背景與目的：
依據美國糖尿病學會公佈之糖尿病照護的標準中建議，所有糖尿病患應被例行的執行糖化血色素（HbA1c）的檢驗，且一年至少二次。糖化血色素的檢驗已成為糖尿病照護過程中品質評估的指標。然而台灣病人喜歡逛醫師的情形，使得過去研究受限於醫師在專業責任的部份無法被評估。本研究區分以就診人次與病人就診次數的不同比例，來歸屬主要照護科別與主要照護醫師，並進一步分析不同科別醫師，在開立糖化血色素檢驗遵循度之差異。本研究的目的有：（一）不同年，醫師在開立糖化血色素檢驗的遵循度是否不同？（二）不同科別，醫師在開立糖化血色素檢驗的遵循度是否有差異？（三）糖尿病患照護量的不同，醫師在開立糖化血色素檢驗的遵循度是否不同？
研究材料與方法：
本研究係以2001－2005年南部某醫學中心所有曾因糖尿病(任一主、次診斷碼ICD-9-CM前三碼為250者)就診者資料，並區分以就診人次與病人就診次數的不同比例，來歸屬主要照護科別與主要照護醫師進行研究。我們以研究對象在研究期間內，當年有接受過二次（含）以上糖化血色素的檢驗為標準，然後比較病人的特性、所屬照護科別、不同年份對醫師開立糖化血色素檢驗遵循度之影響，並以邏輯斯迴歸（logistic regression）進行分析。
研究結果：
我們以病人就診次數的不同比例，分別為大於百分之五十、大於（含）百分之六十、大於（含）百分之七十、大於（含）百分之八十、大於（含）百分之九十，以及百分之ㄧ百，來歸屬病人的主要照護科別。所得結果94年在新陳代謝科的病人比例，相對於大於百分之五十，分別為96％、91％、84％、73％和68％；在家庭醫學科分別為98％、93％、88％、82％和79％；在其他內科分別為79％、72％、65％、53％和50％；以及外科分別為91％、80％、72％、63％和62％。我們發現以不同標準歸屬的結果，差異並不大。因此我們除了採用病人就診次數大於（含）百分之八十，來歸屬病患所屬的主要照護科別與醫師外，同時也以主診斷為糖尿病病人的就診次數大於（含）百分之八十，歸屬所屬的主要照護科別與醫師，並分析醫師遵循糖尿病照護指引在糖化血色素檢驗的開立，藉以確立主要照護科別和醫師應盡的責任。
病人的特性，如年齡、就診次數、所屬照護科別，在糖化血色素的檢驗都有顯著的相關存在。其中糖化血色素的檢驗，隨著病人年齡的增加而減少；也隨著病人就診次數的增加而減少。至於醫師開立糖化血色素檢驗的遵循度，則隨著年的增加而提升，其中新陳代謝科符合照護指引的比例，在90年、92年、94年分別為37.2％、64.7％以及85.4％，而且該科醫師在開立糖化血色檢驗的執行率是最高的。
結論：
雖然糖尿病共同照護的實施，已部分改善了糖尿病患的照護品質，然而如何全面的來推行，以及如何改善照護的成效，仍是一個重要的議題。本研究係以評估醫師遵循糖尿病照護指引在糖化血色素檢驗的行為研究，我們強調了以病人就診次數大於（含）百分之八十的比例，來歸屬主要照護科別與照護醫師。病患的特性、主要照護科別、不同年，是影響醫師開立糖化血色素檢驗的重要因素；而主診斷是糖尿病的病人較容易得到糖化血色素的檢驗。除此之外，糖尿病專科醫師遵循糖尿病照護指引在糖化血色素檢驗的執行率，較其他科別來得高。因此，加強不同科別醫師遵循糖尿病照護指引在糖化血色素檢驗的開立，未來可藉由糖尿病專科或醫院政策來推行。

關鍵字:糖尿病,糖化血色素,糖尿病照護標準

Background and purpose:
According to the standards of medical care in diabetes published by the American Diabetes Association, it recommended HbA1c test should be performed routinely at least two times a year in all patients with diabetes. HbA1c test had become an indicator of quality assessment for diabetes care in process domain. In the past, studies were limited in the professional accountability was not assessed because patients liked shopping among doctors in Taiwan. In our study, we categorized patients into the major care departments and physicians by distinguished between frequency of visiting times and different proportion of visits. Take one step ahead, we analyze the different adherence on HbA1c test prescribed by different specialty.
The purpose of this study is to analyze (1) By the different years, is there any different adherence on HbA1c test prescribed by physicians happened？ (2) By the different specialty , is there any diverse adherence on HbA1c test prescribed by physicians happened？ and (3) By the different diabetes care amount, is there any different adherence on HbA1c test prescribed by physicians happened？
Material and Methods:
In our study, we selected the outpatients from medical center hospital in south with diabetes-related diseases; it means the ICD-9-CM code is from 250.00 to 250.91 as primary or secondary diagnosis, through 2001 to 2005. We further categorized those patients into primary departments and care physicians by distinguished between frequency of visiting times and different proportion of visits and analyzed it. The standard of adherence on HbA1c test prescribed by physicians was defined as the patients had at least two times or more HbA1c tests per year during the study period. Then we compared among the factors of patients’ characteristics, major care departments and different years, to see how adherence on HbA1c test prescribed was influenced by physicians. We used logistic regression analysis to analyze the association among these factors and the adherence.
Results:
We categorized diabetic patients into the major care departments by frequency of visits, they are ＞50%, ≧60%, ≧70%, ≧80%, ≧90%, and 100%. The results of patients’ proportion related to more than fifty percents in Endocrine Division are 96％, 91％, 84％, 73％ and 68％. In Family Medicine Department are 98％, 93％, 88％, 82％ and 79％. In Medical Department are 79％, 72％, 65％, 53％ and 50％. In Surgery Department are 91％, 80％, 72％, 63％ and 62％. We found that there were not significant differences when categorized by different proportion. Thus we categorized diabetic patients into the major care departments by frequency of visits ≧80%. Additionally, we categorized diabetic patients with primary diagnosis code were diabetes into the major care departments and physicians by frequency of visits ≧80%. We also analyzed adherence on HbA1c test prescribed by physicians to identify the professional accountability.
The characteristics of patients such as age, frequency of visits, and major care department had significant associations on the HbA1c test. HbA1c tests were prescribed are reduced by patients’ ages and frequency of visits, too. Besides, adherence on HbA1c test prescribed by physicians are increased yearly. Endocrine Division adherence to guideline’s proportion are 37.2％, 64.7％ and 85.4％ in years of 2001, 2003 and 2005. Compared with other specialties, HbA1c tests prescribed by physicians of Endocrine Division had the highest rate yearly.
Conclusions:
Although the implement of the diabetes shared care system had already improved the quality of diabetes care, how to overall carry through and improve the outcome is still an important issue. This study has evaluated the behavior of physicians who followed the guidelines of diabetes care on HbA1c test. We categorized diabetic patients into the major care departments and physicians, also highlighted the importance of considering about the frequency of outpatients’ visits ≧80%. The characteristics of patients, major care departments and different years are important factors affected HbA1c tests prescribed by physicians. Meanwhile, diabetic patients whose primary diagnosis code was diabetes received HbA1c tests easily. In addition, the endocrinologists followed guidelines of diabetes care on performance rate of HbA1c tests are higher than the other specialties. The accountability for HbA1c tests prescribed in the different departments should be further enhanced either by the diabetes specialty or hospital policy.

Keyword:diabetes , glycosylated hemoglobin（HbA1c）, the standards of medical

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