進階搜尋


   電子論文尚未授權公開,紙本請查館藏目錄
(※如查詢不到或館藏狀況顯示「閉架不公開」,表示該本論文不在書庫,無法取用。)
系統識別號 U0026-2108201403475300
論文名稱(中文) 長期的糖尿病照護品質綜合量表預測第二型糖尿病患者之慢性腎臟病的發生
論文名稱(英文) Long-term quality-of-care summary score predicts the occurrence of chronic kidney disease in type 2 diabetic patients
校院名稱 成功大學
系所名稱(中) 環境醫學研究所
系所名稱(英) Institute of Environmental and Occupational Health
學年度 102
學期 2
出版年 103
研究生(中文) 莊朝凱
研究生(英文) Chao-Kai Chuang
學號 s76004109
學位類別 碩士
語文別 英文
論文頁數 59頁
口試委員 口試委員-吳晉祥
口試委員-林聖翔
指導教授-張志欽
中文關鍵字 第二型糖尿病  慢性腎臟病  全民健康保險資料庫 
英文關鍵字 Type II diabetes  chronic kidney disease  National Health Insurance database 
學科別分類
中文摘要 背景:糖尿病在近三十年高居台灣前五大死因,且為增加多種併發症風險的疾病。目前對於糖化血色素的建議檢查遵循程度、以及整合建議檢查與臨床數值的綜合分數能否預測第二型糖尿病人中慢性腎臟病發生尚未明確。本研究之研究目的為探討糖化血色素檢查的遵循程度以及糖尿病照護綜合量表是否能夠預測第二型糖尿病人慢性腎臟病的發生風險。
目的:本篇研究族群選取自全民健康保險資料庫中的糖尿病抽樣歸人檔,以及台灣某醫療中心之就醫資料,自1999-2003年之第二型糖尿病人新發生個案,並追蹤至2011年。糖化血色素之建議檢查次數為每年兩次以上。在長期照護品質綜合量表部分,考慮並計算設限日前三年之建議檢查情形與中間變項指標(糖化血色素、血壓、低密度脂蛋白膽固醇、微蛋白尿、足部檢查、眼底檢查)所加總的分數,總分範圍自0至45分。利用Cox比例風險模型分析糖尿病的照護與慢性腎臟病發生的關係。
結果:研究族群共有4,754名第二型糖尿病新發生個案,其中1,407名發生慢性腎臟病。研究族群平均追蹤時間為9.06年,平均年齡為55.3歲,有54.8%為男性。在Cox比例風險模型分析中,遵循糖化血色素檢查比起平均每年檢查次數小於一次者,其危險對比值在校正其他干擾因子後為0.59 (95% CI= 0.51-0.68);照護品質綜合量表分數為25分以上者以及介於10-20之族群,比起分數在5分以下者,其危險對比值在校正其他干擾因子後分別為0.42 (95% CI= 0.32-0.56)以及0.85 (95% CI= 0.76-0.95)。
結論:
遵循糖化血色素建議檢查次數之糖尿病患者有較低的慢性腎臟病風險。糖尿病照護品質綜合量表分數與慢性腎臟病的發生呈現顯著的負相關。整合建議檢查與臨床數值的綜合分數量表能夠預測第二型糖尿病人中慢性腎臟病的發生。
英文摘要 Background: Diabetes mellitus is at top 5 of leading causes of death in Taiwan for 30 years. Patients with diabetes are at high risk of causing multiple complications. But little is known about whether adherence to process or intermediate outcome indicators recommendation is effective in predicting the occurrence of chronic kidney disease (CKD) in type 2 diabetic patients. The aim of study was to investigate whether adherence to frequency of HbA1c test recommendation and a quality of care summary score is able to predict the occurrence of CKD in type 2 diabetic patients.
Methods: From 1999 to 2003, incident type 2 diabetes patients were identified from Longitudinal Cohort of Diabetes Patients database of National Health Insurance program and medical records of a medical center in Taiwan, and followed up to 2011. It is recommended that HbA1c test was performed at least twice a year. The long-term and comprehensive quality-of-care summary score were calculated by using process and intermediate outcome indicators (HbA1c, blood pressure, low-density lipoprotein cholesterol, microalbuminuria, foot exam, and eye exam) in the last 3 years before censored date, with scores ranged from 0 to 45. Cox proportional hazard regression model was employed to evaluate the association between diabetic care and CKD.
Results: Overall, 4,754 patients were enrolled, of whom 1,407 developed CKD events after a mean follow-up of 9.06 years. The average age was 55.3 years old, and 54.8 % were male. The adjusted hazard risk (HR) for CKD for those adherence to proposed HbA1c test guideline was 0.59 (95% confidence interval (CI= 0.51-0.68) compared to patients with poor adherence (< 2 times/year). On the other hand, the adjusted HR for CKD for those patients with a score of ≥ 25 and 10-20 were 0.42 (95% CI= 0.32-0.56) and 0.85 (95% CI= 0.76-0.95), respectively, compared to patients with score of ≤ 5.
Conclusion: Adherence to recommended HbA1c test significantly decreases the occurrence of CKD in diabetic patients. The quality of care summary score is reversely associated with the occurrence of CKD. The scoring system which contains process and intermediate outcome indicators may be used to predict the occurrence of CKD in type 2 diabetic patients.
論文目次 摘要 i
Abstract ii
致謝 iii
Content v
I. Introduction 1
I.1 Diabetes mellitus 1
I.1.1 Classification 1
I.1.2 Diagnosis 1
I.1.3 Diabetic complications 2
I.1.4 Epidemiology 4
I.2 Glucose control on diabetic complications 6
I.3 Diabetes care 7
I.3.1 Recommendations and guidelines of diabetes care 7
I.3.2 Diabetes care-related literatures review 7
I.3.3 Diabetes care in Taiwan 9
I.4 Chronic kidney disease 10
I.4.1 Epidemiology 10
I.4.2 The relationship between diabetes and chronic kidney disease 11
I.5 Objective 11
II. Materials and Methods 13
II.1 Study design 13
II.1.1 Study type 13
II.1.2 Data source 13
II.1.3 Disease and drug classification 15
II.1.4 Subjects selection 15
II.1.5 Exclusion criteria of study subjects 16
II.2 Definition of variables 17
II.2.1 Independent variable definitions 17
II.2.2 Dependent variable definitions 17
II.3 Flowchart and data linking illustration 17
II.3.1 Flowchart of subjects selection 17
II.3.2 Guidelines of data linking 17
II.4 Quality-of-diabetes-care summary score 17
II.5 Statistical analyses and tools 19
II.5.1 Descriptive statistics 19
II.5.2 Statistical inference 19
II.5.3 Statistical tools 20
III. Results 21
III.1 Demographic characteristics of study subjects. 21
III.2 Kaplan-Meier plot (HbA1c frequency) 21
III.3 Kaplan-Meier plot (Score group) 22
III.4 Risk of CKD event 22
III.4.1 Univariate analysis 22
III.4.2 Multivariate analysis 23
III.5 The differences of the previous and present summary score systems on predicting the risk of CKD event. 23
IV. Discussion 24
V. Conclusion 28
VI. References 29
VII. Tables and Figures 35
Table 1. Criteria for the diagnosis of diabetes (American Diabetes 2014) 35
Table 2. Recommendations of screening and goals of treatment for type 2 diabetes patients 35
Table 3. Content in registration and original claim data of NHIRD 36
Table 4. Content in the medical center data 37
Table 5. Diagnostic codes used in this study 37
Table 6. Independent variable definitions 39
Table 7. Dependent variable definitions 41
Table 8. Quality-of-care scoring system 42
Table 9. Characteristics of quality-of-care score of type 2 diabetic patients 43
Table 10. Univariate analysis - Relative Hazards of CKD in type 2 diabetes patients 45
Table 11. Multivariate analysis - Relative Hazards of CKD in type 2 diabetes patients 47
Table 12. Association between 5 points increasing of summary score and the risk of CKD (n=4,754) 47
Table 13. Association between each score group of summary score and the risk of CKD (n=4,754) 48
Table 14. Comparisons of the number and percentage in each score of study subjects group defined by present and previous score systems 48
Table 15. Association between each score group of summary score developed and modified in previous studies and the risk of CKD (n=4,754) 48
Figure 1. Flowchart with details of selection of study subjects 50
Figure 2. Guidelines of data linking of Longitudinal Cohort of Diabetes Patients database (LHDB) 50
Figure 3. Kaplan-Meier plot (HbA1c frequency) 51
Figure 4. Kaplan-Meier plot (Score group) 52
Appendix 54
參考文獻 American Diabetes A. 2014. Standards of medical care in diabetes--2014. Diabetes care 37 Suppl 1:S14-80.
Centers for Disease Control and Prevention C. 2014. National diabetes statistics report: Estimates of diabetes and its burden in the united states, 2014. Atlanta, GA.
Chang CH, Shau WY, Jiang YD, Li HY, Chang TJ, Sheu WH, et al. 2010. Type 2 diabetes prevalence and incidence among adults in taiwan during 1999-2004: A national health insurance data set study. Diabetic medicine : a journal of the British Diabetic Association 27:636-643.
Chang HY, Hsu CC, Pan WH, Liu WL, Cheng JY, Tseng CH, et al. 2010. Gender differences in trends in diabetes prevalence from 1993 to 2008 in taiwan. Diabetes research and clinical practice 90:358-364.
Cheng SH, Lee TT, Chen CC. 2012. A longitudinal examination of a pay-for-performance program for diabetes care: Evidence from a natural experiment. Medical care 50:109-116.
Chiou ST, Lin HD, Yu NC, Hseuh HK, Lin LH, Lin LT, et al. 2001. An initial assessment of the feasibility and effectiveness of implementing diabetes shared care system in taiwan--some experiences from i-lan county. Diabetes research and clinical practice 54 Suppl 1:S67-73.
Choo PW, Rand CS, Inui TS, Lee ML, Cain E, Cordeiro-Breault M, et al. 1999. Validation of patient reports, automated pharmacy records, and pill counts with electronic monitoring of adherence to antihypertensive therapy. Medical care 37:846-857.
Chuang LM, Tsai ST, Huang BY, Tai TY, Group DS. 2001. The current state of diabetes management in taiwan. Diabetes research and clinical practice 54 Suppl 1:S55-65.
De Berardis G, Pellegrini F, Franciosi M, Belfiglio M, Di Nardo B, Greenfield S, et al. 2008. Quality of diabetes care predicts the development of cardiovascular events: Results of the qued study. Nutrition, metabolism, and cardiovascular diseases : NMCD 18:57-65.
Deyo RA, Cherkin DC, Ciol MA. 1992. Adapting a clinical comorbidity index for use with icd-9-cm administrative databases. Journal of clinical epidemiology 45:613-619.
Dronavalli S, Duka I, Bakris GL. 2008. The pathogenesis of diabetic nephropathy. Nature clinical practice Endocrinology & metabolism 4:444-452.
Fried LF, Katz R, Sarnak MJ, Shlipak MG, Chaves PH, Jenny NS, et al. 2005. Kidney function as a predictor of noncardiovascular mortality. Journal of the American Society of Nephrology : JASN 16:3728-3735.
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. 2004. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. The New England journal of medicine 351:1296-1305.
Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 2008. 10-year follow-up of intensive glucose control in type 2 diabetes. The New England journal of medicine 359:1577-1589.
Hwang SJ, Tsai JC, Chen HC. 2010. Epidemiology, impact and preventive care of chronic kidney disease in taiwan. Nephrology 15 Suppl 2:3-9.
International Diabetes Federation I. 2014. Complications of diabetes. Available: http://www.idf.org/complications-diabetes.
Karunaratne K, Stevens P, Irving J, Hobbs H, Kilbride H, Kingston R, et al. 2013. The impact of pay for performance on the control of blood pressure in people with chronic kidney disease stage 3-5. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 28:2107-2116.
Kim N, Agostini JV, Justice AC. 2010. Refill adherence to oral hypoglycemic agents and glycemic control in veterans. The Annals of pharmacotherapy 44:800-808.
Krousel-Wood M, Thomas S, Muntner P, Morisky D. 2004. Medication adherence: A key factor in achieving blood pressure control and good clinical outcomes in hypertensive patients. Current opinion in cardiology 19:357-362.
Kuo HW, Tsai SS, Tiao MM, Yang CY. 2007. Epidemiological features of ckd in taiwan. American journal of kidney diseases : the official journal of the National Kidney Foundation 49:46-55.
Kuo HW, Tsai SS, Tiao MM, Liu YC, Lee IM, Yang CY. 2010. Analgesic use and the risk for progression of chronic kidney disease. Pharmacoepidemiology and drug safety 19:745-751.
Laliberte F, Bookhart BK, Vekeman F, Corral M, Duh MS, Bailey RA, et al. 2009. Direct all-cause health care costs associated with chronic kidney disease in patients with diabetes and hypertension: A managed care perspective. Journal of managed care pharmacy : JMCP 15:312-322.
Liu JH, Lin SY, Hsu CY, Lin HH, Liang CC, Sung FC, et al. 2012. The risk for chronic kidney disease in patients with heart diseases: A 7-year follow-up in a cohort study in taiwan. BMC nephrology 13:77.
Middleton RJ, Foley RN, Hegarty J, Cheung CM, McElduff P, Gibson JM, et al. 2006. The unrecognized prevalence of chronic kidney disease in diabetes. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 21:88-92.
Ministry of Health and Welfare M. 2012. Health and vital statistics: (2) vital statistics, taiwan area, roc. Department of health, editor. Taipei: Department of health, the executive yuan, republic of china.
New JP, Middleton RJ, Klebe B, Farmer CK, de Lusignan S, Stevens PE, et al. 2007. Assessing the prevalence, monitoring and management of chronic kidney disease in patients with diabetes compared with those without diabetes in general practice. Diabetic medicine : a journal of the British Diabetic Association 24:364-369.
Oh SW, Lee HJ, Chin HJ, Hwang JI. 2011. Adherence to clinical practice guidelines and outcomes in diabetic patients. International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua 23:413-419.
Parving HH, Lehnert H, Brochner-Mortensen J, Gomis R, Andersen S, Arner P, et al. 2001. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. The New England journal of medicine 345:870-878.
Retnakaran R, Cull CA, Thorne KI, Adler AI, Holman RR, Group US. 2006. Risk factors for renal dysfunction in type 2 diabetes: U.K. Prospective diabetes study 74. Diabetes 55:1832-1839.
Roglic G, Unwin N. 2010. Mortality attributable to diabetes: Estimates for the year 2010. Diabetes research and clinical practice 87:15-19.
Rossi MC, Lucisano G, Comaschi M, Coscelli C, Cucinotta D, Di Blasi P, et al. 2011. Quality of diabetes care predicts the development of cardiovascular events: Results of the amd-quasar study. Diabetes care 34:347-352.
Saydah S, Tao M, Imperatore G, Gregg E. 2009. Ghb level and subsequent mortality among adults in the u.S. Diabetes care 32:1440-1446.
Shurraw S, Hemmelgarn B, Lin M, Majumdar SR, Klarenbach S, Manns B, et al. 2011. Association between glycemic control and adverse outcomes in people with diabetes mellitus and chronic kidney disease: A population-based cohort study. Archives of internal medicine 171:1920-1927.
Sloan FA, Bethel MA, Lee PP, Brown DS, Feinglos MN. 2004. Adherence to guidelines and its effects on hospitalizations with complications of type 2 diabetes. The review of diabetic studies : RDS 1:29-38.
Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, et al. 2000. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (ukpds 35): Prospective observational study. Bmj 321:405-412.
Suying L, Jiannong L, Gilbertson D, McBean M, Dowd B, Collins A. 2008. An instrumental variable analysis of the impact of practice guidelines on improving quality of care and diabetes-related outcomes in the elderly medicare population. American journal of medical quality : the official journal of the American College of Medical Quality 23:222-230.
Tseng CH. 2004. Mortality and causes of death in a national sample of diabetic patients in taiwan. Diabetes care 27:1605-1609.
Tseng CH, Tseng CP, Chong CK, Huang TP, Song YM, Chou CW, et al. 2006. Increasing incidence of diagnosed type 2 diabetes in taiwan: Analysis of data from a national cohort. Diabetologia 49:1755-1760.
U.S. Renal Data System. 2013. Usrds 2013 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the united states.National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.
UK Prospective Diabetes Study group. 1998. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (ukpds 33). Uk prospective diabetes study (ukpds) group. Lancet 352:837-853.
Weiner DE, Tighiouart H, Amin MG, Stark PC, MacLeod B, Griffith JL, et al. 2004. Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: A pooled analysis of community-based studies. Journal of the American Society of Nephrology : JASN 15:1307-1315.
Wen CP, Cheng TY, Tsai MK, Chang YC, Chan HT, Tsai SP, et al. 2008. All-cause mortality attributable to chronic kidney disease: A prospective cohort study based on 462 293 adults in taiwan. Lancet 371:2173-2182.
Wild S, Roglic G, Green A, Sicree R, King H. 2004. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes care 27:1047-1053.
Wu PH, Yang CY, Yao ZL, Lin WZ, Wu LW, Chang CC. 2010. Relationship of blood pressure control and hospitalization risk to medication adherence among patients with hypertension in taiwan. American journal of hypertension 23:155-160.
Young BA, Lin E, Von Korff M, Simon G, Ciechanowski P, Ludman EJ, et al. 2008. Diabetes complications severity index and risk of mortality, hospitalization, and healthcare utilization. The American journal of managed care 14:15-24.
Yu NC, Su HY, Chiou ST, Yeh MC, Yeh SW, Tzeng MS, et al. 2013. Trends of abc control 2006-2011: A national survey of diabetes health promotion institutes in taiwan. Diabetes research and clinical practice 99:112-119.
論文全文使用權限
  • 同意授權校內瀏覽/列印電子全文服務,於2019-08-29起公開。


  • 如您有疑問,請聯絡圖書館
    聯絡電話:(06)2757575#65773
    聯絡E-mail:etds@email.ncku.edu.tw