目標：探討台東地區糖尿病個案在共同照護網介入一年後，糖化血色素三年分佈情形及其控制不佳之影響因素。方法：本研究樣本來自台東某區域醫院糖尿病共同照護網之第二型糖尿病患，收案後完成四次階段性追蹤的個案共242位，就其糖化血色素的控制情形作為糖尿病照護成效的評量，並以邏輯式迴歸分析個案基本特性對於糖化血色素控制不佳的影響因素。結果：(一)糖化血色素控制成效在照護網介入後第一年最明顯，第二、三年略有上升，但相較於基準點仍具顯著的改善成效。(HbA1c分別為9.12%、7.93%、8.20%、8.27%，p＜0.05) (二)影響照護成效的因素：年齡小於65歲、原住民、基準點糖化血色素較高、罹病期較長者與非使用單一種口服降血糖藥物者，其糖化血色素控制不佳的勝算比顯著較高。結論：照護網介入對於糖化血色素長期控制有正面的成效；收案時年齡、種族、基準點糖化血色素、罹病期及糖尿病治療方式，是影響台東地區照護成效的因素。未來對糖尿病民眾之照護，應落實個案管理及結合社區資源，以提供符合個別需求的糖尿病控制計畫。(台灣衛誌 2011；30(1)：19-28)

Objectives: The aim of this study was to assess 3-year outcomes and factors associated with those outcomes in type 2 diabetic patients who joined the diabetes shared-care program in Taitung,Taiwan. Methods: 242 type II diabetic patients in a Taitung regional hospital were enrolled in
this study and completed 4 follow-up measures. The principal measure was the patient’s mean HbA1c at baseline and at each annual follow-up. A logistic regression model was used to examine the factors associated with poor glycemic control. Results: (1) The mean HbA1c level showed the greatest reduction in the first follow-up year. The level gradually increased over time (the mean values for HbA1c at baseline, 1st, 2nd , and 3rd years were 9.12%, 7.93%, 8.20%, and 8.27% respectively, p <0.05); however, the 3rd year level of HbA1c was still a significant improvement
over baseline. (2) Age < 65, aborigines, a higher HbA1c level at baseline, a longer duration of illness, and higher doses of medication were significantly associated with poor glycemic control.Conclusions: Our study demonstrated the long-term efficacy of a diabetes shared- care program in HbA1c control. Age, ethnicity, initial HbA1c level, duration of illness, and medication used were significantly associated with poor diabetes control. It would be helpful in improving the quality of
diabetes-care among the Taitung population if case management were combined with community resources. (Taiwan J Public Health. 2011;30(1):19-28)