目的： 2013年全民健康保險局統計糖尿病及相關合併症占醫療費用支出第4位。糖尿病合併症包括大小血管病變(心肌梗塞、失明)，腎臟病變(腎衰竭)，以及足部潰瘍感染、截肢等。2001年全民健康保險局推出糖尿病共同照護網專案，提供整合性持續性團隊服務，以改善糖尿病醫療品質。本研究以醫療持續性(COC)評價2003~2007年糖尿病群體醫療品質成效。
方法：以全民健康保險資料庫百萬歸人檔，滿18歲以上， 2001/01/01 ~2002/12/31門診就醫紀錄有4次以上，ICD-9 CM前三碼為250為收案標準，得20,070位個案，追蹤期間為2003/01/01至2007/12/31，探討COC (COCI、MMCI)、 糖尿病合併症、醫療資源利用、醫療機構層級，與下肢截肢、再截肢發生之相關性。
結果：每人每年平均門診次數9.29±5.23次， 糖尿病合併症盛行率57.64±0.54%(p< 0.01)，五年內再截肢發生率為23.26%，1/3截肢個案發生3次以上的截肢，周邊血管病變導致截肢發生風險高達22倍(p < 0.01)。高COC勝過低COC，有1.26倍(p < 0.01)、1.62倍(p < 0.01)發生截肢與再截肢風險；低COC看診醫師數量最多，神經病變(41.31%)及周邊血管病變(19.54%)發生比他組COC高，但下肢相關性檢查率卻最低。基層醫療機構與區域醫院並列截肢風險最高(p < 0.01)；基層醫療機構再截肢風險最高(p < 0.01)，但特定糖尿病相關疾病死亡風險，卻比區域醫院、地區醫院就醫者低(p < 0.01)。
結論：經COC與截肢風險得知，COC無法避免再截肢的發生；就醫機構層級越高，不代表急診及住院風險越低、截肢與再截肢風險越低，推論糖尿病醫療政策與就醫機構層級無法證明糖尿病醫療品質可獲得改善。

Objective: The expense of treating Diabetes Mellitus and its complication is the 4th largest part of all in Taiwan Health insurance system. Since continuously multidiscipline team service is the best strategy for Diabetic care. This study is aimed to investigate the relationship between COC (continuity of care) and risk of diabetic foot in Taiwan.
Method: We used Taiwan National Health Insurance database to make a longitudinal study during 2001 to 2007. Only adult diabetes patients who had more than 4 times ambulatory records in 2001-2002 were enrolled. The outcomes from 2003 to 2007 were analyzed as following: risk of amputation, re-amputation, and death. COC and medical expense and organization of care were counted as independent variables.
Result: Re-amputation rate is 23.26%, 1/3 amputated diabetes have been received ≧ 3 times amputation. The highest risk of amputation and re-amputation is high COC, which are 1.26 times (p <0.001) and 1.62 times (p <0.001). Amputated diabetes patient had 3 times (p <0.001) risk of specific diabetes associated death. Different medical organization type was not related to the risk of amputation. Low COC was related to poorer vascular and neurological outcome.
Conclusion: We believed that diabetic foot care was a missing circle of the chain of multidiscipline diabetes care chain.

論文審定書………..……………………………………………………………………………..i
致謝………………………………………………………………………………………………ii
中文摘要………………………………………………………………………………………....iii
英文摘要…………………………………………………………………………………………iv
第一章 緒論……………………………………………………………………………….……1-2
第一節 研究背景與研究動機……………………………………………………………...1
第二節 研究目的…………………………………………………………………………...2
第二章 文獻探討…………………………………………………………………………..…..3-27
第一節 糖尿病………………………………………………………………………..…..3-12
流行病學……………………………………………………………………………….3
醫療耗費……………………………………………………………………………….5
糖尿病足預防措施…………………………………………………………………….8
小結……………………………………………………………………………………11
第二節 全民健康保險之糖尿病醫療給付改善專案…………………………………..….13-15
小結………………………………………………………………………………………14.
第三節 轉診制度、醫療機構層級與就醫行為……………………………………..……..15-17
第四節 醫療持續性指標…………………………………………………………..………18-27
定義…………………………………………………………………………………….....18
醫療持續性用於糖尿病………………………………………………………………… 19
醫療持續性之運用(非糖尿病研究)……………….…………………………………… 24
醫療持續性測量方法…………………………………………………………………… 26
小結……………………………………………………………………………………… 27
第三章 研究方法……………………………………………………………………..……….. 28-34
第一節 研究設計與架構…………………………………………………………………....28
第二節 研究問題與假設……………………………………………………………………28
第三節 研究樣本與資料來源………………………………………………………………29
第四節 研究變項之操作型定義……………………………………………………………29
第五節 資料處理與分析方法……………………………………………………………..33
第四章 研究分析與結果………………………………………………………………………35-59
第一節 研究樣本基本資料描述……………………………………………………………35
第二節 多重線性迴歸分析…………………………………………………………………44
第三節 多重邏輯迴歸分析…………………………………………………………………50
第四節 假設驗證……………………………………………………………………………59
第五章 研究討論……………………………………………………………………………… 60-63
第一節 人口學資料…………………………………………………………………………60
第二節醫療資源利用………………………………………………………………………..61
第三節糖尿病醫療品質指標………………………………………………………………..62
第六章 研究結論與建議…………………………………………………………………………64
第一節 研究結論………………………………………………………………………….64-66
第二節 研究限制……………………………………………………………………………64
第三節 研究建議……………………………………………………………………………66
第四節 研究貢獻……………………………………………………………………………66
參考文獻…………………………………………………………………………………………67-70

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