Your SlideShare is downloading. ×
Quality indicators f...-Word格式(另開視窗).doc
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Quality indicators f...-Word格式(另開視窗).doc

423

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
423
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
3
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. 臨床指引(Clinical Guideline)介紹 壹、臨床問題: Quality indicators for primary health care providers : Diabetes mellitus 貳、結果摘要: 1. Adult diabetes: percentage of patients receiving at least one complete foot examination (visual inspection, sensory exam with monofilament, and pulse exam). 2. percentage of patients with at least one test for microalbumin during the measurement year; or who had evidence of medical attention for existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria). 3. percentage of patients with most recent blood pressure less than 140/90 mm Hg. 4. percentage of patients receiving one or more HbA1c test(s). 5. percentage of patients receiving at least one lipid profile (or ALL component tests). 6. percentage of patients with diabetes mellitus having a retinal exam by an eye care specialist, timely, as indicated by disease control 7. Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes. 8. Influenza immunization: percentage of applicable patients receiving influenza immunizations. 9. percentage of patients who were prescribed aspirin therapy (dose greater than or equal to 75 mg). 10. percentage of patients whose smoking status was ascertained and documented annually. 參、背景說明: 二代健保以品質與病患參與為核心,我們希望透過醫學資料庫的搜尋,找出基 層醫療工作者可以執行的品質指標,借以逐步建立以品質為導向的醫療照護模 式。 肆、期待目標:
  • 2. 臨床指引(Clinical Guideline)介紹 介紹糖尿病醫療照顧的品質指標,並提供有用的文獻資料。 伍、搜尋步驟: A.National Quality Measures Clearinghouse (NQMC) : http://www.qualitymeasures.ahrq.gov/ Keyword: diabetes mellitus: Your search found 62 related measures,選擇十個指標。 陸、文獻選擇: 原則上,以適用於基層醫療的文獻為主 柒、參考文獻: 1.指標:Adult diabetes: percentage of patients receiving at least one complete foot examination (visual inspection, sensory exam with monofilament, and pulse exam). 方法:This measure assesses the percentage of adult diabetes patients aged 18-75 years receiving at least one complete foot examination (visual inspection, sensory exam with monofilament, and pulse exam). 理由:Persons with diabetes are at increased risk for foot ulcers and amputations. Annual, thorough foot examinations and management of risk factors can prevent or delay adverse outcomes. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) and American Diabetes Association (ADA) recommend that a foot examination (visual inspection, sensory exam, and pulse exam) be performed during an initial assessment. AACE/ACE recommends that a foot examination be a part of every follow-up assessment visit, which should occur quarterly. ADA recommends that all individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions. This examination should include
  • 3. 臨床指引(Clinical Guideline)介紹 assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity. The ADA recommends that people with one or more high-risk foot conditions should be evaluated more frequently for the development of additional risk factors. People with neuropathy should have a visual inspection of their feet at every contact with a health care professional. The American Diabetes Association and Veterans Administration/Department of Defense (VA/DoD) guidelines recommend that everyone with diabetes have at least one foot exam screening each year to identify any foot conditions that could pose a risk of developing foot ulcers. The examination should include a monofilament test to assess protective sensation and the presence of nerve damage; palpation of pulses; an analysis of foot structure, mechanics, and circulation; and an assessment of skin health and integrity. Comprehensive foot care programs can reduce amputation rates by 45% to 85%. 2.指標:percentage of patients with at least one test for microalbumin during the measurement year; or who had evidence of medical attention for existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria). 方法:This measure assesses the percentage of adult diabetes patients aged 18-75 years with at least one test for microalbumin during the measurement year; or who had evidence of medical attention for existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria). 理由:Diabetes is the leading cause of end-stage renal disease (ESRD). In the United States, diabetic nephropathy accounts for about one-third of all cases of ESRD. The earliest clinical evidence of nephropathy is the appearance of low, but abnormal levels of albumin (protein) in the urine, referred to as microalbuminuria. Early detection and treatment may prevent or slow the progression of diabetic nephropathy. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommends that the initial assessment should include a urinalysis, test for microalbuminuria and creatinine clearance. The renal complication module should be performed annually and includes a test for microalbuminuria and creatinine clearance. American Diabetes Association (ADA) recommends that a routine urinalysis be performed at diagnosis in patients with type 2 diabetes. If the urinalysis is positive
  • 4. 臨床指引(Clinical Guideline)介紹 for protein, a quantitative measure is frequently helpful in the development of a treatment plan. If the urinalysis is negative for protein, a test of the presence of microalbumin is necessary. 3.指標:percentage of patients with most recent blood pressure less than 140/90 mm Hg. 方法:This measure assesses the percentage of adult diabetes patients aged 18-75 years with most recent blood pressure less than 140/90 mm Hg 理由:Intensive control of blood pressure in patients with diabetes reduces diabetes complications, diabetes-related deaths, strokes, heart failure, and microvascular complications. American Diabetes Association (ADA) recommends a blood pressure determination during the initial evaluation (with orthostatic measurements when indicated) and comparison to age-related norms. The routine follow-up examinations should include blood pressure measurement. Clearly, the clinical recommendations and treatment goals for persons with diabetes define as the target blood pressure less than 130/85 mm Hg 4.指標:percentage of patients receiving one or more HbA1c test(s). 資料:This measure assesses the percentage of adult diabetes patients aged 18-75 years receiving one or more HbA1c test(s) per year. 理由:Intensive therapy of glycosylated hemoglobin (A1c) reduces the risk of microvascular complications. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommends that a glycosylated hemoglobin be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals. AACE/ACE recommend that HbA1c be universally adopted as the primary method of assessment of glycemic control. On the basis of data from multiple interventional trials, the target for attainment of glycemic control should be HbA1c values less than or equal to 6.5%. American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care. In the absence of well-controlled studies that suggest a definite testing
  • 5. 臨床指引(Clinical Guideline)介紹 protocol, expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic goals Clearly, the clinical recommendations and treatment goals for persons with diabetes define the target HbA1c level as less than or equal to 6.5% or less than 7.0% 5.指標:percentage of patients receiving at least one lipid profile (or ALL component tests). 方法:This measure assesses the percentage of adult diabetes patients aged 18-75 years receiving at least one lipid profile (or ALL component tests). 理由:Persons with diabetes are at increased risk for coronary heart disease (CHD). Lowering serum cholesterol levels can reduce the risk for CHD events. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommend that a fasting lipid profile be obtained during an initial assessment, each follow-up assessment, and annually as part of the cardiac-cerebrovascular-peripheral vascular module. American Diabetes Association (ADA) recommends that a fasting lipid profile be obtained as part of an initial assessment. Adult patients with diabetes should be tested annually for lipid disorders with fasting serum cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, and calculated low-density lipoprotein (LDL) cholesterol measurements. If values fall in lower-risk levels, assessments may be repeated every two years. 6.指標:percent of eligible patients with diabetes mellitus having a retinal exam by an eye care specialist, timely, as indicated by disease control (NEXUS clinics cohort). 方法:This measure assesses the percent of eligible patients with diabetes mellitus who have had a retinal exam by an eye care specialist within specified time periods as indicated by disease control. 理由:Detection and treatment of diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50% to 60%.
  • 6. 臨床指引(Clinical Guideline)介紹 7.指標:Chronic stable coronary artery disease (CAD): percentage of patients who were screened for diabetes. 方法:This measure is used to assess the percentage of patients with chronic stable coronary artery disease (CAD) who were screened for diabetes. 理由:According to American Diabetes Association (ADA), Americna College of Endocrinology (ACE), and American Association of Clinical Endocrinologists (AACE) guidelines, screening for diabetes is recommended in patients who are considered high risk (e.g., coronary artery disease [CAD]). 8.指標:Influenza immunization: percent of applicable patients receiving influenza immunizations. 方法:This measure assesses the percent of eligible patients receiving influenza immunizations between September 1, 2004 and January 31, 2005. 理由:Epidemics of influenza typically occur during the winter months in temperate regions and have been responsible for an average of approximately 36,000 deaths/year in the United States during 1990-1999. Influenza viruses also can cause pandemics, during which rates of illness and death from influenza- related complications can increase worldwide. Influenza viruses cause disease among all age groups. Rates of infection are highest among children, but rates of serious illness and death are highest among persons aged greater than 65 years and persons of any age who have medical conditions that place them at increased risk for complications from influenza. Influenza vaccination is the primary method for preventing influenza and its severe complications. 9.指標:Adult diabetes: percentage of patients who were prescribed aspirin therapy (dose greater than or equal to 75 mg). 方法:This measure assesses the percentage of adult diabetes patients aged 18-75 years who were prescribed aspirin therapy (dose greater than or equal to 75 mg). 理由:Daily low-dose aspirin therapy is important for both primary and secondary prevention of cerebral and cardiac events.
  • 7. 臨床指引(Clinical Guideline)介紹 Aspirin has been used as a primary and secondary therapy to prevent cardiovascular events in diabetic individuals. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommends that optimal care of the diabetic patient include the use of antiplatelet therapy for prevention of vascular events. Prevention of vascular events by the antiplatelet effect of daily low-dose aspirin (as low as 30 mg/day) has been well established. Daily low-dose aspirin therapy is important for both primary and secondary prevention of cerebral and cardiac events. American Diabetes Association (ADA) recommends aspirin therapy as a secondary prevention strategy in diabetic men and women who have evidence of large vessel disease. This includes diabetic men and women with a history of myocardial infarction (MI), vascular bypass procedure, stroke or transient ischemic attack, peripheral vascular disease, claudication, and/or angina. Use aspirin therapy (75-325 mg/day) in all adult patients with diabetes and macrovascular disease. • Do not use aspirin in patients younger than 21 years of age because of the increased risk of Reye’s syndrome. • Recommends that people with aspirin allergy, bleeding tendency, anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatic disease are not candidates for aspirin herapy. ADA recommends aspirin therapy as a primary prevention in high-risk men and women with type 1 or type 2 diabetes. This includes: • Family history of coronary heart disease • Cigarette smoking • Hypertension • Obesity (greater than 120% desirable weight); BMI greater than 27.3 kg/m2 in women, greater than 27.8 kg/m2 in men • Albuminuria (micro or macro) • Lipids: cholesterol greater than 200 mg/dL, low-density lipoprotein (LDL) greater than or equal to 100 mg/dL, high-density lipoprotein (HDL) less than 45 mg/dL in men and less than 55 mg/dL in women • Age older than 30 years 10.指標:percentage of patients whose smoking status was ascertained and documented annually. 方法:This measure assesses the percentage of adult diabetes patients aged 18-75 years whose smoking status was ascertained and documented annually.
  • 8. 臨床指引(Clinical Guideline)介紹 理由:American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommends assessment of smoking history during the initial visit. Optimal care of the patient with diabetes must include cessation of smoking. American Diabetes Association (ADA) recommends routine and thorough assessment of tobacco use. Health care providers should advise all individuals with diabetes not to smoke. For people who smoke, the ADA recommends implementation of smoking cessation guidelines incorporated into the routine practice of diabetes care 捌、其它有用的參考文獻: The proportion of persons with fair or good lipid control (LDL cholesterol level < 3.4 mmol/L [<130 mg/dL]) had a statistically significant increase of 21.9% by Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, annual cholesterol level monitoring, and annual foot and dilated eye examination, as defined by the National Diabetes Quality Improvement Alliance measures. Progress of diabetes care is a subject of public health concern. To assess changes in quality of diabetes care in the United States by using standardized measures. National population-based, serial cross-sectional surveys. National Health and Nutrition Examination Survey (1988-1994 and 1999-2002) and the Behavioral Risk Factor Surveillance System (1995 and 2002). Survey participants 18 to 75 years of age who reported a diagnosis of diabetes. Glycemic control, blood pressure, low- density lipoprotein (LDL) cholesterol level, annual cholesterol level monitoring, and annual foot and dilated eye examination, as defined by the National Diabetes Quality Improvement Alliance measures. In the past decade, the proportion of persons with diabetes with poor glycemic control (hemoglobin A1c > 9%) showed a nonstatistically significant decrease of 3.9% (95% Cl, -10.4% to 2.5%), while the proportion of persons with fair or good lipid control (LDL cholesterol level < 3.4 mmol/L [<130 mg/dL]) had a statistically significant increase of 21.9% (Cl, 12.4% to 31.3%). Mean LDL cholesterol level decreased by 0.5 mmol/L (18.8 mg/ dL). Although mean hemoglobin A1c did not change, the proportion of persons with hemoglobin A1c of 6% to 8% increased from 34.2% to 47.0%. The blood pressure distribution did not change. Annual lipid testing, dilated eye examination, and foot examination increased by 8.3% (Cl, 4.0% to 12.7%), 4.5% (Cl, 0.5% to 8.5%), and 3.8% (Cl, -0.1% to 7.7%), respectively. The proportion of persons reporting annual
  • 9. 臨床指引(Clinical Guideline)介紹 influenza vaccination and aspirin use improved by 6.8 percentage points (Cl, 2.9 percentage points to 10.7 percentage points) and 13.1 percentage points (Cl, 5.4 percentage points to 20.7 percentage points), respectively. Data are self-reported, and the surveys do not have all National Diabetes Quality Improvement Alliance indicators. Diabetes processes of care and intermediate outcomes have improved nationally in the past decade. But 2 in 5 persons with diabetes still have poor LDL cholesterol control, 1 in 3 persons still has poor blood pressure control, and 1 in 5 persons still has poor glycemic control. More details are in” Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002.” by Saaddine JB; Cadwell B; Gregg EW; Engelgau MM; Vinicor F; Imperatore G; Narayan KM in Annals Of Internal Medicine [Ann Intern Med] 2006 Apr 4; Vol. 144 (7), pp. 465-74. 玖、後記及臨床經驗: About 19.2% patients who diagnosed as having diabetes never received any one of the measures, such as HBA1c, urinalysis, renal function test, lipid profile, and eye ground, in Taiwan. This study examined the performance of diabetes care measures in Taiwan and evaluated the influencing factors for professional accountability. This study analyzed the year 2001 claims data from National Health Insurance (NHI) program in Taipei Branch. 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 ever received measures in the year for plasma glucose, HBA1c, 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. About 19.2% patients never received any one of the measures. Patients with hypoglycemic, anti- hypertensive or anti-hyperlipidemic 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. This analysis revealed sub-optimal diabetes care in Taiwan and concluded the importance of enhancing care quality from primary settings. More details are in “Professional accountability for diabetes care in Taiwan,” by Tseng FY, Lai MS, Syu CY, Lin CC in Diabetes Res Clin Pract. 2006
  • 10. 臨床指引(Clinical Guideline)介紹 Feb;71(2):192-201. 拾、證據醫學專案小組成員: 1.審查醫師 賴鈺嘉醫師 劉秋松醫師 柯存財醫師 吳三源醫師 2.全民健康保險基層總額支付制度中區委員會 許鵬飛醫師 黃錫鑫醫師 3.社區醫師 賴明美醫師 曾思遠醫師 陳豪江醫師 4.健保局中區分局 陳經理明哲 施副理志和 專案小組行政人員王慧英等七人

×