糖尿病患就醫專科別、照護連續性與照護結果之關係

Abstract

中文摘要 前言： 自全民健康保險實施以來，對於不同社經地位的國民，改善其就醫公平性與就醫可近性。有別於歐美的轉診制度，台灣的全民健康保險制度並未限制病人就醫機構、就醫科別與照護的主治醫師。台灣成年人的糖尿病盛行率逐年上升，糖尿病造成的醫療支出也日漸增加。對糖尿病患的照護，有文獻認為由次專科醫師的照護有較佳的結果，但也有報告顯示，家庭醫學科醫師可以提供病人更周全的照護；另外有研究指出，病患有較佳的照護連續性時會有較好的照護結果。對於糖尿病患照護結果之差異是與醫師專科別有關，還是與照護連續性有關，過去文獻尚未有完整的討論，值得進一步探討。 研究目的： 本論文旨在檢驗不同專科別醫師照護的糖尿病患，其照護連續性的差異；以及糖尿病患就醫專科別與照護連續性對於照護結果之影響。 研究方法： 本研究採用橫斷面研究法，以國家衛生研究院全民健康保險學術資料庫2005年百萬抽樣歸人檔做為樣本母群體，研究對象是二十歲以上成年糖尿病患。主要照護醫師以就診次數最高者為判斷標準，其專科類別分為：「家庭醫學科」、「新陳代謝科」、「內科」與「其他次專科」。糖尿病患門診就醫之照護連續性指數(continuity of care index)，分成低、中、高三組，控制變項包括病人年齡、性別、家戶收入類別、糖尿病嚴重度指數、共病症指數、有無使用胰島素、主要就醫機構特約類別、以及投保縣市醫師人口比。本研究以糖尿病相關的急診或住院為依變項，使用邏輯斯迴歸分析醫師專科別與照護連續性對照護結果的影響。使用SAS 9.3版統計軟體進行資料分析。 研究結果： 在83,472位糖尿病患中，其主要照護醫師專科別分布為：家庭醫學科17.10%，新陳代謝科2.37%，內科51.47%，其他次專科29.06%。在2005年當中，有17280位病患(20.70%)曾經住院，有14521位病患(17.40%)曾經使用急診。若以醫師為基準，2005年期間，病患因糖尿病在門診就醫的平均照護連續性指數為0.64 (標準差，SD=±0.30)。四個專科醫師組別中，主要在「家庭醫學科」就醫的糖尿病患，有較高的照護連續性；主要在新陳代謝科與內科以外之「其他次專科」就醫的糖尿病患，其照護連續性最低。雙變項卡方分析顯示，照護連續性愈高，糖尿病患急診使用率與住院率愈低。主要在「家庭醫學科」就醫的糖尿病患，急診使用佔11.97%、住院佔13.44%，相對最低；主要在新陳代謝科與內科以外之「其他次專科」就醫的糖尿病患，急診使用佔20.65%、住院佔26.86%，相對最高(P<0.0001)。 邏輯斯迴歸分析顯示，當以照護連續性高分組為參考組時，在中分組的糖尿病患有較高的急診使用(OR: 1.743；95% CI: 1.475~2.060)與住院(OR: 2.044；95% CI: 1.730~2.414)，在低分組的糖尿病患有最高的急診使用(OR: 2.853；95% CI: 2.424~3.358)與住院(OR: 3.704；95% CI: 3.152~4.352)；在四個專科別間，當以家庭醫學科為參考組時，主要在新陳代謝科與內科以外之「其他次專科」就醫的糖尿病患，有最高的急診使用(OR: 1.258；95% CI: 1.029~1.540)與住院(OR: 1.219；95% CI: 1.005~1.478)，而於新陳代謝科或內科就醫的糖尿病患，則沒有顯著差異。在「照護連續性低分組」，主要於新陳代謝科就醫之糖尿病患的急診使用，是在家醫科就醫之糖尿病患的1.892倍(OR: 1.892；95% CI: 1.011~3.541)。在「照護連續性中分組」，主要在新陳代謝科與內科以外之「其他次專科」就醫的糖尿病患之住院，是在家醫科就醫之糖尿病患的1.440倍(OR: 1.440；95% CI: 1.007~2.058)。在「照護連續性高分組」，主要於新陳代謝科、內科或其他次專科就醫之糖尿病患的急診使用或住院，與在家醫科就醫之糖尿病患相比，沒有顯著差異。 結論： 糖尿病患之照護結果，顯著的與門診照護連續性有相關，而主要在「家庭醫學科」就醫者比在新陳代謝科與內科以外之「其他次專科」就醫者，也有較佳的照護結果，其真正原因還有待進一步分析。在高照護連續性下，醫師專科別造成之照護結果差異，則不具顯著性。

關鍵詞：照護連續性；醫師專科別；照護結果

Abstract Foreword：Since the implementation of National Health Insurance (NHI) program, there was significant improvement in equality and accessibility of medical care for all citizens in Taiwan, irrespective of their socio-economic status. Unlike the referral system in Europe and America, Taiwan's NHI system does not prohibit patient from seeking consultation from any medical institution or any specialties. The prevalence of adult diabetes in Taiwan is increasing every year, so are the medical expenses related to treatment of diabetes. In regard to diabetes care, some literatures indicated that care delivered by endocrine specialist have yielded better patient results, while other reports has shown family medicine physicians are capable of providing more comprehensive patient care. Furthermore, evidences have shown high continuity of care is related to better patient outcome. Whether the difference in outcomes of diabetic patients is influenced more by the physician specialties or by the continuity of care is still debatable, but there is paucity of literatures providing complete discussion regarding to this issue. Therefore, the aim of our research is aiming to investigate and clarify this issue. Purpose：The aim of this study was to investigate the difference in continuity of care of diabetic patients provided by different specialties; and the effects of different specialties and continuity of care on the patient outcomes. Methods：This is a cross-sectional study, utilizing population data of adult diabetes patients from the National Health Insurance Research Database in 2005 as the study sample, who were 20 years of age or older. The physicians whom the patients visited most frequently for diabetes related problems were identified as the main treating doctor for these patients. Different physician specialty categories were listed: “family medicine”, “endocrinology”, ”internal medicine”, and “other sub-specialties”. Continuity of care index was categorized into low, intermediate, and high index groups. The independent variables included patient’s age, gender, household income, Diabetes Complications Severity Index, Charlson Comorbidity Index, receiving insulin or not, the primary medical institutions for medical treatment, and the physician-population ratio in local counties. In this study, dependent variables were diabetes-related hospital emergency department visits or hospital ward admission. Logistic regression was used to investigate the effects of different specialties and continuity of care on patient outcomes. SAS version 9.3 statistical software was utilized for data analysis. Study results：Data was collected from a total of 83472 patients. The distribution percentages of specialty categories of main care physicians were found as the followings: 17.1% were family medicine physicians, 2.37% were endocrinologists, 51.47% were internal medicine physicians, and 29.06% were doctors from other sub-specialties. In year 2005, 17280 patients (20.70%) were hospitalized at least once, while 14521 patients (17.40%) had visited emergency departments. The average continuity of care index was 0.64 (SD=0.30). Among these four specialties, family physicians provided the most continuity of care for the patients. In contrast, the physicians designated in the category of “other sub-specialties” provided the least continuity of care. Results from bivariate chi-square analysis showed that the better the continuity of care, the less frequent hospitalization and utilization of emergency room by the patients. In those patients cared mainly by the family physician, only 11.97% attended emergency departments, and only 13.44% were hospitalized for diabetes related diagnosis, and these numbers were the lowest when compared with those patients cared by specialists from the other 3 categories. In those patients cared mainly by the physicians designated in the category of “other sub-specialties”, 20.65% had at least one emergency department visit, 26.86% were hospitalized. These numbers were the highest compared with the patients cared by the physicians from the other 3 categories. Results from logistic regression analysis showed that when the group with highest continuity of care was used as a reference group, the group of patients with intermediate index had higher frequency of emergency department visit (OR: 1.743; 95% CI: 1.475 ~ 2.060) and hospitalization (OR: 2.044; 95% CI: 1.730 ~ 2.414), patients in the group with low continuity of care index had with the highest frequency of emergency department visit (OR: 2.853; 95% CI: 2.424 ~ 3.358) and hospitalization (OR: 3.704; 95% CI: 3.152 ~ 4.352); Among the four specialty categories, when family medicine was used as a reference specialty, patients cared by physicians from 'other sub-specialties' category had the most frequent emergency department use (OR: 1.258; 95% CI: 1.029 ~ 1.540) and hospitalization (OR: 1.219; 95% CI: 1.005 ~ 1.478). However, there was no difference in frequency of emergency department visit and hospitalization between patients cared by endocrinologists and internal medicine physicians. Within the group of low continuity of care index, the number of emergency department visits by patients cared mainly by physicians in the category of endocrinology was 1.892 times more than patients cared by family physicians (OR: 1.892; 95% CI: 1.011 ~ 3.541). Within the group of intermediate continuity of care index, the number of hospitalization by patients cared mainly by physicians in the category of “other sub-specialties” was 1.44 times more than patients cared by family physicians (OR: 1.440; 95% CI: 1.007 ~ 2.058). Within the group of high continuity of care index, there was no difference in the number of hospitalization and emergency department visit among patients cared by physicians from 4 different specialty categories. Conclusion：Our results showed that the outcomes of diabetes patients were significantly correlated with continuity of care. Patients cared by the family physicians had better outcomes than those cared by physicians in the category of 'other sub-specialties'. The reasons behind these results will require further investigation. There was no difference in the number of hospitalization and emergency department visit among patients cared by different specialties in high continuity of care.

Key words Continuity of care; physician specialties; outcome of care