整合門診對糖尿病病患品質指標及醫療資源利用的影響-以北部某區域醫院為例

Abstract

背景與目的 糖尿病為一種代謝異常的慢性病，隨著人口老化及糖尿病盛行率的增加，糖尿病引起的高醫療花費也成為國家健保財務的重大負擔。雖然已經發展出了糖尿病患的臨床照護指引及照護品質指標，然而實際執行的結果和理想的目標，仍有相當的變異及落差。糖尿病常伴隨著其他慢性病出現，多重慢性病病患常常無法得到整合式的照顧。為了解決多重慢性病患醫療資源無效率使用的問題，健保局自98年12月起，逐年推動「醫院以病人為中心的門診整合照護試辦計畫」(以下簡稱整合門診)，透過病患門診就醫模式的改變，讓病患能同日多科就診，希望能確保病患就醫品質，減少醫療資源浪費。整合門診的實施，是否會同時影響糖尿病病患的醫療利用及糖尿病的照護品質，仍待進一步研究。 研究方法 本研究利用北部某一區域醫院糖尿病病患就醫病歷資料，使用回溯性世代研究，研究自2009年4月至2013年3月期間定期於門診追蹤，並於2010年4月1日起加入「醫院以病人為中心門診整合照護試辦計畫」個案為研究對象，病患每年依不同的整合程度分為零門診整合、低門診整合及高門診整合三組，連續追蹤三年(2010年4月至2013年3月)，並以加入整合門診前一年(2009年4月至2010年3月)為基期比較，研究不同的門診整合程度是否會影響每人每年門診醫療費用及糖尿病照護品質。研究結果包括兩方面：每年門診總醫療費用及糖尿病照護品質指標。糖尿病照護品質指標研究內容包括相關的過程指標及結果指標。研究結果以卡方檢定、ANOVA進行雙變項分析，以廣義估計方程式差異中的差異法進行多變項分析。 研究結果 本研究最終收案對象共1095人，研究對象每年門診整合程度變動不大。門診整合程度不同的病患，年齡、就診醫師科別和共病症略有差異，但性別及健保就醫優惠身分與否差異不大。就醫療利用而言，高門診整合病患每年門診醫療費用最高，零門診整合病患的醫療費用最低，三組的門診醫療費用，每年皆呈下降趨勢。利用廣義估計方程式差異中的差異法，評估整合門診程度、時間及其他相關變因，對於門診醫療費用及糖尿病品質指標的影響。研究結果發現控制其他變因之後，高整合門診病患年平均醫療費用會高於零整合門診病患5875.83元(p<0.0001)，低整合門診病患年平均醫療費用會高於零整合門診病患3306.17元(p=0.0018)。整合門診實施後，不管高或低門診整合皆能改善糖尿病照護品質的項目有：「尿液微白蛋白檢測頻率佳」、「眼底視網膜檢查頻率佳」及「過程指標組合分數佳」，可能可以改善的項目有「血清糖化血色素檢測頻率佳」；不管高及低門診整合皆無法改善糖尿病照護品質的項目包括：「血清糖化血色素檢測濃度佳」、「血清低密度膽固醇檢測濃度佳」、「血清低密度膽固醇檢測頻率佳」、「血清總膽固醇檢測頻率佳」及「結果指標組合分數佳」。 研究結論 整合門診實施後，整合門診程度增高會導致糖尿病病患每年門診醫療利用增高，但隨著實施時間加長，醫療費用會逐年降低；醫療利用增加的結果，可以改善部分糖尿病照護品質過程指標，但整合門診實施無法改善糖化血色素及低密度膽固醇等結果指標。

Background：In recent decades, Diabetes mellitus (DM) had become a significant burden on the Taiwanese national health insurance due to its increased prevalence and disease entity. The clinical guidelines for diabetes care suggested several quality indicators that include glycosylated hemoglobin (A1C), blood pressure, total cholesterol (CHO), low density lipoprotein cholesterol (LDL), urine microalbumin and retinopathy screening, etc. However, in reality, there is still a disparity between the actual diabetic care and clinical guidelines. Patients with diabetes and multiple chronic disorders were less likely to be covered by patient-centered integrated care. In Dec. 2009, the Taiwanese National Health Insurance Bureau launched a “patient-center outpatient integrated care program” in hospitals around Taiwan. The program is aimed to improve the care of quality for patients with multiple chronic diseases and to decrease medical cost by introducing a different outpatient care model. However, the benefits of such integrated care program on the improvements of the care quality for diabetic patients with multiple chronic diseases are still unknown. Objectives：The purpose of the study is to analysis the impacts of national outpatient integrated care program on medical utilization and diabetes care quality indicators. Method：This retrospective cohort study was designed in a northern Taiwan regional hospital to assess the effects of national integrated care program on medical expenditures and diabetic care quality indicators. From March, 2009 to March, 2013, diabetes patients with multiple chronic diseases who joined the national outpatient integrated care program were enrolled. The patients were divided according to the frequency of successfully integrated outpatient care into zero, low and high integrated groups. The change of medical expenditures and care quality indicators was analyzed by comparing the post-enrollment data of consecutive three years follow-up after enrollment to the results gathered one year before the program initiation. Generalized estimating equations method (GEE) was used to examine the differences of outpatient medical cost and care quality indicators over time among the different integrated groups and patient characteristics, which includes age, gender, preferential health insurance status, physician specialty and co-morbidity. Result： A total of 1095 patients were enrolled in this study. The annual change of individual integrated outpatient care status was minimal. The characteristics between three integrated groups were similar in gender and preferential health insurance status, but were significantly different in age, physician specialty and co-morbidity. As to medical expenditures, the outpatients medical cost decreased annually but the high-integrated care group had higher medical cost than the low and zero-integrated groups. After controlling the variables with GEE difference-in-differences method, the average annual outpatient medical expenditure for the high-integrated patient group is 5875.83, new Taiwanese dollar (NTD), more than the average annual cost for the zero- integrated patient group. The average annual outpatient medical expenditure for the low-integrated group is also 3306.17 NTD, more than the annual cost for the zero-integrated patient group. After the initiation of the national outpatient integrated care program, quality indicators such as urine microalbumin screening, retinopathy screening and process composite score were improved in both the high or low-integrated care group. However, the integrated care program did not influence A1C level, LDL level, LDL, and CHO check-up and outcome composite score. Conclusion：Higher outpatient integrated status will increase the medical expenditures. However, the medical cost maybe decreased annually during follow-up periods. The increased medical cost may result in improving partial process indicators of diabetes care. The outpatient integrated care can not improve A1C and LDL levels related outcome quality indicators of diabetes care.