糖尿病之醫師服務量、潛在不當用藥與照護結果之研究

Abstract

背景與目的：糖尿病之盛行率、醫療花費、疾病負擔與死因等造成台灣重大健康問題，其衍伸併發症與共病症導致老人經常被處方多重藥物，故容易造成照護不良結果之潛在不當用藥遂成為一個重要議題。過去以手術或住院疾病為主要服務量研究主題發現醫師服務量越高，照護過程與結果越佳。然而，在門診為主要就醫選擇之疾病中，醫師服務量與過程面品質指標或結果面品質指標之研究則呈現了不一致之結論。故本研究有三目的：探討糖尿病人之潛在不當用藥盛行率與常見藥物；探討糖尿病人中，醫師服務量與照護結果的關係；探討糖尿病人中，潛在不當用藥是否為醫師服務量與照護結果之關係的中介因子。 研究方法：本研究資料來源為全民健保資料庫，以第二型糖尿病病人作為研究對象，利用多階層模型探討糖尿病人服務量、總病人服務量以及糖尿病人占比與照護結果之間的關聯性。並進一步再以2019年版Beers criteria評估糖尿病病人之潛在不當用藥，加以檢驗關聯性之中介效果。 研究結果：老年糖尿病人潛在不當用藥盛行率為85.54%，常見藥物為苯二氮平類藥物、第一代抗組織胺、長效磺胺類藥物及肌肉鬆弛劑。病人就診醫師為中或高糖尿病人量，相較於低糖尿病人量之急診與住院就醫風險較低(OR值分別為0.91/0.83、0.81/0.70)；病人就診醫師為中或高總病人量，相較於低總病人量之急診與住院就醫風險較低(OR值分別為0.92/0.91、0.82/0.76)；病人就診醫師為中或高糖尿病占比，相較於低糖尿病占比之急診與住院就醫風險OR值分別為1.01/0.92、1.04/0.93。潛在不當用藥之中介效果約為7.55%~10.46%。 結論：醫師服務量越高，照護結果越佳，且潛在不當用藥對服務量與照護結果關係具有中介效果。

Background and Objectives: Diabetes is an important health issue in Taiwan, with high prevalence rates, healthcare costs, disease burden, and mortality. The complications and comorbidities associated with diabetes often result in elderly patients being prescribed multiple medications, leading to potential improper medication use and poor caregiving outcomes, making it an important issue. Previous research of volume-outcome focused on surgical or hospitalization cases and found that higher physician service volume was associated with better care processes and outcomes. However, studies on physician volume and quality indicators in terms of care processes and outcomes in outpatient settings, have yielded inconsistent conclusions. Therefore, this study aims to achieve three objectives: to explore the prevalence of potential inappropriate medication use and common medications among diabetic patients; to examine the relationship between physician volume and healthcare outcomes among diabetic patients; and to investigate the mediating effect of PIM on volume-outcome relationship among diabetic patients. Methods: We used the National Health Insurance Research Database and focused on patients with type 2 diabetes as the study population. Multilevel models were used to examine the relationship between volume and healthcare outcome. Furthermore, the 2019 version of the Beers criteria was employed to assess PIM among diabetic patients and we examine the mediating effects of PIM in volume-outcome relationship. Results: In elderlies with diabetes, the prevalence rate of PIM was 85.54%, with common medications including benzodiazepines, first-generation antihistamines, long-acting sulfonylureas, and muscle relaxants. Patients receiving care from physicians with high or medium diabetes-patient-volume had a lower risk of emergency department visits and hospitalization compared to those with low diabetes-patient-volume (OR values of 0.91/0.83 and 0.81/0.70). Patients receiving care from physicians with high or medium total-patient-volume had a lower risk of emergency department visits and hospitalization compared to those with low total-patient-volume (OR values of 0.92/0.91 and 0.82/0.76). Compare to patients receiving care from physicians with a low diabetes-patient-proportion, OR values of emergency department visits and hospitalization were 1.01/0.92 and 1.04/0.93 in those with a high or medium diabetes-patient-proportion. The mediating effects of PIM ranged from 7.55% to 10.46%. Conclusion: Higher physician service volume is associated with better healthcare outcomes, and potential inappropriate medications partially mediate the volume-outcome relationship.