糖尿病的門診醫療專業品質初探

A Preliminary Study on Professional Quality Assessment for Diabetes Outpatients

背景：全民健保實施迄今已逾6年，目前正面臨財務與品質兩難的困窘。而醫療產業由於財圍的介入經營，營業效率逐漸掛帥，醫療服務品質日受重視，醫療專業品質相形遭受忽視。1項1998年國內的大型研究顯示：糖尿病（DM）的門診控制，空腹血糖（AC）平均為162 ± 59mg/dl （平均值±標準偏差），其中50% > 140mg/dl ； 醣化血色素（HbA1C）平均為8.1 ± 1.6%，其中59% ≧ 7.4% ；成績不臻理想。本研究便以糖尿病為例，探討糖尿病的門診專業品質實況。材料與方法：從12家醫療院所的資料中，找出DM患者集中看診的3個門診，分別為A、B和C。看診醫師均為專科醫師，出身於醫學中心，在1998年1月至1999 年12月間，平均每時段（3小時）分別看診111.3 土 14.8、65.9 ± 16.2和33.6 土 7.2 名（F-test, p < 0.001）。 取樣：2000年3月第2週前3天門診連續患者中，62歲以上而在2年內（1998至1999年）接受DM治療連續6個月（含）以上者為有效樣本， 計A門診34位、B門診50位、和C門診30位。測量：以門診頻度（OPD-N）、血壓量度頻度（BP-N ）、空腹血糖測試頻度（AC-N ）、尿蛋白測試頻度（UR-N）、血脂測試頻度（chole/TG-N與HDLC/LDLC-N）、肌酸酐測試頻度（Cr-N ）、醣化血色素測試頻度（HbA1C-N）與肌酸酐清除率測試頻度（CCr-N）等9項為過程指標；而以血壓計量（BP）、空腹血糖測試（AC）、尿蛋白檢查（UR）、血脂測試（chol/TG 與 HDLC/LDLC）、肌酸酐測試（Cr）、醣化血色素測試（HbAIC）與肌酸酐清除率測試 （CCr）等8項的不正常率為結果品質指標；而以上述之過程與結果品質指標來探討 A、B和C門診的品質差異。結果：過程品質的觀察：C門診患者持續看診的意願較A、B門診為高（0PD-N≧1/m者，A、B和 C 門診分別為79%、60%與 100% ；x2 test, p < 0.01 ） ; BP、 AC、HDLC/LDLC、UR、Cr、HbAIC和CCr諸項中，C門診患者獲得較合理而完整的監視（請看本文表2）；在AC-N、HDLC/LDLC-N兩項，B、C門診相仿；在Cr-N方面， A、C相近；chol/TG-N則3者相似。結果品質的觀察：C門診在BP、AC、UR、chol/TG、HDLC/LDLC、HbAIC與CCr等7項的結果，較為優良（請看本文表3）。換句話說，C門診較重視、且較能達到高品質的DM療程之長期監視。結論：本研究提出DM患者長期治療中，過程與結果品質的觀察指標。2.對於老年DM患者的長期治療，看診人數多寡應該是影響醫療專業品質的重要因素之一。

Background: The National Health Issurance has been operating for more than 6 years in Taiwan, although it now encounters 2 major problems: the difficulry on both finance and quality. While several Enterprices have been engaging in the management of the medical industry, operating efficiency became more and more important, and thus the medical service quality became; however, the medical professional quality seems overlooked or even ignored. In 1998, an island-wide survey revealed that the clinical control for diabetes (DM) outpatients was not so ideal, but nearly 50% of them had a fasting blood surgar (AC)>140mg/dl and 60% had a glycosated hemoglobin (HbA1C)≧7.4%. In this study, we intend to observe the real situation of medical professional quality control for DM outpatients.Materials and Methods: 3 DM-OPDs (outpatient clinics) among the 12 hospitals, encoded as A, B and C repectively, were enrolled. Their Patient volumes per service section, spending about 3 to 4 hrs each, were 111.3±14.8, 65.9±16.2 and 33.6±7.2 (mean ± SD, F-test, P>0.001) respectively, during 1998 and 1999. Sampling: Those patients, aged≧62 yr-old and visiting the above 3 OPDs during the 1st 3 week-days of the 2nd week in March 2000, but receiving DM control continuously for ≧ 6ms during 1998 and 1999, were the subjects. These included 34, 50 and 30 patients per service section for OPD A, B and C, respectively. Measurements: For evaluation of process quality, there were 9 items as frequency of OPD-visits (OPD-N), BP-measurements (BP-N), AC sugar tests (AC-N), Urine-protein tests (UR-N), serum lipid tests (chole/TG-N & HDLC/LDLC-N), creatinine tests (Cr-N), HbA1C tests (HbA1C-N) and creatinine-clearance tests (CCr-N). And, for evaluation of outcome quality, there were 8 items as measurements of BP, AC, UR, chole/TG, HDLC/LDLC, Cr, HbA1C and CCr, the abnormal rates were used for observation. X2-test was utilized for statistical analysis.Results: P rocess quality: Patients of OPD C had an OPD-N higher than OPD A and B; for OPD-N≧1/m, there were 79%, 60% and 100% of patients in OPD A,B and C, respectively (P<0.01). Also, patients of OPD C had received a significantly higher frequency of observation than OPD A and B in BP-N, AC-N, UR-N, HDLC/LDLC-N, HbA1C, Cr-N and CCr-N (see table 2). Outcome quality: Patients of OPD C had a better result on measurements of BP, AC, UR, Chole/TG, HDLC/LDLC and HbA1C than OPD A and B (see table 3).Conclusion: 1. We developed those items for evaluation of process and outcome quality in OPD DM-control; and 2. It seems that patient volume could be an important factor influencing both the process and the outcome quality.