三節 研究問題 3
第四節 研究重要性 4
第五節 重要名詞解釋 4
第二章 文獻探討 5
第一節 健康不平等概念、定義與測量 5
第二節 糖尿病照護與評估 10
第三節 糖尿病人健康不平等架構及實證研究 20
第四節 多層次分析與實證研究 34
第五節 健康政策評估、論質計酬與實證研究 46
第六節 論質計酬對健康不平等之影響 63
第七節 文獻小結 69
第三章 研究方法 70
第一節 研究設計 70
第二節 研究架構 73
第三節 研究假說 74
第四節 研究對象及樣本 75
第五節 資料來源 76
第六節 研究變項定義及測量 79
第七節 資料處理流程 82
第八節 統計分析方法 86
第四章 研究結果 92
第一節 社經位置與糖尿病患之健康照護與健康之關係 92
第二節 區域資源對社經位置與糖尿病患之健康照護與健康關係之影響 105
第三節 論質對不同社經位置糖尿病患之健康照護品質與健康結果影響 113
第四節 研究結果綜合比較 123
第五章 討論 169
第一節 研究方法的討論 169
第二節 研究結果的討論 173
第三節 研究限制 183
第六章 結論與建議 185
第一節 結論 185
第二節 建議 186
參考文獻 187
附錄1：投保單位屬性分類表 198
附錄2：AHRQ 中與糖尿病有關PQI之條件範圍 199
附錄2：AHRQ 中與糖尿病有關PQI之條件範圍(續) 200
附錄2：AHRQ 中與糖尿病有關PQI之條件範圍(續) 201
附錄2：AHRQ 中與糖尿病有關PQI之條件範圍(續) 202
附錄3：ELIXHAUSER之共病 類別與ICD-9對照碼 203
附錄4：急診個案撈取代碼 205
附錄5：照護盡責度醫令撈取代碼 205
附錄6：糖尿病醫療給付方案修訂第三版 206
附件一：全民健康保險糖尿病醫療給付改善方案支付標準 209

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