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研究生:盧介祥
研究生(外文):Chieh-Hsiang Lu
論文名稱:醫院對於糖尿病病人照護之負責度(accountability)的研究----評估一地區醫院內糖尿病專科門診及一般門診照護之負責度與品質改善
論文名稱(外文):Hospital-based Accountability for Diabetes Care----Assessment of the Accountability and Quality Improvement in Two Different Settings within A Regional Hospital
指導教授:賴美淑賴美淑引用關係
指導教授(外文):Mei-Shu Lai
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:預防醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2002
畢業學年度:90
語文別:中文
論文頁數:70
中文關鍵詞:糖尿病負責度品質改善
外文關鍵詞:DiabetesAccountabilityQuality improvement
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由於盛行率和發生率的逐年增加,糖尿病已成為現階段主要的公共衛生課題。因糖尿病患者常會伴隨相關併發症,包括大血管病變(如心臟血管疾病、腦血管疾病、週邊血管疾病)、微血管病變(如視網膜病變、腎臟病變)及末梢神經病變。依流行病學三段五級的觀念,如果未能透過有效的篩檢和完整的治療模式,許多民眾在未被正確診斷和適當治療的情況下,容易造成相關併發症的發生及社會成本的增加。
此研究希望能從嘉義地區一家區域教學醫院的一般門診及糖尿病專科門診對於糖尿病病人照護的數量、方式、責任和品質著眼來探討醫院內的糖尿病照護現況,並藉此一研究來了解與現行糖尿病照護標準的差異,依此可以改善照護的過程和品質,並且可以提供在機構內評量照護負責度和品質的測量方法,以做為品質改善計畫的參考。
本研究顯示專科照護以HbA1c、血糖、尿液平均年檢查次數而言比一般科的檢驗平均次數多,且在統計學上達顯著差異;在年度受檢比例上則顯示專科照護負責度的表現在HbA1c、血脂肪、血壓及尿液的年度檢查比例比一般科比例多,在統計學上達顯著差異,專科照護已達到美國國家的水平(PRP研究),甚至超越(分別為99%Vs.87%; 73%Vs.47%; 94%Vs.92%; 68%Vs.54%),一般科照護除了血壓方面(80.7%Vs.92%)接近先進國家的水平外,其餘項目皆需要多加補強。在眼睛、足部、神經檢查的比例在兩科皆低於建議標準;在腎臟、血脂的檢驗方面則尚可符合標準;在血壓、尿液的測量方面專科的照護是合於標準但在一般科對於尿液檢驗部份則有待加強。整體而言專科照護對於病人照護負責度的表現較優。
在醫療照護結果品質改善部分中,在實驗室檢查追蹤表上可見,HbAlc、膽固醇、腎功能(Cr.)控制在不良的範圍者以一般科較多,且有統計上之顯著差異;專科病患住院平均次數以及住院比例明顯較一般科少(0.14Vs.0.41次/年); 糖尿病護照發放使用也較一般科顯著良好(34.0%Vs.4.6%)。
醫院管理機構以及醫療人員對於糖尿病照護之負責度都應採用以證據為基礎的計劃,提高對糖尿病高品質照護的機會,像美國糖尿病協會已發展出一套臨床建議,可幫助每個地區取得一致性的照護負責度準則以及持續性的品質指標改善計劃。雖然負責度與照護品質不一定成正相關,但良好的負責度卻是照護品質不可缺少的要件。
第一章 前言
研究緣起與動機
第二章 研究目的
第三章 文獻探討
第一節 糖尿病的流行病學
第二節 醫療照護與慢性併發症的實証醫學相關研究
第三節 糖尿病的醫療照護標準
第四節 糖尿病負責度(ACCOUNTABILITY) 的定義
第五節 糖尿病照護有關負責度之發展
第六節 糖尿病照護品質與負責度表現之評量
第七節 糖尿病照護品質的評估研究
第四章 研究方法
第一節 研究架構
第二節 研究基本假設
第三節 研究對象資料來源及處理
第四節 研究變項與操作
第五節 統計及分析方法
第五章 研究結果
第六章 討論
第一節 研究限制
第二節 研究結果之討論
第七章 結論與建議
第八章 參考文獻
第九章 表格與圖表
1. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence,numerical estimate, and projections. Diabetes Care 1998; 21: 1414-1431.
2. WHO Ad Hoc Diabetes Reporting Group, King H, Rewers M. Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults. Diabetes Care 1993; 16: 157-177.
3. Chou P., Li CL, Tsai ST, Epidemiology of type 2 diabetes in Taiwan, Diabetes Res Clin Pract 2001; 39(suppl.1): S29-S35.
4. Burke JP, Williams K, Gaskill SP, Hazuda HP, Haffner SM, Stern MP. Rapid rise in the incidence of type 2 diabetes from 1987 to 1996: results from the San Antonio Heart Study. Arch of Intern Med 1999; 159:1450-1456.
5. Diabetes Epidemiology Research Internationl Group, Geographic patterns of childhood insulin-dependent diabetes mellitus. Diabetes 1988;37: 1113-1119.
6. Tuomilehto J, Karvonen M, Pitkaniemi J, Virtala E, Klhtamaki K, Toivanen L. Tuomilehto-Wolf E. Record-high incidence of Type I (insulin-dependent) diabetes mellitus in Finnish children. The Finnish Childhood Type I Diabetes Registry Group, Diabetologia 1999;42:655-660.
7. Chuang LM, Tsai ST, Juang JH, Tsai WY, Tai TY. Genetic epidemiology of type I diabetes mellitus in Taiwan. Diabetes Res. Clin. Pract 2000;50(Suppl. 2):S41-S47.
8. 蔡世澤,臺灣糖尿病照護現況與省思。臨床醫學 民89;45:316-320。
9. Lin RS, Lee WC. Trends in mortality from diabetes mellitus in Taiwan, 1960-1988. Diabetologia 1992; 35: 973-979.
10. World Health Organization (WHO).Prevention of Diabetes Mellitus. In: WHO Technical Report Series No 844. Geneva: WHO1994.
11. Semenkovich CF, Heinecke JW. The mystery of diabetes and atherosclerosis: time for a new plot. Diabetes 1997; 46(3):327-334.
12. Panzram G. Mortality and survival in type 2 (non-insulin-dependent) diabetes mellitus. Diabetologia 1987; 30(3):123-131.
13. Meigs JB, Singer DE, Sullivan LM, Dukes KA, D''Agostino RB, Nathan DM, Wagner EH, Kaplan SH, Greenfield S. Metabolic control and prevalent cardiovascular disease in non-insulin-dependent diabetes mellitus (NIDDM): The NIDDM Patient Outcome Research Team. Am J Med 1997; 102(1):38-47.
14. Chen HH, Yen MF, Tung TH. A computer simulation model for cost-effectiveness analysis of mass screening for type 2 diabetes mellitus. Diabetes Res Clin Pract 2001; 39(suppl.1): S37-S42.
15. Lin T., Chou P., Lai MS, Tsai ST, Tai TY, Direct costs-of illness of patients with diabetes mellitus in Taiwan. Diabetes Res Clin Pract 2001; 39(suppl.1): S43-S46.
16. Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and the progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977-978
17. Ohkubo Y, Kishikawa H, Araki E, et al: Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin dependent diabetes mellitus: a randomized prospective 6 year study. Diabetes Res Clin Pract 1995; 28:103-117
18. UK Prospective Diabetes Study (UKPDS) Group: Intensive blood glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352:837-853
19. Stratton IM, Adler AI, Neil H, et al: Association of glycemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000; 321:405-412
20. Khaw K-T, Wareham N, Luber R, et al: Glycated hemoglobin, diabetes and mortality in men in Norfolk cohort of European Prospective Investigation of Cancer and Nutrition (EPIC Norfolk). BMJ 2001; 322:15-18
21. Adler AI, Stratton IM, Neil HA, et al: Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000; 321:394-395
22. Hansson L, Zanchotti A, Carruthers SG, et al, for the HOT Study Group: Effects of intensive blood pressure lowering and low dose aspirin in patients with hypertension: principle results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet 1998; 351:1755-1762
23. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med 1997; 157:2413-2446
24. Bell DSH: Should angiotensin-converting enzyme inhibitors be added to the water supply of patients with diabetes? Endocr Prac 2001; 7:59-63
25. Yusuf S, Sleight P, Pogue J: Effects of angiotensin-converting enzyme inhibitor, ramapril, on cardiovascular events in high-risk patients. Heart Outcomes Prevention Evaluation Study Investigators. [Published errata appear in New Engl J Med 2000 342:1376]. New Engl J Med 2000; 342:145-153
26. Pyorala K, Pedersen TR, Kjekshus J, et al: Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary artery disease. Diabetes Care 1997; 20:614-620
27. Goldberg RB, Mellies MJ, Sacks FM, et al: Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: subgroup analyses in the cholesterol and recurrent events (CARE) trial. The Care Investigators. Circulation 1998; 98:2513-2519
28. Rubins HB, Robins SJ, Collin D, et al, for the Veterans Affairs High Density Lipoprotein Cholesterol Intervention Trial Study Group: Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. N Engl J Med 1999; 34:410-418
29. Ovalle F, Bell DSH: Differing effects of thiazolidinediones on HDL subfractions, LDL subfractions, and Lp(a). Diabetes 2001; 50(suppl 2):A453-A461
30. George Steiner, et al, Effect of fenofibrate on progression of coronary-artery disease in type 2 diabetes: the Diabetes Atherosclerosis Intervention Study, A randomized study. Lancet 2001;357:905-910.
31. Haire-Joshu D, Glasgow RE, Tibbs TL: Smoking and diabetes (Technical Review). Diabetes Care 22:1887—1898, 1999
32. Stamler J, Vaccaro O, Neaton JD, Wentworth D, fro the Multiple Risk Factor Intervention Trial Research Group. Diabetes, other risk factors and12-year cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes care 1993;16:434-44
33. Franz MJ, Horton ED, Bantle JP, Beebe CA, Brunzell JD, Coulston AM, Henry RR, Hoogwerf BJ, Stacpoole PW: Nutrition principles for the management of diabetes and related complications (Technical Review). Diabetes Care 17:490—518, 1994
34. American Diabetes Association: Nutrition recommendations and principles for people with diabetes mellitus (Position Statement). Diabetes Care 24(Suppl. 1):S44—S47, 2001
35. Schafer R, Bohannon B, Franz MJ, Freeman J, Holmes A, McLaughlin S, Haas L, Kruger D, Lorenz R, McMahon M: Translation of the diabetes nutrition recommendations for health care institutions (Technical Review). Diabetes Care 20:96—105, 1997
36. Schneider SH, Ruderman NB: Exercise and NIDDM (Technical Review). Diabetes Care 13:785—789, 1990
37. Wasserman DH, Zinman B: Exercise in individuals with IDDM (Technical Review). Diabetes Care 17:924—937, 1994
38. American Diabetes Association: Diabetes and exercise: the risk-benefit profile. In The Health Professional’s Guide to Diabetes and Exercise. Devlin JT, Ruderman N, Eds. Alexandria, VA, American Diabetes Association, 1995, p. 3—4.
39. U.S. Department of Health and Human Services: Physical Activity and Health: A Report of the Surgeon General. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Washington, DC, U.S. Govt. Printing Office, 1996
40. Centers for Disease Control and Prevention and the American College of Sports Medicine: Physical activity and public health: a recommendation. JAMA 273:402—407, 1995
41. American College of Sports Medicine: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults (Position Statement). Med Sci Sports Exercise 22:265—274, 1990
42. Clement S: Diabetes self-management education (Technical Review). Diabetes Care 18:1204—1214, 1995
43. Funnell MM, Haas LB: National standards for diabetes self-management education programs (Technical Review). Diabetes Care 18:100—116, 1995
44. WHO Regional Office for Europe. Quali Care: quality management in health care in the information age. Programme of quality of care and technologies. Copenhagen, December 1997 (document).
45. Policy statement. Ottawa, Ontario: Canadian Hospital Association, 1989.
46. Donabedian A. The quality of care. How can it be assessed. JAm MedAssoc 1988; 260:1743-8.
47. WHO Regional Office for Europe. Continuous quality development: a proposed national policy. Copenhagen:WHO, 1993 (document EUR/ICP/CLR 059).
48. The DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of l ong-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86.
49. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837-53.
50. Deeb LC, Pettijohn FP, Shirah JK, Freeman G. Interventions among primary-care practitioners to improve care for preventable complications of diabetes. Diabetes Care 1988; 11: 275-80.
51. Kenny SI, Smith PT, Goldschmid MG et al. Survey of physician practice behaviors related to diabetes mellitus in the U.S. Physician adherence to consensus recommendations. Diabetes Care 1993; 16:1507-10.
52. Payne TH, Gabella BA, Michael SL et al. Preventive care in diabetes mellitus. Current practice in urban health-care system. Diabetes Care 1989; 12: 745-7.
53. American Diabetes Association: Clinical Practice Recommendations 2001 (Diabetes Care 2001; 24: S1-S132.)
54. Day P, Klein R. Accountabilities : Five Public Services. London : Tavistock Publications, 1987.
55. Vaughan B. Autonomy and accountability. Nursing Times 1989; 85: 84.
56. Moloney M. Professionalisation of Nursing. Philadelphia: Lippincott, 1986.
57. Dearlove J, Saunders P. Introduction to British Politics Cambridge: Polity Press,1987.
58. Barbara B, Greenfield S, Michael M et al. The Diabetes Quality Improvement Project. Diabetes Care 2001; 24(10):1815-20
59. Greenfield S, Kaplan SH, Kahn R et al. Profiling care provided by different groups of physicians: effects of patient case-mix(bias) and physician-level clustering on quality assessment results. Ann Intern Med. 2002;136
60. Harris MI. Racial and ethic differences in health insurance coverage for adults with diabetes. Diabetes Care 1999;22(10): 1679-82
61. Pincus T, Esther R, DeWalt DA, Callahan LF. Social conditions and self-management are more powerful determinants of health than access to care. Ann Intern Med 1998;129:406-11
62. Frances CD, Go AS, Dauterman KW et al. Outcome following acute myocardial infarction: are differences among physician specialties the result of quality of care ore case mix? Arch Intern Med 1999;159:1429-36
63. Rathore SS, Berger AK, Weinfurt KP et al. Race, sex, poverty, and the medical treatment of acute myocardial infarction in the elderly. Circulation 2000; 102:642-8
64. Benjamin EM, Schneider MS, Hinchey KT. Implementing practice guidelines for diabetes care using problem-based learning. A prospective controlled trial using firm systems. Diabetes Care 1999; 22(10):1672-8.
65. Miller CD, Phillips LW, Tate MK et al. Meeting American Diabetes Association Guidelines in Endocrinologist Practice.
66 Jinan B. Michael M. Gloria L. et al. A Diabetes Report Card for the United States : Quality of care in the 1990s Ann. Intern. Med. 2002;136:565-74
67 Fen-Yu Tseng Quality of medical care for noninsulin-dependent diabetic patients in a community teaching hospital in Taiwan J Formos Med. Assoc 1996;95:414-16
68 Madeleine Akel and Ghassan Hamadeh Quality of diabetes care in a university health center in Lebanon International Journal for Quality in Health Care 1999;2:517-521
69 World Health Organization. The Asia-Pacific Perspective: Redefining obesity and its treatment WHO: Geneva, 2000
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