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EFFECTS OF PATIENT CASE-MIX, PHYSICIAN SPECIALTY, AND HOSPITAL CHARACTERISTICS ON PROCESS AND OUTCOMES OF DIBAETES CARE IN TAIWAN

Fen-Yu Tseng, ¹Mei-Shu Lai, ¹Ci-Yong Syu, ²Cheng-Ching Lin

Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, ¹Institute of Preventive Medicine, College of Public Health, National Taiwan University, ²Department of Family Medicine, Taipei Medical University Municipal Wan-Fang Hospital, Taiwan

The first part of the study evaluated the influence of patient case-mix and hospital characteristics on professional accountability for diabetes care in Taiwan. The second part of the study examined the effects of physician specialty on the process and outcomes of diabetes care.

The year 2001 claims data from National Health Insurance (NHI) program in Taipei Branch was used in the first part of this study. Professional accountability for diabetes care was measured by the adherence for laboratory monitor, either from patient- or hospital- viewpoint. Identifying the major care unit for each patient, a multiple logistic regression model was used to further assess the mixed effects of patient and hospital characteristics. The percentage of patients received measures in the year for plasma glucose, A1C, urinalysis, renal function test, lipid profile, liver function test, and eye ground was 76.3%, 42.7%, 40.2%, 59.7%, 59.2%, 53.2%, and 16.8% respectively. Patients with hypoglycemic, anti-hyperlipidemic, or anti-hypertensive 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 had persistently effects on all the measures. Our analysis revealed sub-optimal diabetes care in Taiwan and concluded the importance of enhancing care quality from primary settings.

In the second part of the study, one tenth of the patients with diabetes who visited National Taiwan University Hospital more than 4 times in the year 2002 were randomly sampled out. A retrospective chart review was conducted of those who were regularly cared for by endocrinologists (EN), other specialists in internal medicine (IM) and family medicine physicians (FM). Effects of physician specialty on the process or outcome indicators were analyzed by logistic regression or linear regression, accordingly. A total of 875 diabetic patients (477 men and 398 women) with a mean age of 62.3 ¡Ó 12.7 years were recruited. EN patients showed a significantly better adherence to glucose checkup, glycated hemoglobin A1C measures and urinalysis than IM patients. EN patients also had better adherence to glucose checkup and urinalysis than FM patients. 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. We concluded that physician specialty had significant effects on the process and outcomes of diabetes care.