臺灣博碩士論文加值系統

背景：心血管疾病為糖尿病主要的併發症之一，過去許多研究證實女性糖尿病患者其罹患心血管疾病之相對風險更甚於男性，但糖尿病與心血管疾病間之性別差異現象影響成因尚不明確，部分可能歸因於先天生物學上差異、患者之就醫行為等。本研究欲探討醫療服務提供者特性對於特定性別糖尿病患者心血管疾病絕對與相對風險之可能影響。
目的：本研究有三：（一）男女性糖尿病人之主要醫療服務提供者（醫師）特性分析；（二）醫師特性與男、女性第二型糖尿病患者的心血管疾病發生風險（主要是缺血性心臟病與中風）的相關性；以及（三）醫師特性是否會修飾男女性糖尿病人心血管併發症的相對風險。
方法：本研究採用回溯性世代追蹤研究法，研究對象取自我國全民健康保險申報資料之2000年100萬人承保抽樣歸人檔，以2000年被診斷為第二型糖尿病患者為研究之世代，並透過年齡、性別配對及1：4方式，隨機擷取非糖尿病個案為對照世代。糖尿病暴露世代其主要照顧醫師定義為2000年第一次具糖尿病診斷後之三年內就醫紀錄中，開立糖尿病診斷次數最多之醫師。研究對象追蹤至2013年，並以發生密度及危害風險對比值探討醫師特性對男、女性第二型糖尿病患者的心血管疾病發生風險的影響，及探討醫師特性是否能夠解釋第二型糖尿病患族群中男女心血管疾病發生風險差異縮小的現象。
結果：（一）2000年之第二型糖尿病暴露世代為10,105人（男性4,962人），對照世代為39,804人（男性19,569人），糖尿病患之主要照醫師大多為男性、45-54歲、新陳代謝專科。（二）不論在整體心血管疾病、缺血性心臟病或中風，男性糖尿病患發生密度皆高於女性病患，以醫師特性分層來看，照顧醫師為男性、小於35歲、心臟血管科之組別大多有較高之發生密度。進一步利用Cox proportional hazard model分析，以女性第二型糖尿病患者為參考組之男性病患心血管疾病調整後風險對比值（adjusted HR）及交互作用檢定結果顯示，雖然醫師特性對於男性心血管疾病發生風險有變異性，但這些差異未達統計上的顯著意義。（三）在對照組個案中，經校正年齡、社經地位、與共病狀態後，男性罹患心血管疾病之風險顯著高於女性。而在第二型糖尿病患中，男性個案其罹患心血管疾病之相對風險略比非糖尿病個案為低，且進一步校正醫師特性後，其相對風險無太大變化。
結論：研究發現，醫師特性無法解釋第二型糖尿病與對照組個案之男性心血管疾病（包含缺血性心臟病及中風）相對風險的差異。但本篇研究同時也指出，基線資料中女性糖尿患者罹患其與心血管疾病有關之危險因子比例較男性患者為高，根據此一特性，建議仍應將性別觀點納入醫療照護決策中，除了考量不同病患性別之特殊性外，更達到高品質之健康照護目的。

There is limited research on the impact of the characteristics of medical service providers on the quality of diabetes care in Taiwan. Most of them focus on the indicators of the process, and there are few in-depth discussions on the impact of clinically relevant outcomes such as cardiovascular disease. This retrospective cohort study, including 10,105 subjects with type 2 diabetes and 39,804 matched controls identified from the Longitudinal Health Insurance Database 2000 (LHID 2000) in 2000, conducted to evaluate the relationship between physician characteristics and the sex differences in the excess risk of cardiovascular diseases. Followed up to 2013, In the control group , after adjusting for age, socioeconomic status, and comorbidity, the risk of cardiovascular disease in men was 1.302 times that of women (95% CI=1.244-1.362). In type 2 diabetes, the relative risk of cardiovascular disease in male is slightly lower than in non-diabetic male (adjusted HR=1.220, 95% CI=1.136-1.309), and the relative risk does not change much after further control of physician characteristics (adjusted HR=1.219, 95% CI=1.136-1.309). This study found that physician characteristics could not explain the relative risk of cardiovascular disease in type 2 diabetes and control group.

摘要 I
目錄 VIII
表目錄 X
第一章、前言 1
第一節　研究背景 1
第二節　研究目的 2
第二章、文獻回顧 3
第一節　國際及臺灣第二型糖尿病之疾病負擔現況 3
第二節　糖尿病心血管疾病併發症之性別差異 4
第三節　造成糖尿病心血管疾病併發症性別差異之可能因素 4
第三章、研究材料與方法 12
第一節　資料來源 12
第二節　研究設計 12
第三節　研究世代定義與選取 12
第四節　心血管疾病定義 13
第五節　主要照顧醫師之認定 16
第六節　研究追蹤時間定義 16
第七節　其他控制變項 16
第八節　統計分析 22
第四章、研究結果 24
第一節　暴露世代之人口學分布與其主要照顧醫師特性 24
第二節　各分層醫師特性對於糖尿病患者心血管併發症之影響 26
第三節　醫師特性對第二型糖尿病與對照組個案男女性心血管疾病相對風險差異的影響 28
第五章、討論 31
第一節　本研究主要發現 31
第二節　研究結果的比較與闡釋 31
第二節　研究優勢與研究限制 34
第六章、結論 37
參考資料 54

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