臺灣博碩士論文加值系統

背景：糖尿病及其相關疾病佔國人十大死因前幾位，影響國人健康甚鉅；於2014年，台灣糖尿病患者約有176萬人，相關醫療花費達新台幣226億。其併發症影響全身，相關科別均有可能收治糖尿病患者，但國內目前少有比較不同科別糖尿病照護之相關研究；國外文獻則顯示不同的比較結果。
目的：探討家醫科及新陳代謝科於第二型糖尿病病人的照顧品質，分析病人特性及照顧品質不同的可能原因。
方法：此為一回溯性世代研究，分析新北市某醫學中心電子病歷，研究對象為2011至2015年間於家醫科或新陳代謝科接受照顧的第二型糖尿病病人。若於此期間至兩科別就診的病人則予以排除。照顧品質指標包含盡責度（年度血液、尿液檢查及視網膜篩檢的達成率）及血糖控制，並分析急診、住院次數，及疫苗施打、戒菸諮詢、癌症篩檢的使用情形。以血糖控制狀況為主要結果。統計方法以卡方檢定、費歇確率檢定和t檢定比較兩科盡責度，並使用廣義估計方程式（Generalized estimating equations）分析家醫科及新陳代謝科在2011至2015年間，於第二型糖尿病病人血糖控制的影響因素，變項有病人的年紀、性別、共病、胰島素施打與否，並設虛擬變項來同時比較新陳代謝科是否加入共照網與家醫科於血糖控制之影響。
結果：於2011年，共有12813人於家醫科或新陳代謝科接受照顧，其中於家醫科追蹤者為1591人，於新陳代謝科則有11222人。盡責度以新陳代謝科病人達成率較高，尤其是接受共照網照護的病人。在調整了年紀、性別、共病、胰島素施打及基線血糖值後，新代科沒有加入共照網病人血糖控制不好相對家醫科病人血糖控制不好（糖化血色素> 9.5%）的風險為0.91倍，統計上沒有顯著差異；新代科有加入共照網病人血糖控制不好相對家醫科病人血糖控制不好的風險為1.55倍，統計上達顯著差異。在調整了年紀、性別、共病及基線血糖值後，新代科沒有加入共照網病人血糖控制良好（糖化血色素< 7%）相對家醫科病人血糖控制良好的風險為1.01倍，統計上沒有顯著差異；新代科有加入共照網病人血糖控制良好相對家醫科病人血糖控制良好的風險為0.61倍，統計上達顯著差異。急診及住院次數以新陳代謝科病人較高；家醫科病人在疫苗施打、戒菸諮詢及癌症篩檢的實行比例較高。
結論：家醫科及新陳代謝科於第二型糖尿病病人的照顧品質，盡責度以新陳代謝科較佳；在調整可能之干擾變項後，加入共照網的病人血糖控制不理想的風險較高。未來的研究應進一步討論整體醫療花費及生活品質，以期能更完整的評估不同科別及共照網的照顧品質。

Background:
Diabetes mellitus has become one of the major causes of death and has great impact on people’s health in Taiwan. The complications of diabetes involve the whole body, and patients may be treated by any of the associated departments. Few studies compared the quality of care in type 2 diabetes provided by different departments in Taiwan, and conflicting outcomes were reported in previous studies in other countries.
Objectives:
This study aims to compare the quality of care in patients with type 2 diabetes provided by Departments of Family Medicine and Endocrinology.
Methods:
This is a retrospective cohort study. Data were collected from electronic medical records in one medical center in New Taipei City. Records of all patients diagnosed as type 2 diabetes and followed up at Departments of Endocrinology or Family medicine during 2011-2015 were retrieved. Patients visited 2 departments at any time during this period were excluded. Quality of care was assessed included accountability, glycemic control, adverse outcomes and the use of preventive services. The primary outcome is annual glycemic control. As for inferential analysis, Chi-square test and Fisher exact test were used for categorical variables, and continuous variables were analyzed by using t-test. Generalized estimating equations (GEEs) were used to evaluate the effects of factors associated with annual glycemic control, defined as good (HbA1c <7%) and poor (>9.5%), respectively.
Results:
In 2011, there were 12813 patients diagnosed with type 2 diabetes with at least once HbA1c measurement followed up at Departments of Endocrinology or Family Medicine. Accountability indicators, including the percentage of HbA1c examination more than 2 times per year, fasting lipid test once per year, urinary test for nephropathy screen and ophthalmoscopy examination per year, were better in patients followed at Endocrinology, especially those under the Pay for Performance (P4P) program.
After adjusting age, gender, comorbid conditions, insulin treatment and the baseline HbA1c, the odds ratio of poor glycemic control (HbA1c >9.5 %) of non-P4P Endocrinology versus Family Medicine was 0.91 (95% CI 0.59 to 1.32; p=0.55); that of P4P Endocrinology versus Family Medicine was 1.55 (95% CI 1.09 to 2.45; p=0.02). On the other hand, after adjusting age, gender, comorbid conditions and the baseline HbA1c, the odds ratio of good glycemic control (HbA1c <7 %) of non-P4P Endocrinology versus Family Medicine was 1.01 (95% CI 0.95 to 1.51; p=0.12); that of P4P Endocrinology versus Family Medicine was 0.61 (95% CI 0.60 to 0.96; p=0.02).
The number of emergency visits and hospitalizations were more frequent in patients followed at Endocrinology. Preventive service were generally more frequent in patients followed at Family Medicine, including vaccination for influenza or pneumococcus, smoking cessation consultation and cancer screening.
Conclusions:
Accountability was generally better in patients followed at endocrinology department, especially those under P4P program, while after adjusting age, gender, comorbid conditions, insulin treatment and the baseline HbA1c data, patients enrolled in P4P program by endocrinologists versus those under family physicians’ care had poorer glycemic control. On the other hand, Family Medicine performed better in preventive services. To further analyze the performance of the different department and the P4P program, a longer follow up duration and overall medical expenses should be included in future analysis.

口試委員會審定書…………………………………………………………………..2
致謝……………………………………………………………………………….. …3
中文摘要…………………………………………………………………………......6
英文摘要……………………………………………………………………………..8
Chapter 1 Introduction.…………………………………………………………….. 11
Chapter 2 Literature review……………………………………………………….. 13
2-1 Diabetes care in different departments ……………...……………………13
2-2 Pay-for-performance (P4P) program..…………………………………… 16
2-3 Holistic health care in diabetes..…..……………………………………… 17
Chapter 3 Aims and Hypotheses……………………………………….…………..18
Chapter 4 Subjects and methods…..………………………………………………..19
4-1 Subjects…………….………………...…………………………………19
4-2 Diabetes care in the 2 departments…………………...…………………... 21
4-3 Items of quality of care……..……….………………………………… 25
4-4 Statistical methods……………………………………………………… 28
Chapter 5 Result……….………….……………………………………………….. 29
Chapter 6 Discussion….………………………….……………………………….. 49
6-1 Accountability……………………….……………...……………………49
6-2 Glycemic control……...……………….……………...……………………50
6-3 Adverse outcome and preventive service…………...……………………51
6-4 Strengths and limitations...………………………….…………………53
Chapter 7 Conclusion….………….…………………………………………………55
Chapter 8 Recommendation.……………………...……………………………….. 56
Reference……………………………………………………………….…… 57

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