本研究目的在規劃、執行區域醫院式糖尿病個案管理照護第二型糖尿病患並評值成效，分析受試者實驗室結果和自我照顧行為改變情形，以探討疾病管理成效。研究設計以全民健康保險糖尿病醫療給付改善方案試辦計畫和美國糖尿病協會(American Diabetes Association, ADA)2003版糖尿病照護標準為藍圖，建立符合區域醫院體制之糖尿病照護團隊和臨床指引；同時編製符合在地居民特性的糖尿病自我照顧手冊。採前瞻性研究且追蹤受試病患一年。病患成效以實驗室檢驗和自我照護行為評量。資料收集包括收案日以及一年內的4次追蹤測試結果。本研究分別採用GEE統計方法之多變項線性迴歸與邏輯斯迴歸處理重複測量資料並調整影響因素之效應。共計60位第二型糖尿病患（平均罹病期3.25年）為研究樣本，皆為已婚、年齡介於23-84歲（平均52.5歲）、男性(58.3%)稍多於女性、其中65%為本省客家籍。六類自我照顧認知與行為達成率分別為：自主服藥91.3%（藥物認知正確率25.4%）、低血糖處理23.3%、血糖監測相關行為46.7%、運動35.8%、飲食管理51.7%和足部護理92.8%。依照ADA糖尿病照護標準呈現統計上成效的檢驗值包括：糖化血色素(p<.0001)、空腹血糖(p<.01)、三酸甘油脂(p<.05)。本研究結果顯示整合臨床指引、政府健康部門策略、自我照護手冊而成的「醫院式糖尿病個案管理」能提供綜合性照護並能有效地達成照護目標和改善糖尿病患自我照護行為。

The aim of this study was to design, implement and evaluate disease outcomes at a regional hospitalbased case management program of care for patients with type 2 diabetes. Amedical team and practice guidelines were established in line with the health insurance strategy of Taiwan's Bureau of National Health Insurance (BNHI) and American Diabetes Association (ADA) Standards of Care for Diabetes (2003 edition). Also, a set of self-care booklets was designed suitable for use by the subject group. The study was prospective and followed the patients from enrollment to one year. Patient outcomes were determined based on laboratory examinations and recorded self-care behavior. Data were collected at enrollment and over 4 follow-up times within a one year period. Generalized Estimating Equation (GEE) multiple linear regression and logistic regression were used for repeated measurements and adjustments of the effects of specific prognostic factors. Sixty subjects diagnosed with type 2 diabetes (mean duration 3.25 years) were recruited. All participants were married with a mean age of 52.5 years. A majority (58.3%) was male and 65% were ethnic Hakka. Self-care knowledge and behavior accomplishment rates were: taking medications by oneself, 91.3% (knowing medicines, 25.4%); hypoglycemia management, 23.3%; monitoring blood sugar, 46.7%; exercise, 35.8%; diet management, 51.7% and foot care, 92.8%. Significantly improved ADA diabetes care standard items included HbA1C (p＜.0001), fasting glucose (p＜.01) and triglycerides (p＜.05). The study incorporated evidence-based guidelines, public health insurance strategies and self-care booklets into a protocol to provide comprehensive care. The implemented diabetes program achieved diabetes care goals and improved patient self-care.