第二型糖尿病病人照護品質指標與臨床結果相關性的再探討：病人層級的分析

Abstract

背景與研究目的 糖尿病是一種很常見的而且很複雜的慢性代謝性疾病，盛行率有逐漸上升的趨勢；糖尿病的病人最後的死亡原因常是因為心臟血管疾病或是腎臟衰竭，導致糖尿病致死率會被低估，即使如此糖尿病仍是國人十大死因之一。因為高盛行率、高致死率和併發症風險，糖尿病治療是公共衛生重要議題。 研究顯示糖尿病病人得到的照護與臨床指引的建議有落差，而以群眾為基礎的研究在過程面的品質指標和臨床結果的關係結果並不一致，因此本研究想從病人層級來探討糖尿病病人照護的品質指標與臨床結果的關連性。 材料與方法 本研究利用國泰醫院和新竹國泰醫院的電腦資訊系統，篩選出第二型糖尿病病人後，讀取這些病人的基本資料，包括病人的年齡、性別、身高和體重以及在民國97年1月1日到100年12月31日間的檢查結果，過程面的品質指標包括糖化血色素、低密度膽固醇和高密度膽固醇的檢查頻率，以最後一次測量值做為判斷是否達成臨床目標的依據；另外針對過程面品質指標和臨床結果發展全或無的組合分數。 定期檢查和未定期檢查兩組的基本資料和檢查結果用t-檢定或卡方檢定檢驗，過程面的品質指標和臨床結果的關係以卡方檢定檢驗，利用logistic regression 和multinomial logistic regression來分析影響臨床結果的可能因子。 結果 本研究一共收集5734位病人，3432位病人（59.9%）定期接受糖化血色素檢查，定期接受低密度膽固醇檢查和高密度膽固醇的病人各有4934位(86.0%)和4579位(79.9%)，三項檢查都能定期檢查的只有2782位(48.5%)。達到糖化血色素治療目標的有2431位病人(42.4%)，糖化血色素控制非常不好（>9.5mg/dL）的有901位病人(15.7%)；達到低密度膽固醇和高密度膽固醇治療目標的病人各有2954位(51.5%)和2578位(45.0%)病人，三項目標都能同時達成的只有650位病人(11.3%)。 糖化血色素過程面的品質指標和臨床結果並不相關 (p = 0.436)，不過沒有定期接受糖化血色素檢查的病人比較容易控制非常不好 (p < 0.001)；膽固醇過程面的品質指標和臨床結果則有明顯相關 (p=0.015 for LDL，p=0.003 for HDL，p=0.006 for both)；過程面品質指標和臨床結果的組合分數間也有明顯相關 (p=0.004)。 Logistic regression 結果顯示個別比較糖化血色素或膽固醇過程面的品質指標並不是影響臨床結果顯著因子，但是當合併糖化血色素和膽固醇的組合分數時，過程面的品質指標是影響臨床結果的顯著因子；其他容易同時達成糖化血色素和膽固醇控制目標的顯著因子包括年齡較大、低身體質量、男性病人、國泰醫院的病人。另外Multinomial logistic regression結果顯示，照護過程面的品質指標和臨床結果只有在最好的一組和最差的一組有顯著的相關。 結論 個別的血糖或血脂肪品質指標不是影響臨床結果顯著因子，不過若合併兩者的組合分數時，過程面的品質指標卻是影響臨床結果的顯著因子；另外雖然定期檢查糖化血色素或膽固醇並不能確保很好的臨床結果，沒有規律的檢查會使得糖化血色素和膽固醇的控制非常不好；還需要研究設計來監測和促進藥物的加強以提高糖尿病的照護品質。

Introduction Diabetes mellitus is a common but complex chronic metabolic disease. The incidence increased in recent year. Diabetes itself is one of leading causes of death and many persons with diabetes die of cardiovascular disease or renal failure, rather than a complication specific to diabetes. Because of increasing prevalence, high mortality rate and risks of chronic complications such as renal failure and cardiovascular diseases, management of diabetic patients is an important issue on public health. Studies of the quality of diabetes care have frequently demonstrated a wide gap between recommended medical practices and the care the diabetic patients actually receive. There are paradoxical results about the link between quality indicators (process measure) and clinical outcome according population-based studies. I now attempt to evaluate the relationship between the quality indicators and intermediate clinical outcomes in patient level Materials and methods This study retrospectively collected outpatient laboratory test results and demographic data of type-2 diabetic patients from healthcare information system of CGH and HCGH between January 2008 and December 2010. Quality indicators of process measures including frequency of HbA1c, LDL, and HDL measurements were identified, so did the intermediate clinical outcomes. All-or-none composite measurements to indicate both the quality of process measurement and clinical outcome were also reconstructed. Demographic data and laboratory results of those diabetic patients who received or did not receive regular checkup were compared using independent t-test or chi-square test. The process indicators and outcome indicators were compared using chi-square test. Logistic regression and multinomial logistic regression were used to examine possible factors associated with outcome indicators. Results There were total 5734 patients enrolled for analysis in this study. 3432 (59.90%) patients received regular check-up of HbA1c, 4934 (86.0%) patients received regular check-up of LDL, 4579 (79.9%) patients received regular check-up of HDL and only 2782 (48.5%) patients received regular check-up of both HbA1c and lipid profiles. Only 2431 (42.40%) patients achieved HbA1c goal of less than 7%, and there were 901 (15.7%) patients with poor control of HbA1c (HbA1C > 9.5%). There were 2578 (45.0%) patients and 2954 (51.5%) achieved HDL and LDL management goal, respectively, and only 1304 (22.7%) patients achieved both HDL and LDL goals. Only 650 (11.3%) patients achieved both goal of HbA1c and lipid control. For glucose control, there were no correlation between good quality indicator (process measurement) and good HbA1c outcome (p = 0.436). However, those patients without regular checkup of HbA1c were more likely to have poor control of HbA1c (p < 0.001). There was strong correlation between good quality indicator (process measurement) and good lipid outcome (p = 0.015 for LDL, p = 0.003 for HDL, and p = 0.006 for both LDL and HDL). There were also strong correlation between composite measurement of quality indicators and intermediate clinical outcome (p = 0.004). Logistic regression revealed individual quality indicator of glucose or lipid monitor did not correlate with clinical outcome when compared alone, but there was correlation between them when composite measurement as used for comparison. Older patients (Odd ratio=1.014, p < 1.001), patients with lower BMI (Odd ratio=1.014, p < 1.001), male patients (Odd ratio=1.723, p < 1.001) and patients cared at CGH (Odd ratio= 1.853, p < 0.001) were associated with increased possibility of achieving both HbA1c and lipid goals. Multinomial logistic regression revealed that the association of quality indicator of process measurement and clinical outcomes only between comparison of the best group and the worst group. Conclusions The major finding of this study was individual quality indicator of glucose or lipid monitor did not correlate with clinical outcome when compared alone, but there was correlation between them when composite measurement was used for comparison. Although regular check-up did not guarantee good control of all parameters, patients without regular check-up were associated with worst outcomes of HbA1c control, lipid control, and both. It requires further studies designed to monitor and promote therapy intensification to improve diabetic care.