一、研究目的: 為了解基層醫療中,糖尿病初診斷後,一開始由家醫科醫師、內科醫師與一般科醫師提供照護的病人,在急性併發症發生率、慢性併發症發生時間,與醫療資源耗用上是否有差異。
二、研究方法:本研究使用健保資料庫 2001-2007 年百萬人抽樣歸人檔,針對 2002 年初 診斷糖尿病患者,針對低血糖、高血糖高滲透壓非酮體性昏迷、酮酸中毒等 三項急性併發症,以及糖尿病大血管疾病(冠狀動脈心臟病與中風)、糖尿病 腎病變、糖尿病眼底病變、糖尿病神經病變與糖尿病周邊血管病變等五種慢 性併發症進行醫療品質相關探討,並分析各組病患每人年平均門診、急診、 住院費用,以了解醫療資源使用概況。
三、結果: 在急性併發症上,家醫科醫師的病人較內科病人有較高的低血糖發生率,但有比內科及一般科病人都較低的酮酸中毒加上高血糖高滲透壓非酮體性昏迷發生率。針對慢性併發症的發現情況,家醫科醫師對大血管病變一年內的發現比率較低,其餘皆無顯著差異;而一年至五年內慢性併發症的發生時間與發生率,家醫科醫師在糖尿病神經病變的發生時間,與慢性腎病變的發生率上皆有較好的控制成效。在費用的部份,家醫科醫師的病人其每人年門診費用較內科醫師為低,而急診、住院費用則稍高,糖尿病相關總費用則又是三者最低,但除門診費用外其他並無顯著差異。
四、討論: 一開始於家醫科醫師門診就診的民眾,在醫療品質相關指標並無明顯差異的情況下,其門診就醫費用明顯少於內科醫師的病患。但因健保資料庫的限制,仍有許多後續研究需持續進行。

Objective:
To recognize the difference of patient care offered by primary care family physician, internist and generalist, according to the incidence rate of the acute complications, time to event interval of the chronic complications and the cost of OPD, admission and emergency care.
Method:
The first diagnosed diabetes patients were extracted from the National Health Insurance database, utilizing data from 2001 to 2007 to fit the criteria. Patients with catastrophic illness and who attended to the primary care clinic less than 20% of total OPD visits were excluded. The incidence rate of DM acute complications such as hypoglycemia, NKHS and DKA, and the time to event interval of DM chronic complications such as CAD, stroke, DM nephropathy, DM retinopathy, polyneuropathy and DM peripheral artery disease were investigated. Furthermore, the cost of OPD visit, emergency care and hospital admission was also evaluated.
Result:
The patients cared by primary care family physician tended to get hypoglycemia more frequently, but less likely to get hyperglycemic complications including both DKA and NKHS.The family physician did not recognize the large vessel complications well but can effectively control the diabetic neuropathy and diabetic nephropathy. Compare to those cared by internist, the patients cared by family physician have the lower expense on diabetic related OPD visit, but a little higher on emergency and admission. Totally, the patients cared by family physician have the lowest cost compared to internist and generalist, but without significant difference.
Conclusion:
The cost of OPD visit was significantly lower in patient cared by primary care family physician compared to internist without sacrifice the quality of care. Further study was necessary due to the limitation of the application of secondary database.

中 文 摘 要 I
英文摘要 II
目 錄 III
圖 次 IV
表 次 V
第一章 緒論 1
研究背景及動機 1
研究目的 3
第 二 章 文 獻 查 證 4
糖尿病的診斷與盛行率 4
糖尿病的預後與急慢性併發症 6
糖尿病與醫療資源利用 8
家庭醫學科門診特性與基層醫療 9
糖尿病與照護科別 10
第 三 章 研 究 方 法 11
研究假設與架構 11
一、 研究假設 11
二、 研究架構 11
研究對象、抽樣方法與資料收集程序 12
一、 研究對象與抽樣方法 12
二、 資料收集程序 12
資料處理與分析方法 18
一、 描述性統計分析 18
二、 推論性統計分析 18
第 四 章 研 究 分 析 與 結 果 21
描述性統計分析 21
一、 基本資料分析: 21
推論性統計分析 22
一、急性併發症 22
二、慢性併發症 24
三、醫療費用 28
第五章 討論與建議 29
研究討論 29
研究限制 32
建議 33
參考文獻 34
一、 中文文獻: 34
二、 英文文獻: 35

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