醫療提供者對糖尿病疾病管理計畫的認知與參與度之相關性研究

The Effects of Providers' Perception of the Diabetes Disease Management Program on Their Participation

任何基於獎勵以增加和維持醫療提供者參與疾病管理計畫的努力，必須考量激勵與參與程度的相關性。本研究旨在探討台灣糖尿病疾病管理(DDM)計畫中，醫療人員對該計畫的激勵認知與參與程度的相關性。本研究為一橫斷式自填式問卷調查，樣本為全國有代表性的1600名醫師，問卷內容包括經過信效度檢驗的激勵認知量表(PPI)。在381份寄回問卷，有345份完成問卷調查(22%)，其中DDM計畫參與者與非參與者的回應率分別為為35%及12%。研究結果顯示，DDM計畫參與者的PPI分數均明顯高於非參與者（平均數±標準差，3.3±0.5比3.0±0.5），但差異程度不大。激勵認知的各面向中，專業自主權、照護品質和財務獎勵與各項參與指標（加入、收案、參與程度）呈顯著正相關，但與持續收案無顯著相關；執行成本和行政負擔，則與任何參與指標無顯著相關。在控制環境因素和醫師個人因素後，照護品質的認知程度與加入DDM計畫仍呈現顯著正相關；財務獎勵的認知程度則與DDM參與程度有正向相關。研究亦發現，照護品質的認知程度，對於DDM計畫的加入及收案，比財務獎勵的認知程度影響要大；後者對於DDM參與程度的影響，則大於前者。此外，專業自主的認知分數，每增加一個單位的勝算比，45歲以上受訪者為年齡較小者的4.4倍（95%信賴區間為1.2-16.9）；財務獎勵的認知分數，年長者為年輕者的4.6倍（95%信賴區間1.2-17.9）。本研究為第一個探討台灣糖尿病疾病管理計畫對醫師的激勵認知與參與度的相關性研究。激勵認知的各面向，對於醫師參與計畫的每一階段的影響性有顯著不同，提醒決策者應修正計畫內容，以滿足醫師的需求。任何改善醫師參與計畫的措施，應考慮醫師的年齡，並應注意系統層面及管理層面的問題。

Evidence of the incentive-participation relationship is essential to any incentive-based approach to increase and sustain provider participation in disease management programs. This study was aimed at exploring the relationship between physician perceptions of National Diabetes Disease Management Program incentives and their participation in the NDDMP in Taiwan. A cross-sectional survey of a nationally representative sample of 1600 physicians was conducted with mailed questionnaires, which included a validated instrument to measure provider perceptions of incentives (PPI). A total of 381 subjects responded to the survey and 345 completed the questionnaire. The response rates were 22% for the overall sample, 35% for the NDDMP-participating sample, and 12% for the NDDMP-nonparticipating sample. Results showed that the PPI scores of NDDMP participants were significantly higher than non-participants (mean ± SD, 3.3±0.5 vs. 3.0±0.5), although the magnitude of the difference was not large. Perceptions of incentives related to professional autonomy, quality of care, and financial rewards were positively associated with adoption and implementation and extent of participation, but not the maintenance phase of participation. Perception of cost and administrative burden were not associated with any measure of provider participation. After controlling for context factors and other adopter factors that were significantly associated with provider participation but were less controllable by program managers, perception of the quality of care was still positively associated with adoption, while perception of financial reward was related to the extent of participation. Perception of the quality of care had a larger effect than measures of financial incentives on adoption and implementation, while perception of financial reward had a larger effect than measures of professional incentives on the extent of physician participation. In addition, the ratio of odds ratios of adoption per one unit increase in professional autonomy score between physicians older than 45 years of age and younger physicians was 4.4 (95% CI, 1.2-16.9). On the contrary, younger physicians had higher odds ratios of adoption in regard to financial reward score than physicians older than 45 years of age (the ratio of odds ratios was 4.64 and 95% CI, 1.21-17.90). This is the first study to demonstrate the relationship between provider incentive and participation in the NDDMP in Taiwan. The importance of different dimensions of perception of program incentives in each phase of participation calls for a careful redesign of the program to address the needs of physicians. Age should be considered in implementing provider interventions. Issues at both the system and management levels should also be addressed.