Sieng Sokha, Hurst Cameron
Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand.
School Health Department, Ministry of Education, Youth and Sport, Phnom Penh, Cambodia.
BMC Health Serv Res. 2017 Aug 7;17(1):533. doi: 10.1186/s12913-017-2486-7.
This study compares a combination of processes of care and clinical targets among patients with type 2 diabetes mellitus (T2DM) between specialist diabetes clinics (SDCs) and general medical clinics (GMCs), and how differences between these two types of clinics differ with hospital type (community, provincial and regional).
Type 2 diabetes mellitus patient medical records were collected from 595 hospitals (499 community, 70 provincial, 26 regional) in Thailand between April 1 to June 30, 2012 resulting in a cross-sectional sample of 26,860 patients. Generalized linear mixed modeling was conducted to examine associations between clinic type and quality of care. The outcome variables of interest were split into clinical targets and process of care. A subsequent subgroup analysis was conducted to examine if the nature of clinical target and process of care differences between GMCs and SDCs varied with hospital type (regional, provincial, community).
Regardless of the types of hospitals (regional, provincial, or community) patients attending SDCs were considerably more likely to have eye and foot exam. In terms of larger hospitals (regional and provincial) patients attending SDCs were more likely to achieve HbA1c exam, All FACE exam, BP target, and the Num7Q. Interestingly, SDCs performed better than GMCs at only provincial hospitals for LDL-C target and the All7Q. Finally, patients with T2DM who attended community hospital-GMCs had a better chance of achieving the blood pressure target than patients who attended community hospital-SDCs.
Specialized diabetes clinics outperform general medical clinics for both regional and provincial hospitals for all quality of care indicators and the number of quality of care indicators achieved was never lower. However, this better performance of SDC was not observed in community hospital. Indeed, GMCs outperformed SDCs for some quality of care indicators in the community level setting.
本研究比较了糖尿病专科诊所（SDCs）和普通内科诊所（GMCs）中2型糖尿病（T2DM）患者的护理流程与临床指标的组合情况，以及这两类诊所之间的差异如何因医院类型（社区、省级和地区级）而有所不同。
2012年4月1日至6月30日期间，从泰国的595家医院（499家社区医院、70家省级医院、26家地区级医院）收集了2型糖尿病患者的病历，最终得到26,860名患者的横断面样本。采用广义线性混合模型来检验诊所类型与护理质量之间的关联。感兴趣的结局变量分为临床指标和护理流程。随后进行亚组分析，以检验GMCs和SDCs之间临床指标和护理流程差异的性质是否随医院类型（地区级、省级、社区级）而变化。
无论医院类型（地区级、省级或社区级）如何，在SDCs就诊的患者进行眼部和足部检查的可能性都要大得多。就大型医院（地区级和省级）而言，在SDCs就诊的患者更有可能完成糖化血红蛋白（HbA1c）检查、全面足部检查（All FACE exam）、血压达标以及达到7项质量指标（Num7Q）。有趣的是，仅在省级医院，SDCs在低密度脂蛋白胆固醇（LDL-C）达标和7项综合质量指标（All7Q）方面的表现优于GMCs。最后，在社区医院GMCs就诊的T2DM患者比在社区医院SDCs就诊的患者更有可能实现血压达标。
对于地区级和省级医院的所有护理质量指标而言，糖尿病专科诊所的表现均优于普通内科诊所，且实现的护理质量指标数量从未更低。然而，在社区医院并未观察到SDCs的这种更好表现。事实上，在社区层面的环境中，GMCs在某些护理质量指标上的表现优于SDCs。
