背景：臺灣於2001年實施糖尿病論質計酬方案，截至2013年，仍有六成以上的糖尿病患未加入方案，其中一項重要原因為病患就醫的醫療院所或醫師未參與方案，導致病人無法獲得方案的照護機會。若高度都市化地區，比起低度都市化地區，更有能力推動方案時，糖尿病論質計酬可能會造成不同地區糖尿病患獲得照護機會的不平等。

目的：探討不同都市化程度地區間，獲得照護機會的比例是否有不平等的現象，以及分析造成不平等的解釋因素。

方法：使用國家衛生研究院的「糖尿病抽樣歸人檔」，研究對象為2004年至2009年的新發糖尿病患，選取在2010年存活且符合糖尿病論質計酬資格的對象分析，共納入151,860人。地區社經指標為病患投保地的都市化程度，分為高度、中度、低度三類。能否獲得論質計酬照護機會依據糖尿病患的固定就醫院所及醫師有無參與方案，若上述兩者皆未參與，則判定病人為無法獲得照護機會，而其餘的病人則判定為可獲得照護機會。統計方法使用邏輯斯迴歸分析，分析不同都市化地區無法獲得照護機會的比例是否有不平等及其影響因素，控制與解釋變項有病患的年齡、性別、居住縣市別、罹病年數、糖尿病門診次數、是否開立慢性病處方調劑、糖尿病併發症嚴重度、醫療院所層級。

結果：全國有53.29%的糖尿病患因為無法獲得糖尿病論質計酬的照護機會而未能加入方案。在控制居住縣市與罹病年數後，發現都市化程度越低，無法獲得照護機會的風險越高，達統計上顯著(中度都市化vs.高度都市化，OR=1.08；低度都市化vs.高度都市化，OR=1.26)。進一步分析造成不平等的原因，發現隨著都市化程度越低，糖尿病患依賴基層診所就醫的比例越高；而不同層級無法獲得照護機會比例也有差異，以基層診所最高；在基層診所就醫的人，隨著都市化程度越低，無法獲得照護機會的風險越大。

結論：有一半以上的糖尿病患無法獲得論質計酬的照護機會，若要有效提升論質計酬的納入率，需要先提高病人可獲得照護機會的比例。不同都市化地區獲得論質計酬的照護機會上有不平等的情形存在。原因為都市化程度越低的地區，越依賴基層診所就醫，而多數的基層診所皆未能參與方案。因此，需瞭解基層診所未參與的真實原因與可能障礙，思考相關配套措施，才能降低地區間照護機會不平等的情形。

In 2013, there is still sixty percent diabetes patients did not be enrolled in the Taiwan pay-for-performance (P4P) program for diabetes. One of the reasons is the unavailability of healthcare system, means patient’s hospital or physician noninvolved. P4P program may increase inequalities if higher urbanization degree areas are more able to respond to the program requirement than lower urbanization degree areas.The objective of this study is to analysis the availability of diabetes P4P program. Further, examined the relation between different urbanization degree areas and availability of P4P program.This study samples selected new diagnostic diabetes patients during 2004 to 2009, analysis their medical claim data in 2010. Urbanization degree was stratified to high, middle, low classes. Statistical analysis use logistic regression models to estimate the availability of P4P program in different urbanization degree areas after control patient’s demographic characteristics and hospital level.There was 53.29 percent of diabetic patients didn’t be enrolled because of unavailability . In logistic regression analysis, availability of P4P program was associated with lower urbanization degree. Further, the lower urbanization degree, the percent of hospital’s level in clinic is more. More than seventy percent of patient’s hospital in clinic didn’t be enrolled because of clinic didn’t participate the program.
Our results suggest different level of urbanization was associated with the availability of P4P program. One reason is most clinic didn’t participate P4P program. Government should encourage clinic enrolled in the program in order to decrease inequalities in different level of urbanization.

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