臺灣博碩士論文加值系統

摘要
由於糖尿病罹患人數增加，不但盛行率及發生率都逐年增加，還是高遺傳性的疾病。尤其是伴隨的合併症所產生的高費用，已經造成醫療費用嚴重的負擔。自民國90年中央健保局藉以實施以疾病管理為依據，實施糖尿病醫療服務改善方案試辦計畫，來解決糖尿病所製造高費用的問題，同時也希望藉由運用實證醫學，作為提供糖尿病照護的規範，及提供高品質的護理，本研究目的在於探討在實施糖尿病醫療服務改善方案試辦計畫下，是否能改善糖尿病的臨床數值和得到適當的控制，及減少醫療費用的支出。期望能對未來的糖尿病疾病管理決策施針，有參考的價值。
本研究採前後測比較設計，使用糖尿病醫療服務改善方案試辦計畫為依據，適用對象為經診斷是糖尿病(ICD-9CM碼為250) 之病人，並領有衛生署版之「糖尿病護照」者，研究取樣的時間為自92年1月至12月，蒐集264位病人的兩年醫療費用的紀錄，以作醫療資源的利用比較分析。樣本為在本院所的新陳代謝科初診的病人1110人，取樣的樣本中，以女性患者居多，與國內盛行率及發生率相似，省籍及族群並無呈現不同罹患率，51.6%病人具高血壓及46.5%有高脂血症，僅有3.7%有腦血管病變。在自我檢查中，有自行檢查血糖僅有19.1%，有自行檢查血壓有30.3%，同時有自行檢查血糖及血壓僅有15.68%。在年度的定期檢查中，接受眼底鏡檢有83.7%，尿液微量白蛋白檢查有45.8%，足部檢查有97.5%。在年度的檢查中HbA1c，血壓，及血脂檢查則高達 75%。以上。以 pair t 檢定作分析則只有HDL（高密度膽固醇）有顯著的改善，BMI則反而增加。每人年度的門診費用、次數則呈現顯著的減少。
目前在糖尿病病患在本院所接受糖尿病照護雖有明顯的改善，但離專家所建議的糖尿病照護標準仍有一段的距離，尤其病人對臨床的定期的檢查的遵循度仍待加強，血糖及血壓自我檢查仍需督促，由於糖尿病罹患人數增加，尤其是伴隨的合併症所產生的高費用，已經造成醫療費用嚴重的負擔。故短期的醫療費用在初期管理照護下，很難達到成效，但是透過管理照護下，糖尿病及其合併症的篩檢率會因此增加，合併症的預防效果也愈好，在疾病管理下，未來醫療費用的減少仍然是可預期的。

Abstract
Objective:
At the end of 2001, The Bureau of the National Health Insurance (BNHI) had been broadly applicable to disease management setting to develop the medical service improvement program for diabetes. By developing the standards of the treatment direction, sharing of medical information, and the model of the application in long-term disease management, the program can promote the quality of caring and effectiveness of the treatment in reasonable medical resource environment. The objective of this study was to systematically analysis the results of selected samples to ascertain the effectiveness of diabetes disease management program, to provide summary information to guide diabetes disease management programs and future quantitative analyses, and to identify future research needs.
Methods:
The study participants were 1110 individual with asthma who were recruited into the trial between January 2003 and December 2003. The primary data for this study would be obtained from purposely selected samples, conducted in metabology outpatient department and stratified by K Hospital region. The study evaluation would be based on diabetes patients of outpatient department for one-year study period, pretest groups (initial visit) and posttest groups (follow-up at 1 year) would show the results. The five outcome measures would be included in this evaluation: (1) clinical outcomes (2) health service utilization (3) screening rates of complications (4) index of perceived health status, and (5) physician adherence in care guideline. Pretest and posttest of health service utilization were investigated for 264 patients enrolled the program for one full year and with total two-year health care utilization. Statistical analyses were performed by SPSS, Version10.0 statistic software, using frequency, and pair t-test for bivariate analysis. Significance was accepted at the 0.05 level (two-tailed).
Results
Of total number of enrollees, among 646 were female (58.2%) and among 464 were male (41.8%). At 1-year follow-up, patient with diabetes received ophthalmic screening test comprised about 83.7%, the ratio of microalbuminuria test was 45.8%, and the ratio of foot exam was 97.5%. Also, they finished annual exams in HbA1c measure, blood pressure reading, and cholesterol test more than 75%. However, it was not significant improvement after exercising the program except for HDL-C result based on pair t test. Even BMI outcome become worse after enrolled the program. It showed also significantly decreasing in outpatient visits, and annual per capita outpatients expenditure at 1-year follow-up.
Conclusion:
These results had great significance in the design of future study for diabetes disease management and aim at improving the care of people with diabetes and its complications.
Key words: Disease management, Health care promotion improvement program, Health education, Care quality.

Table of Context
Chapter One Introduction
1-1 Back ground………………………………………………………1
1-2 The Problem………………………………………………………3
Statement of the problems……………………………….……….…...3
The significance of the study………………………………….. ….4
The general purposes of the study……………………………….… 6
Chapter Two Literature Review
2-1 Definition of the term…………………………………………7
2-2 Diabetes diagnosis and epidemiology…………………………9
2-3 Emergence of the concept for diabetes………………….……23
2-4 Empirical paper on diabetes disease management…………32
2-5 Implications of Literature……………………………………40
2-6 Diabetes disease management in Taiwan…………………….42
2-7 Diabetes disease management in other countries…………47
2-8 Theoretical framework for the study………………………53
2-9 Hypothesis………………………………………………………54
Chapter Three Methodology
3-1 BNHI disease management for patients with diabetes………56
3-2 Research methodology……………………………………………58
3-3 Research Target…………………………………………………61
3-4 Instrument………………………………………………………65
Chapter Four Results
4-1 Study target……………………………………………………...68
4-2 Patient demographic……………………………………………..68
4-3 Physician adherence to frequency of care guidelines……74
4-4 Statistics result of comparisons of pretest and postest……….….75
4-5 Patient adherence and annual completed clinical exam report…..79
4-6 The comparison of total health care expenditures and annual
per capita health care expenditure related diabetes care between 2002 and 2003……………………………………………...….….82
Chapter Five Discussion
5-1 Conclusion………………………………………………….…...84
5-2 Limitations of study………………..………………….…...89
5-3 Suggestions……………………..……………………………….90
5-4 Future directions on diabetes disease management…….93
Reference……………………………………………….………………95
Appendix
Appendix 1全民健康保險糖尿病醫療給付改善方案試辦計畫支付標準
………………………………………..…102
Appendix 1-1初診之標準照護項目表（適用編號P1401C）
Components of the initial visit………………………………………..…104
Appendix 1-2複診之標準照護項目表（適用編號P1402C）
Potential components of continuing care visits…….…………………...106
Appendix 1-3年度檢查之標準照護項目表（適用編號P1403C）.
Potential components of continuing care visits（annual exam）………108
Appendix 2-1 糖尿病共同照護網糖尿病健康護照領用清冊………...110
Appendix 2-2糖尿病共同照護網病人基本照護資料表………………112
Appendix 2-3病人管理照護資料表…………………………………….114
Appendix 3 Abbreviations……………………………………………….116
List of Table
Table 2-1 Types of Diabetes and characteristics……………..11
Table 2-2 Comparison of HHNK and DKA………….………………..13
Table 2-3 Number of inpatients and outpatients with Diabetes from 1998 to 2002……………………………………………………20
Table 2-4 Health care utilization rates of patients in per 100,000 population by age group ………………………….………20
Table 2-5 1997-2002 The distribution in admission case of avoidable disease…………………………………………………….21
Table 2-6 1997-2002 The distribution in admission case of avoidable diseases after adjustment………………………22
Table 2-7 Empirical papers on diabetes disease management………….…32
Table 2-8 Baseline characteristics of pretreatment and posttreatment……44
Table 2-9 Changes in clinical outcome screening rate of medical care usage Tao-Yuan County…………………45
Table 2-10 Hypotheses………………………………………………54
Table 4-1 The principal of demographic and characteristics of patients….69
Table 4-2 Characteristics of personal history, habit, and nutrition status…71
Table 4-3 Social support system………………………………..72
Table 4-4 Comorbidities of complications related diabetes……………....72
Table 4-5 Comorbidities of acute complications related diabetes..………73
Table 4-6 Physician Adherence to frequency of care guidelines (mean and percentage of patients screened)…………………….74
Table 4-7 Mean and SD of clinic outcomes between pretest and posttest..76
Table 4-8 Clinical outcome standard index…………………….76
Table 4-9 Patient adherence in self- monitoring blood glucose and blood pressure…………………………………………………..80
Table 4-10 The ratio of annual completed clinical exams….81
Table 4-11 Screening abnormal rate of urine analysis………81
Table 4-12 The comparison of total health care expenditures and annual per capita health care expenditure related diabetes care between 2002 and 2003…………………….83
Table 5-1 Percentage of complication in patients with diabetes between Japan and Taiwan…………………………………………86
List of Figure
Figure 2-1 Taiwan area main causes of death per 100,000 population.…..15
Figure 2-2 Standard death rates in Taiwan area per 100,000 population…………………………………………………....16
Figure 2-3 Conceptual framework of the study………….53
Figure 3-1 Diabetes disease management enrollment flow process……...64
Figure 3-2 The recruitment flow process of health care expenditure for patient with diabetes………………………67
Figure 4-1 BMI change between pretest and posttest……….77
Figure 4-2 Blood glucose change between pretest and posttest…………..77
Figure 4-3 The change of HbA1c at baseline after 1-year follow-up……...77
Figure 4-4 SBP change between pretest and posttest………..77
Figure 4-5 Diastolic blood pressure change between pretest and
Posttest………………………………………………….……77
Figure 4-6 Cholesterol change between pretest and posttest……………..77
Figure 4-7 Triglycerides change between pretest and posttest…….……...78
Figure 4-8 HDL-C change between pretest and posttest………78
Figure 4-9 LDL-C change between pretest and posttest………78

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1.行政院衛生署（2002）‧中華民國生命統計‧台北: 衛生署。
2.行政院衛生署網站 http://www.nhi.gov.tw/
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