| Summary: | 碩士 === 高雄醫學大學 === 醫務管理學研究所碩士在職專班 === 99 === Research Objectives: It has been ten years ever since the implementation of Diabetes Medical Benefit Improvement Project (hereinafter referred to as “disease management”) by National Health Insurance in 2001. The care quality of the related care plan as well as the effect of medium- and long-term medical resource use are worthy of making further analysis. The study has six objectives: 1. Explore the demographic features of disease management group for diabetes, the overall seriousness of the disease, and the characteristics of hospitals where diabetes patients seek medical treatment. 2. Explore the effects of disease management for diabetes on the quality of diabetes care, and the predictive factors. 3. Explore the characteristics of the disease management group and non-disease management group for diabetes as well as the medium- and long-term medical resource use. 4. Explore the impact factors of medium- and long-term medical resource use of the disease management group and non-disease management group for diabetes. 5. Explore whether there is any case of emergency treatment or hospitalization in the disease management group and non-disease management group for diabetes, as well as the impact factors. 6. Explore the survival situation in the disease management group and non-disease management group for diabetes, as well as the impact factors.
Research Design: The research samples of the disease management group were 2,181 adult patients of diabetes type 2 having joined the new diabetes disease management cases of the designated hospitals of Kaohsiung and Pingtung Area Health Insurance Bureau in 2006, and these patients continued joining the Project in 2006~2008. Besides, from the file of medical expenses in January ~ March, 2006 (screening the patients of Diagnosis Codes 250.X0 and 250.X2 of ICD-9-CM who took diabetes medication), the patients without joining the disease management were one-to-one paired according to the age and gender of the cases of disease management group, thus producing the research samples of the non-disease management group. The study analyzes the quality of diabetes care of the disease management group (clinical indicator), the medical resource use of the research targets in 2003 ~ 2009 and the survival situation of diabetes patients in 2007 ~ 2009, and also explores different impact factors.
Research Results: 1. Regarding the quality of clinical care: When compared with the time that the disease management group accepted the cases, the HbA1C was decreased by 0.86% one year after case acceptance, and decreased by 0.93% two years after case acceptance; the LDL-C was decreased by 11.2 mg/dl one year after case acceptance, and decreased by 15.67 mg/dl two years after case acceptance; and the AC was decreased by 15.85 mg/dl one year after case acceptance, and decreased by18.75 mg/dl (P＜0.001) two years after case acceptance. The results show that all these biochemical indicators improve continuously because of the continuous care. Besides, the care time, age, gender and morbidity period are the impact factors of seven clinical indicators. 2. Regarding medium- and long-term medical resource use: In the first, second and third years after disease management was involved (in 2007, 2008 and 2009), for the number of times of outpatient service, number of times of emergency treatment, expense of emergency treatment, number of times of hospitalization, number of hospitalization days, hospitalization expense and total medical expenses, the non-disease management group has significantly higher figures than the disease management group; and as to the expense of outpatient service, the non-disease management group has significantly lower figures than the disease management group. The seriousness of disease and chronic complications are the significant impact factors of hospitalization expense and total medical expenses in each year from 2006 to 2009. And whether disease management is joined is the significant impact factor of hospitalization expense in each year from 2007 to 2009 (the hospitalization expense of the non-disease management group is higher than that of the disease management group by $9,496, $10,861 and $5,177 in 2007, 2008 and 2009 respectively). 3. Regarding the poor care quality indicator (the number of hospitalized patients and the number of emergency patients): In each year from 2003 to 2009, the percentage of the number of hospitalized patients of the non-disease management group is higher than that of the disease management group, but there is no statistical difference in 2006. Besides, in each year from 2003 to 2009, the percentage of the number of emergency patients of the non-disease management group is higher than that of the disease management group, but there is no statistical difference in 2004, 2006 and 2009. The seriousness of disease, seriousness of chronic complications, and chronic complications (the main complications caused are cardiovascular complications, neuropathy, nephropathy complications and other complications) are the significant impact factors of hospitalization and emergency treatment in 2007, 2008 and 2009. Whether disease management is joined is the significant impact factor of emergency treatment (OR=1.25) in 2007 and that of hospitalization (OR=1.33) in 2008. 4. Regarding the number of deaths in each year from 2007 to 2009, the non-disease management group is significantly higher than that of the disease management group. Besides, as found in the result of Kaplan-Meier survival analysis, the survival situation of the disease management group is better than that of the non-disease management group. Whether disease management is joined, age and the seriousness of disease are the predictive factors of patients’ survival. In each year from 2007 to 2009, the risk of death of the non-disease management group is significantly higher than that of the disease management group (HR =21.72、6.57、3.44).
Conclusions and suggestions: After the patients of the disease management group received care continuously, the patients’ HbA1C, LDL-C, AC, TG and DBP were all improved continuously. In addition, because of the appropriate and complete care for outpatients, hospitalization and emergency treatment could be decreased, the risk of death could be reduced, and the consumption of overall medical resources could be decreased. Therefore, such a caring project for diabetes is worthy of continuous promotion. Nevertheless, up to now, there is nearly 70% or more diabetes patients having not joined the Program yet. The enhancement of diabetes care rate should be an issue that the competent authorities of public health have to pay concern for.
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