1,721,002 research outputs found
Effects of Physician Specialty on Use of Antidiabetes Drugs, Process and Outcomes of Diabetes Care in a Medical Center
No full textNon-Attendance in Endocrinology and Metabolism Patients
No full textBACKGROUND/PURPOSE: Non-attendance in outpatient clinics might disrupt medical care, interfere with outpatient clinic processing, and waste health service resources. This study was performed to identify predictive factors for non- attendance in endocrinology and metabolism (Endo/Meta) patients. METHODS: Non-attendance was examined for a period of 6 months in Endo/Meta outpatient clinics in a medical center in Taiwan. Effects of physician, clinic, and patient characteristics, and appointment patterns in non-attendance were assessed by (2) test and multivariate logistic regression. RESULTS: During the study period, a total of 13, 584 patients booked appointments for 609 Endo/Meta clinics managed by 11 specialists. The mean number of appointments per patient was 2.3 1.1. The total number of registered visits was 31,143. The total number of non- attendances was 2272. The overall proportion of non-attendance in Endo/ Meta patients was 7.3%. The proportion of non-attendance varied with different physician teaching status and on different weekdays. In multivariate logistic regression, physician age (p = 0.0009), physician teaching status (p = 0.0013), number of physician shifts per week (p< 0. 0001), patient age (p< 0.0001), first-time appointment (p< 0.0001) and registration order in the clinic (p < 0.0001) had significant effects on non-attendance, whereas physician and patient sex, weekdays and daytimes of clinics had no significant effect on non-attendance. CONCLUSION: Determinants of non-attendance in Endo/Meta patients include older physician age, lower physician teaching status, number of physician shifts per week, younger patient age, first-time appointment, and later registration order in the clinic. Research on non-attendance should be applied to improve quality of medical care. Optimal ways to ensure attendance deserve further investigation
Prognostic Factors of Anaplastic Thyroid Carcinoma
No full textBackground and purpose: Anaplastic thyroid carcinoma (ATC) is one of the most aggressive malignancies. We tried to elucidate the possible prognostic factors. Methods: A retrospective review was conducted of ATC patients in National Taiwan University Hospital from 1978 to 2003. Their demographic characteristics, clinical presentations, laboratory data and treatment modalities were reviewed. Possible prognostic factors for survival were evaluated. Results: Forty-five patients (114 males and 31 females) of mean age 61.9 +/- 12.6 yr were included in this study. The median survival time was 94 days (range 6 to 776 days). The overall survival rate was 27% at 6 months and 10% at 1 yr. Thirty-two patients receiving intervention regimens had a median survival of 106 days, while 13 patients receiving palliative therapy had a median survival of 39 days. The difference in survival is statistically significant (logrank test, p= 0.017). Adjusted with sex and age, increment in white blood cell count ( per 10(9)/l) and serum albumin (per 1.0 g/l) had a hazard ratio of 1.12 ( Cox regression, p 10(10)/l] or hypoalbuminemia (serum albumin <35 g/l) had significant shorter survival than patients without leukocytosis or hypoalbuminemia (logrank test p=0.008 and p=0.032, respectively). Patients with serum T-4 levels lower than 64. 35 nmol/l had significantly shorter survival than patients without hypothyroxinemia (median survival 24 vs 128 days, logrank test, p=0.004). Conclusions: ATC is an aggressive malignancy. Leukocytosis, hypoalbuminemia and hypothyroxinemia indicated poor prognosis. Survival time might be prolonged if intervention treatment is tolerable
Outcome evaluation associated with quality measures of diabetes care: Type 1 and type 2 diabetes
No full text背景及研究目的：
台灣地區糖尿病盛行率約為百分之四，估計糖尿病人口超過100萬人。糖尿病是台灣第四大死因，糖尿病之醫療花費每年超過三億美元，不論著眼於民眾健康或是衛生經濟，提升糖尿病照護品質均是重要的課題。本論文對於臺灣的糖尿病照護品質做多面向的分析。
研究對象及方法：
本研究之第一部分以中央健康保險局台北分局2001年的申報資料分析，計算糖尿病人實際接受的檢驗次數並與糖尿病照護準則所建議的檢驗做比較，以評估糖尿病照護的專業盡責度，並且探討病人特徵與醫院特徵對於盡責度的影響。本研究之第二部分以十分之一隨機抽樣2002年於台大醫院就診四次以上的糖尿病人，其中固定於内科、家庭醫學科、內分泌科接受治療的875位糖尿病人為研究對象。以病人之病歷資料作回溯性分析，使用Chi-square、logistic regression、linear regression 等統計方法探討醫師及病人特徵對於相關檢驗執行、以及血糖、血壓、血脂控制之影響。本研究之第三部分以十分之一隨機抽樣2002年在臺大醫院就診四次以上且2003年曾經回診的糖尿病人。以郵寄方式做問卷調查，512位回覆者為研究對象。利用回溯性病歷資料分析以及問卷答覆，以logistic regression、Chi-square等統計方法，分析糖尿病人對於他們自己的檢驗值或臨床狀況的了解程度，並探討臨床狀況認知與自我監測血糖的相關。本研究之第四部份回溯研究自1995年至2005年在台大醫院就診的第一型糖尿病人的病歷，擷取各項臨床資料以及檢驗數據，紀錄糖尿病慢性併發症的發生率。估算自糖尿病發病以至產生視網膜病變、神經病變、末期腎衰竭或死亡之期間，並分析導致腎病變的危險因子。
結果：
以收錄的2259位糖尿病人健保申報資料分析，一年當中約有76.3%、42.7%、40.2%、59.7%、59.2%、53.2%、16.8%的病人曾經接受至少一次血糖、糖化血色素、尿液、腎功能、血脂、肝功能以及視網膜病變的檢查。約有19.2%的糖尿病人一年當中未曾接受上述任何一項檢查。使用降血糖、抗高血壓或降血脂藥物、曾經住院、曾經急診、就診次數多的病人，接受檢驗的比率較高。醫院層級、所在地、權屬、是否為糖尿病照護機構等特徵會影響糖尿病照護專業盡責度。
在台大醫院就診的第二型糖尿病人一年當中曾經接受至少一次血糖、糖化血色素、尿液、腎功能、血脂、肝功能以及視網膜病變檢查的百分比為89.7%、82.5%、48%、53.6%、69%、45.9%、18.0%。內分泌科醫師比內科醫師或家庭醫學科醫師注重對於糖尿病人血糖、糖化血色素、以及尿液檢查的監測。在台大醫院就診的第二型糖尿病人的平均糖化血色素值為7.3 ± 1.5%。與內科或家庭醫學科病人相較，在內分泌科門診追蹤治療的病人有較低的血糖值。
約有73%、17.9%的糖尿病知道自己的血糖值、糖化血色素值及其意義。有33.3%、66.7%、65.5%、70.6%的病人知道自己有蛋白尿、腎功能異常、肝功能異常或是高血脂等臨床狀況。年老、低教育程度、低收入、就診次數較少的病人對於自己的檢驗值或臨床狀況認知較不足。以胰島素治療、醫師年紀較大、或是糖尿病專科醫師的病人臨床認知較足夠。年青、糖尿病得病期間較久、收入較多、使用胰島素治療、有較多併發症或合併症、糖尿病專科醫師的病人比較會執行自我血糖監測。對於血糖值以及糖化血色素的認知與自我血糖監測有正相關。
以病歷上記載的最後一次數據分析，臺大醫院第一型糖尿病患者的平均糖化血色素值為8.9 ± 1.5%。這些病人在長期追蹤後產生視網膜病變、神經病變、腎病變、腦血管疾病、冠狀動脈疾病、周邊血管疾病之比例分別為23.1%、15.1%、25.7%、1.1%、4.0% 以及5.5%。共有5位(1.1%)病人死亡。女性病人、血糖控制不良、血脂異常是微白蛋白尿的風險因子。高血壓、高血脂、抽菸是產生蛋白尿的危險因子。發病年齡大於15歲、糖尿病發病期間長以及高血壓會增加末期腎衰竭的風險。多數合併有高血壓、腎病變、血脂異常的病人並沒有被投予糖尿病照護準則所建議的相關用藥。
結論:
醫院、醫師、以及病人特徵均會影響糖尿病照護品質。臺灣地區對於糖化血色素、尿液、視網膜等檢查之專業盡責度較低，尤其是基層醫療院所。不同專科醫師對於檢驗監測的執行有所不同，他們照護的病人的血糖控制程度也有不同。糖尿病人的臨床認知可以增加他們的自我照護，但並不是所有的糖尿病人都了解他們的檢驗結果或是臨床狀況。與其他國家相較，台灣第一型糖尿病患者的腎病變有較早期、進展較快速的特徵。台灣地區糖尿病患者所接受的檢驗監測以及相關用藥與照護準則所建議的相較，均有所不足。我們希望提昇糖尿病照護品質，可以由定期檢驗追蹤、針對病情需要用藥、加強對於病人的溝通教育等著手，希望可以讓我們的糖尿病人有好的血糖、血壓、血脂控制，並減少糖尿病腎病變等慢性併發症的發生。Aims:
The diabetic population in Taiwan is estimated to be over 1,000,000. Diabetes is the fourth leading cause of death in Taiwan. Improvement in the quality of diabetes care is critical, both for patients and health care costs. The main purpose of this study is to evaluate the quality of diabetes care in Taiwan.
Study design and methods:
Four study populations were recruited for evaluating quality of diabetes care in different domains. Study population I (NHI-DM population) enrolled diabetic patients randomly sampled from year 2001 National Health Insurance Bureau Taipei Branch claims data. Effects of patient factors or hospital factors on adherence to diabetes care measures were analyzed by logistic regression. Study population II (NTUH-T2DM patients) recruited 875 type 2 diabetic patients who were regularly cared for by endocrinologists (EN), internists (IM) and family medicine physicians (FM) at National Taiwan University Hospital (NTUH) in the year 2002. Adherence to laboratory exams and quality improvement measures (glycemic, blood pressure, and lipid control) of diabetic patients were evaluated. Effects of physician specialty on professional performance or patient health status indicators were analyzed by logistic regression or linear regression, accordingly. Study population III (NTUH-T2DM-Q patients) recruited 512 type 2 diabetic patients who were regularly treated at NTUH and responded to our questionnaire. Awareness of test results and self-management in diabetic patients were assessed. Effects of patient characteristics or physician factors on the clinical awareness, and self-monitoring of blood glucose (SMBG) were evaluated by logistic regression. Study population IV (NTUH-T1DM patients) recruited 471 type 1 diabetic patients who were treated at NTUH in the period between 1995 and 2005. Adherence to diabetes care measures, glycemic control, blood pressure control, lipid control, and long-term clinical outcomes of the study cohort were evaluated. Risk factors for developing diabetic nephropathy were analyzed by logistic regression and Cox regression.
Results:
Adherence rates to plasma glucose, glycated hemoglobin A1C (A1C), urinalysis, renal function test (RFT), lipid profile, liver function test (LFT), and eye ground exam (eye) in the NHI-DM population was 76.3%, 42.7%, 40.2%, 59.7%, 59.2%, 53.2%, and 16.8%, respectively. Patients with hypoglycemic medications, anti-hypertensive drugs, lipid-lowering 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 persistently affected all the measures.
The adherence rates to annual measures in NTUH-T2DM patients for glucose, A1C, urinalysis, RFT, lipid profile, LFT, and eye exam were 89.7%, 82.5%, 48%, 53.6%, 69%, 45.9%, and 18%, respectively. EN patients showed a significantly better adherence to glucose checkup, A1C measure and urinalysis than IM patients. EN patients also had better adherence to glucose checkup and urinalysis than FM patients. The mean A1C for NTUH-T2DM patients was 7.3 ± 1.5%. About 49.3% patients had an A1C level < 7.0%. 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.
Percentages of patients who knew their test results were: glucose level 73%, A1C level and meaning 17.9%, proteinuria 33.3%, impaired renal function test 66.7%, liver disease 65.5%, dyslipidemia 70.6%. Unawareness of clinical conditions was remarkable in patients with older age, lower education level, lower income, or less frequent visits. Patients treated with insulin, under the care of older physicians or diabetologists had better awareness of test results. About 49.3% patients performed SMBG. Patients with younger age, longer diabetes duration, higher income, insulin therapy, more comorbidities/complications, under the care of diabetologists were more likely to perform SMBG. Clinical awareness of glucose level or A1C meaning had significant correlations with SMBG.
The NTUH-T1DM patients had a mean latest A1C of 8.9 ± 1.5%. The percentages of NTUH-T1DM patients with retinopathy, neuropathy, nephropathy, cerebral vascular disease, coronary artery disease, and peripheral vascular disease were 23.1%, 15.1%, 25.7%, 1.1%, 4.0%, and 5.5%, respectively. Female, poor glycemic control, and dyslipidemia are risk factors for microalbuminuria. Hypertension, dyslipidemia, and smoking are risk factors for proteinuria. Older age at diagnosis, longer diabetes duration, and hypertension significantly increased risks for end stage renal disease (ESRD). The mean interval between DM diagnosis and ESRD was 13.3 ± 7.7 years. Five patients (1.1%) died. Medications for blood pressure control, renal protection, and lipid control were not prescribed as recommended by practice guideline for diabetes care.
Conclusions:
Hospital-, physician-, and patient- characteristics influence quality of diabetes care. Adherence to A1C measure, urinalysis, and eye ground exam is sub-optimal, especially in primary health care units. Physician specialty had significant effects on adherence to diabetes care measures and outcomes of diabetes care. Clinical awareness and self-care of diabetic patients should be further enhanced. Taiwanese type 1 diabetic patients had a tendency of early onset and rapid progress to develop microvascular complications. However, screening and follow-up exams were inadequate. Medications for preventing and slowing diabetic complications were not promptly prescribed. To improve quality of diabetes care in Taiwan, we should establish Taiwanese diabetes database, enhance adherence to diabetes care measures, encourage effective physician-patient communication, and reinforce fulfillment of the practice guideline.Table of Contents Page
Abstract 3
中文摘要 7
I. Introduction 10
II. Literature Reviews 12
1. Standards of diabetes care 12
2. Assessment for the quality of diabetes care 12
2a. Professional accountability 13
2b. Quality improvement measures 15
3. Clinical awareness and self-care in diabetic patients 17
4. Chronic complications of diabetes 18
5. Diabetic nephropathy in type 1 diabetes 19
III. Aims 23
IV. Subjects and methods 26
1. Professional accountability for recommended diabetes care measures in NHI-DM population 26
2. Professional performance indicator and quality improvement indicators in NTUH-T2DM patients 29
3. Awareness of test results and self-management in NTUH-T2DM-Q subjects 32
4. Adherence to recommended diabetes care measures, quality improvement indicators, and long-term follow-up in NTUH-T1DM subjects 35
Table of Contents (cont.) Page
V. Results 40
1. Professional accountability for recommended diabetes care measures in NHI-DM population 40
2. Professional performance indicator and quality improvement indicators in NTUH-T2DM patients 43
3. Awareness of test results and self-management in NTUH-T2DM-Q subjects 45
4. Adherence to recommended diabetes care measures, quality improvement indicators, and long-term follow-up in NTUH-T1DM subjects 48
VI. Discussions 52
1. Adherence to recommended diabetes care measures 52
2. Quality improvement indicators 57
3. Awareness of test results and self-management 59
4. Co-morbidities and chronic complications in T1DM patients 61
VII. Limitations of the study 67
VIII. Conclusions 71
IX. References 73
X. Tables 94
XI. Appendix 115
Publications 11
Effects of Physician Specialty on Use of Antidiabetes Drugs, Process and Outcomes of Diabetes Care in a Medical Center
No full textBackground/Purpose: Physician characteristics might determine the quality of diabetes care. This study evaluated the effects of physician specialty on the use of antidiabetes drugs, process and outcomes of diabetes care. Methods: In 2002, 12,023 diabetes patients visited outpatient clinics more than four times at National Taiwan University Hospital. One-tenth of the patients were randomly sampled out. A retrospective chart review was conducted for those who were regularly cared for by endocrinologists (EN) , other specialists in internal medicine (IM) and family medicine (FM) physicians. The use of antidiabetes drugs was assessed. Effects of physician specialty on the process or outcome indicators were analyzed by logistic or linear regression, accordingly. Results: A total of 875 diabetes patients (477 men, 398 women) with a mean age of 62.3 +/- 12 .7 years were recruited. EN patients had the highest rate of being prescribed insulin, metformin or nonsulfonylurea insulin secretagogues, and the lowest rate of being given sulfonylureas. EN patients showed a significantly better adherence to glucose checkup, glycosylated hemoglobin A(1C) measures and urinalysis than IM patients. EN patients also showed 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. Conclusion: The use of antidiabetes drugs differed among patients cared for by EN, internists or generalists. Physician specialty had significant effects on the process and outcomes of diabetes care
Ultrasound-Guided Fine Needle Aspiration Cytology of Parathyroid Lesions - a Review of 72 Cases
No full textOBJECTIVE: To elucidate the specific cytomorphologic patterns and diagnostic pitfalls in fine needle aspiration cytology (FNAC) of parathyroid lesions. STUDY DESIGN: Seventy-two cases of surgically excised and pathologically verified hyperparathyroidism (20 cases of parathyroid hyperplasia, 51 of parathyroid adenoma and one of parathyroid carcinoma) received preoperative, ultrasound- guided FNAC examination for enlarged parathyroid glands. The smears were reviewed and analyzed. RESULTS: Parathyroid lesions were diagnosed cytologically in 60 cases (83.3%). The presence of colloidlike substance, macrophages or follicular structures in smears led to six cases (8.3%) being misinterpreted as thyroid lesions. The cellularity of the smears was insufficient for interpretation in six cases( 8.3%); however, two of these cases were diagnosed by determination of parathyroid hormone (PTH) levels in the fluid. Parathyroid hyperplasia had more tightly cohesive cell clusters with monomorphism, while parathyroid adenoma had more dispersed or loosely cohesive cells with pleomorphism and anisokaryosis. High PTH concentration in an aspirate was noted in all four cases of cystic lesions
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