| Summary: | 博士 === 國立臺灣大學 === 預防醫學研究所 === 94 === Aims:
The diabetic population in Taiwan is estimated to be over 1,000,000. Diabetes is the fourth leading cause of death in Taiwan. Improvement in the quality of diabetes care is critical, both for patients and health care costs. The main purpose of this study is to evaluate the quality of diabetes care in Taiwan.
Study design and methods:
Four study populations were recruited for evaluating quality of diabetes care in different domains. Study population I (NHI-DM population) enrolled diabetic patients randomly sampled from year 2001 National Health Insurance Bureau Taipei Branch claims data. Effects of patient factors or hospital factors on adherence to diabetes care measures were analyzed by logistic regression. Study population II (NTUH-T2DM patients) recruited 875 type 2 diabetic patients who were regularly cared for by endocrinologists (EN), internists (IM) and family medicine physicians (FM) at National Taiwan University Hospital (NTUH) in the year 2002. Adherence to laboratory exams and quality improvement measures (glycemic, blood pressure, and lipid control) of diabetic patients were evaluated. Effects of physician specialty on professional performance or patient health status indicators were analyzed by logistic regression or linear regression, accordingly. Study population III (NTUH-T2DM-Q patients) recruited 512 type 2 diabetic patients who were regularly treated at NTUH and responded to our questionnaire. Awareness of test results and self-management in diabetic patients were assessed. Effects of patient characteristics or physician factors on the clinical awareness, and self-monitoring of blood glucose (SMBG) were evaluated by logistic regression. Study population IV (NTUH-T1DM patients) recruited 471 type 1 diabetic patients who were treated at NTUH in the period between 1995 and 2005. Adherence to diabetes care measures, glycemic control, blood pressure control, lipid control, and long-term clinical outcomes of the study cohort were evaluated. Risk factors for developing diabetic nephropathy were analyzed by logistic regression and Cox regression.
Results:
Adherence rates to plasma glucose, glycated hemoglobin A1C (A1C), urinalysis, renal function test (RFT), lipid profile, liver function test (LFT), and eye ground exam (eye) in the NHI-DM population was 76.3%, 42.7%, 40.2%, 59.7%, 59.2%, 53.2%, and 16.8%, respectively. Patients with hypoglycemic medications, anti-hypertensive drugs, lipid-lowering agents, hospitalization, emergency service visit and frequent visits were more likely to receive exams. Hospitals with different levels, ownerships, locales or qualifications as diabetes care institutions presented different accountability for diabetes care measures. After regression, counts of visits and levels of hospitals persistently affected all the measures.
The adherence rates to annual measures in NTUH-T2DM patients for glucose, A1C, urinalysis, RFT, lipid profile, LFT, and eye exam were 89.7%, 82.5%, 48%, 53.6%, 69%, 45.9%, and 18%, respectively. EN patients showed a significantly better adherence to glucose checkup, A1C measure and urinalysis than IM patients. EN patients also had better adherence to glucose checkup and urinalysis than FM patients. The mean A1C for NTUH-T2DM patients was 7.3 ± 1.5%. About 49.3% patients had an A1C level < 7.0%. EN patients had the lowest mean fasting plasma glucose (FPG) and lowest mean postprandial plasma glucose (PPG). The difference in PPG between EN and IM patients, and the difference in FPG between EN and FM patients were persistently significant following adjustment by patient and physician characteristics.
Percentages of patients who knew their test results were: glucose level 73%, A1C level and meaning 17.9%, proteinuria 33.3%, impaired renal function test 66.7%, liver disease 65.5%, dyslipidemia 70.6%. Unawareness of clinical conditions was remarkable in patients with older age, lower education level, lower income, or less frequent visits. Patients treated with insulin, under the care of older physicians or diabetologists had better awareness of test results. About 49.3% patients performed SMBG. Patients with younger age, longer diabetes duration, higher income, insulin therapy, more comorbidities/complications, under the care of diabetologists were more likely to perform SMBG. Clinical awareness of glucose level or A1C meaning had significant correlations with SMBG.
The NTUH-T1DM patients had a mean latest A1C of 8.9 ± 1.5%. The percentages of NTUH-T1DM patients with retinopathy, neuropathy, nephropathy, cerebral vascular disease, coronary artery disease, and peripheral vascular disease were 23.1%, 15.1%, 25.7%, 1.1%, 4.0%, and 5.5%, respectively. Female, poor glycemic control, and dyslipidemia are risk factors for microalbuminuria. Hypertension, dyslipidemia, and smoking are risk factors for proteinuria. Older age at diagnosis, longer diabetes duration, and hypertension significantly increased risks for end stage renal disease (ESRD). The mean interval between DM diagnosis and ESRD was 13.3 ± 7.7 years. Five patients (1.1%) died. Medications for blood pressure control, renal protection, and lipid control were not prescribed as recommended by practice guideline for diabetes care.
Conclusions:
Hospital-, physician-, and patient- characteristics influence quality of diabetes care. Adherence to A1C measure, urinalysis, and eye ground exam is sub-optimal, especially in primary health care units. Physician specialty had significant effects on adherence to diabetes care measures and outcomes of diabetes care. Clinical awareness and self-care of diabetic patients should be further enhanced. Taiwanese type 1 diabetic patients had a tendency of early onset and rapid progress to develop microvascular complications. However, screening and follow-up exams were inadequate. Medications for preventing and slowing diabetic complications were not promptly prescribed. To improve quality of diabetes care in Taiwan, we should establish Taiwanese diabetes database, enhance adherence to diabetes care measures, encourage effective physician-patient communication, and reinforce fulfillment of the practice guideline.
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