論質計酬及照護協調對糖尿病腎病變病患照護利用及結果之影響

Abstract

目標：糖尿病腎病變因其耗費健保資源甚多，後續更因病程進展需要透析治療，實為我國亟應積極照護之慢性疾病，爰我國已針對是類病人提供糖尿病及慢性腎臟病論質計酬方案多種，惟針對多種論質計酬方案之照護結果與照護利用之研究甚少，並缺乏照護協調相關研究。本研究針對多種論質計酬方案對於糖尿病腎病變病人之照護結果及照護利用影響進行探討，並分析照護協調對於該影響是否具有中介效果。 方法：本研究採回溯性世代研究法，利用初級與次級資料，以診所為分析單位，探討糖尿病腎病變病患參加論質計酬方案情形對病患照護結果及照護利用之影響，並分析照護協調於兩者關係間之中介效果。本研究以27家診所之病患為研究對象，在初級資料部分，郵寄「慢性病照護評估工具(Assessment of Chronic Illness Care , ACIC)」結構式問卷，收集醫療相關人員照護協調分數。次級資料則由衛生福利部國民健康署2018年至2019年「基層診所暨社區醫療群推動預防失能之慢性病介入服務試辦獎勵計畫」資料庫，選取本研究個案參加論質計酬方案情形、人口特質、醫療機構特質、照護結果及照護利用等相關變項。使用傾向配對法增加個案之可比較性後，以迴歸分析瞭解參加論質計酬方案情形對病患照護結果及照護利用之影響，並進一步探討照護協調是否對於論質計酬方案與照護結果及照護利用間之關係造成影響。 結果：照護利用(腎絲球過濾率追蹤、糖化血色素追蹤)顯示參加多種論質計酬優於僅參加1種或未參加者，惟照護結果(糖化血色素)卻顯示非P4P組及參加1種P4P組均優於參加2種P4P組。本研究目的二顯示參照組為參加2種P4P組時，非P4P組及僅參加1種P4P組與照護協調分數為負相關，顯示參加較多種論質計酬期照護協調分數較高。研究目的三，慢性病照護協調可顯著降低糖化血色素、血壓、低密度脂蛋白之不良結果。研究目的四顯示對照護結果與照護利用之部分項目有中介效果。 結論：糖尿病腎病變實為影響我國公共衛生之重大疾病，當前已發展為整合照護之論質計酬制度，多種研究結果及本研究結果亦說明結合多項單一疾病論質計酬制度有利於病人之照護利用結果，且多重慢性協調照護亦為推動良好疾病照護成果之要素之一。後續可利用ACIC量表檢視慢性病協調照護要素是否齊備，進而增進醫療服務品質，提供國人更優質之糖尿病腎病變照護。

Objective: Chronic Illness such as diabetes and related complications such as diabetic nephropathy consume large amount health insurance resources, and subsequently require insulin treatment due to the progression of the disease. In fact, these chronic diseases should be actively cared for. Taiwan has demonstrates many studies on the diabetes and chronic kidney disease demonstration qualitative remuneration programs for targeted patients, however, only few studies focus on the care results and care utilization of multiple qualitative remuneration schemes and care coordination. The objective of this study is to analyze whether care coordination has an intermediary effect on the impact between the programs and the care results and care utilization . Methods: This study adopts a retrospective generation research method, using primary and secondary data. We have used clinics as the analysis unit to explore the impact of patients with diabetic nephropathy participating in the qualitative remuneration program on patient care results, care utilization, and analyze care coordination of the mediating effect between the two relations. This study took analyzed patients from 27 clinics as the research object. In the primary data section, the 'Assessment of Chronic Illness Care (ACIC)' structured questionnaire was mailed to the clinics, information on care coordination scores of medical personnel was collected. The secondary information is from the National Health Administration of the Ministry of Health and Welfare, using data from 2018 to 2019 in the 'Primary Clinics and Community Medical Groups Promoting Disability Prevention of Chronic Disease Interventional Services Pilot Award Program' database, we have analyzed demographic characteristics, medical institution characteristics, care results and care utilization and other related variables. After using the propensity matching method to increase the comparability of cases, use regression analysis to understand the impact of participation in the quality-based payment plan on the patient's care results and care utilization, and further explore whether care coordination has an effect on the quality-based payment plan, care results, and care utilization rate. Results: Care utilization (tracing of glomerular filtration rate, tracking of glycosylated hemoglobin) showed that participating in multiple types of qualitative remuneration was better than participating in only one or not participating, but the care results (glycated hemoglobin) showed that the non-P4P group and participating in one P4P Groups are better than participating in the 2 P4P groups. The second purpose of this study shows that when the reference group is participating in the 2 types of P4P groups, the non-P4P group and the only participation in the 1 type of P4P group are negatively correlated with the care coordination scores, indicating that the care coordination scores of participating in more qualitative remuneration periods are higher. Research objective three, the care coordination for chronic diseases significantly reduce the adverse results of glycated hemoglobin, blood pressure, and low-density lipoprotein. The fourth research objective shows that there is an intermediary effect between the comparison of care results, and some items of care utilization. Conclusion: Diabetic nephropathy is actually a major disease that affects public health in Taiwan. It has been developed into an integrated care based on quality and remuneration system. The results of various studies and the results of this study indicate that combining multiple single disease based on quality and remuneration systems is beneficial to patient care. As a result, multiple chronic coordinated care is also one of the factors that would produce effective and desirable health results. In the future, the ACIC scale can be used as a tool to examin the elements of coordinated care for chronic diseases, thereby improving the quality of medical services and providing better quality diabetic nephropathy care in Taiwan.