摘要
目的：
台灣己邁入「高齡化社會」，病人所罹患的慢性共病性疾病不僅使患者在生活品質上受到嚴重的影響，同時亦造成健保醫療及國家社會福利上沈重的負擔。國外對於糖尿病患具慢性共病性疾病（例如心血管疾病、腦血管疾病、腎臟疾病及高血壓等）其醫療資源使用之情形已有相當多的研究，反觀國內多傾向於研究單一糖尿病患，尚缺乏有系統性的針對具共病性患者進行分析。本研究以量化的層面來進行共病性數目多寡對於醫療資源使用之分布情形，進而深入的探討其分別罹患的共病性疾病，其相互間影響醫療資源使用程度為何，並期望藉由此研究結果可以做為未來健康保險支付制度及醫療保健政策修訂之參考。
方法：
利用國家衛生研究院全民健康保險資料庫2005和2006年之罹患「糖尿病」的65歲以上老人，取得其『門診處方及治療明細檔』、『住院醫療費用清單明細檔』及『醫事機構基本資料檔』等資料，合併以上資料檔，並控制糖尿病患特質中的性別、年齡、區域、年度以及醫院機構特性（權屬別、評鑑等級）等變項，並利用獨立樣本t檢定、相關分析、複迴歸與邏輯斯迴歸進行其慢性共病性疾病(心血管疾病、腦血管疾病、腎臟疾病、高血壓)相關之醫療資源使用情形。
結果：
本研究發現糖尿病患具共病性者，在門診部份顯示：共病數0、1、2、≧3，其門診次數分別為52、69、70及86次；每人門診總費用分別 50,505、97,347、83,006及146,954元；住院部份顯示：共病數0、1、2、≧3，其住院次數分別為共病數0為2次，共病數1、2皆為3次，共病數≧3為5次；共病數0、1、2、≧3其住院天數分別為24、29、27及60天；每人住院總費用分別為118,079、174,727、147,639及271,725元。
使用邏輯式迴歸分析，結果發現年齡、醫療評鑑等級、所在地區、共病數與年度皆為影響糖尿病患其是否住院的主要因素。其中就共病數上結果顯示：共病數1、共病數2、共病數≧3者，比無具共病性者，分別高出1.689倍、1.599倍及3.319倍的住院機率。
結論：
由本研究結果可見，糖尿病患具共病性疾病者是佔相當高比重的一群族群，且共病性數目愈多其消耗相關醫療資源使用的情況也愈趨嚴重，故如何規劃醫療體制使其能提供適當整合式的醫療照護，乃是當前醫療政策制訂者必須重視的課題。建議有關政策擬定單位可以提升給付、保障點數等方法，或將其相關費用排除在醫院個別總額之外，以支持所有參與的醫療院所結合相關疾病之照護體系，充分運用已有資源及經驗，擴大發展全方位的共病性疾病照護體系。

Abstract
Research Objectives：The chronic diseases of the elderly not only influence their life quality but also become a great burden of the society on the health care costs. International studies focused on the utilization of medical care resources for diabetes mellitus patients of comorbidity, such as cardiovascular disease、cerebrovascular disease、renal disease and hypertensive. However, systemic analyses on the medical care utilization of the diabetes patients with comorbidity have not been well-studied in Taiwan. The purposes of the study are to quantitatively analyze the relationships between the number of comorbidity and the utilization of medical are resources, and to further discuss the interference on the utilization of medical care resources among individual diseases of the comorbidity. The research questions are: What is the effect of comorbidity on the type and volume of the utilization of medical care resources? Which comorbidity pattern has the highest effect?
Methods：Based on the databases established by the Bureau of National Health Insurance during the period of 2005 to 2006, the diabetes patients with aged 65 or older have been analyzed. The data analyses have been carried out by Chi-square test, T-test, Pearson’s correlation, and Multiple Regression and Logistic regression.
Result：Our results showed that the clinic-visiting frequencies of outpatients with a comorbidity score of 0, 1, 2 and 3 are 52, 69 , 70 and 86 times, respectively, and their expenses are NT dollars 50,505, 97,347, 83,006 and 146,954, respectively. The hospital admission frequency of inpatients with a comorbidity score of 0, 1, 2 and 3 are 2 , 3, 3 and 5 times, respectively; the length of stay are 24, 29, 27 and 60 days, respectively; and the inpatient expense are NT dollars 118,079, 174,727, 147,639 and 271,725 respectively. In addition, the logistic regression model showed that ORs for the probability of hospitalization for the patients with comorbidity scores of 1, 2 and 3 were higher than those with the comorbidity score of 0（OR=1.689, OR=1.597, OR=3.319）respectively.
Conclusion：A clear gradient was observed between the number of comorbidities and the increased health care utilizations. Moreover, comorbidity among diabetes patients is associated with considerable consequences of health care and related costs. In addition, current single-disease approach of diabetes care should be extended to the integrated care modules, which must be generic and include comorbidity disease in order to meet the complex health care demands of diabetes patients in the future.

目錄
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究方法與目的 3
第三節 預期結果及應用 4
第二章 文獻探討 5
第一節 糖尿病之介紹 5
第二節 流行病學、醫療支出層面與其共病性之醫療資源使用概況 12
第三節 綜合文獻小結 25
第三章 研究設計與方法 26
第一節 研究設計與架構 26
第二節 研究問題與假設 29
第三節 研究樣本及資料蒐集 30
第四節 研究變項之操作型定義 34
第五節 研究資料之處理與分析 37
第四章 研究結果與分析 41
第一節 描述性統計 41
第二節 推論性統計 46
第五章 研究討論 66
第一節 重要發現與結論 66
第二節 研究假設驗證 69
第六章 研究建議 70
第一節 研究限制 70
第二節 研究建議 70
第三節 研究貢獻 71
參考文獻 72
表目錄
表 2-1 ：第一型糖尿病與第二型糖尿病之比較 6
表 2-2 ：糖尿病併發症分類 9
表 2-3 ：2000年和2030年糖尿病人數各國排行表 12
表 2-4 ：1995年和2025年糖尿病人數各國排行表 12
表 2-5 ：1995-2006台灣糖尿病死因順位、死亡人數、每十萬人口死亡率 15
表 2-6 ：國外糖尿病醫療支出層面相關研究整理 19
表 2-7 ：國內糖尿病醫療支出層面相關研究整理 20
表 2-8 ：國外糖尿病之共病性醫療資源使用影響相關研究整理 23
表 3-1 ：全民健保資料庫進行研究分析之優缺點比較 27
表 3-2 ：國外糖尿病共病性疾病相關研究ICD-9 CODES整理 31
表 3-3 ：研究樣本ICD-9 CODES 33
表 3-4 ：變項說明表 36
表 4-1 ：門診糖尿病患具共病性疾病之描述性統計 42
表 4-2 ：住院糖尿病患具共病性疾病之描述性統計 44
表 4-3 ：糖尿病患具共病性疾病之門診醫療資源使用情況 45
表 4-4 ：糖尿病患具共病性疾病之住院醫療資源使用情況 45
表 4-5 ：門診糖尿病患具共病性疾病人口學特質卡方分析表 47
表 4-6 ：門診糖尿病患具共病性疾病醫療機構特質卡方分析表 47
表 4-7 ：門診糖尿病患具共病性疾病所在地區、年度卡方分析表 48
表 4-8 ：住院糖尿病患具共病性疾病人口學特質卡方分析表 49
表 4-9 ：住院糖尿病患具共病性疾病醫療機構特質卡方分析表 49
表 4-10：住院糖尿病患具共病性疾病所在地區、年度卡方分析表 50
表 4-11：糖尿病患具共病性疾病門診醫療資源使用之T-檢定結果分析表 51
表 4-12：糖尿病患具共病性疾病住院醫療資源使用之T-檢定結果分析表 52
表 4-13：門診各變項之PEARSON相關分析 54
表 4-14：住院各變項之PEARSON相關分析 56
表 4-15：門診次數影響因素之複迴歸分析結果 58
表 4-16：每人門診總費用影響因素之複迴歸分析結果 59
表 4-17：住院次數影響因素之複迴歸分析結果 61
表 4-18：住院天數影響因素之複迴歸分析結果 62
表 4-19：每人住院總費用影響因素之複迴歸分析結果 63
表 4-20：糖尿病患具共病性疾病之住院邏輯斯迴歸分析 65
表 5-1 ：本研究假設與成果彙整表 69



圖目錄
圖 2-1：糖尿病的三段預防 9
圖 2-2：1995年和2025年糖尿病人數(百萬)-依年齡別、年、區域別 13
圖 2-3：2000年和2030年糖尿病人數(百萬)-依年齡別、年、區域別 14
圖 2-4：歷年糖尿病死亡概況-每十萬人口死亡人數按年齡別分 16
圖 3-1：本研究架構圖 28
圖 3-2：門診次級資料處理流程圖 38
圖 3-3：住院次級資料處理流程圖 39

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