DAROC-TADE：DAROC-TADE Joint Symposium

DAROC-1 RECOMMENDATIONS FOR DIABETES MELLITUS FROM TAIWAN LIPID GUIDELINES

HAO-CHANG HUNG

Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan,, Taiwan, ROC

Diabetes mellitus refers to a group of metabolic disorders characterized by the presence of hyperglycemia that results from insulin deficiency, insulin resistance, or both. Chronic hyperglycemia is associated with both microvascular and macrovascular complications. Intensive glycemic control reduces the risk of microvascular complications, but its effect on reducing macrovascular complications is less clear.

Diabetic patients are frequently associated with dyslipidemia and atherosclerotic cardiovascular diseases. Diabetic dyslipidemia is featured with increased serum triglyceride, increased VLDL, decreased HDL-C, and increased small dense LDL-C. The risk of cardiovascular disease appears early in the course of dysglycemia and correlates with plasma glucose level.

Aggressive management for lipid disorder and other risk factors has been proven to reduce macrovascular complications in these patients. Comprehensive assessment and treatment of dyslipidemia in diabetic patients are recommended, and it may be prudent to apply the same principles to prediabetic patients as well. Intensive lifestyle intervention is simple and cost-effective and should always be incorporated into dyslipidemia treatment plans.

DAROC-2 PCSK9, A NEW SOLUTION TO LIPID TREATMENT

CHO-KAI WU

Department of Cardiology, National Taiwan University Hospital, Taiwan, ROC

Statins have established strong evidences of efficacy in LDL-C reduction, which is related to prevent patients away from CVD events. PCSK9 inhibitors, a novel lipid lowering therapeutic choice, dramatically lower plasma LDL levels by increasing LDL receptor number within hepatocyte cell membranes. LDL-C receptor (LDL-C R) help on clearance of LDL-C in plasma, which is considered as one of cholesterol regulation mechanism. However,PCSK9 binds to LDL-C R and that reduces the usage of LDL-C R recycle within hepatocyte. PCSK9i inhibits PCSK9 and avoids the decreased recycle usage of LDL-C R. Statin reduces the cholesterol production, however, PCSK9i increases the clearance of LDL-C in plasma, that will help to lower LDL-C level. This novel therapeutic choice also help to reduce the LDL-C level in patients with familial hypercholesterolemia (FH), include HoFH and HeFH, those who have significant higher lipid profile and always lead to CVD in early age. FH is considered as a inherit disease, gene mutation results in cholesterol regulation function loss. In current practice, patients receive high intensity statin at tolerated dose. Ezetimibe is also considered if patients require aggressive LDL-C reduction.

PCSK9i can be considered for statin intolerant population (SI). Fewer medication can be applied for this group of patients. Increased number of scientific evidence showed the efficacy of PCSK9i in LDL-C reduction for different types of patients, including ASCVD, HoFH, HeFH and SI.

Over 60% additional LDL-C reduction is predictable when add to original therapy

The multi-channel model, but not the conventional model, may explain how statins and PCSK9 inhibitors can produce sustained increases in LDL receptor number.

DAROC-3

從糖尿病防治暨其合併症談臺灣醫療整合照護展望

王英偉

衛生福利部國民健康署 署長

世界衛生組織 (WHO) 2017 年公布非傳染性疾病 (NCD) 每年全球造成 1,500 萬人死亡，而四 大非傳染疾病 ( 癌症、糖尿病、心血管疾病、慢性呼吸道疾病 ) 約占死亡人數 6 成，吸菸、身體 活動不足、不健康飲食及有害使用酒精為其四大共同危險因素。目前全世界有 4 億 2,000 萬人罹 患糖尿病，在臺灣，糖尿病是國人十大死因第 5 位，2016 年因糖尿病死亡的人數達 9,960 人。依 據 2013-2016 年「國民營養健康狀況變遷調查」發現，18 歲以上國人糖尿病盛行率為 11.5%，粗 估全國約有 222 萬名糖尿病友，而糖尿病病人 5 年內發生心臟病的風險是一般人的 1.5 倍、中風 風險為 2.9 倍、腎臟疾病風險為 2.4 倍，若未良好控制血糖，糖尿病及其合併症將嚴重危害國人 健康。 為提升糖尿病之照護品質，國民健康署積極形塑各場域健康環境，落實民眾養成健康生活型 態知能，並提供成人預防保健服務，及早發現高血糖個案以提供介入服務；在糖尿病照護方面則 結合公共衛生部門、臨床醫療團隊及地方縣市政府等，於全國 22 縣市全面推動糖尿病共同照護 網，建構醫師、護理、營養等跨專業團隊，提升糖尿病品質照護，迄今已完成 9,366 人認證。同 時成立 255 家糖尿病健康促進機構及 176 家腎臟病健康促進機構，機構涵蓋了 6 成以上糖尿病病 人。此外，配合健保署「糖尿病品質支付服務」，藉由跨專業服務提升個案糖尿病照護品質。截 至 2016 年糖尿病照護涵蓋率為 46%，每年仍以 3% 成長率成長中。 由於醫療保險支付制度仍以單一疾病分類為主，而糖尿病病人病程與疾病嚴重度複雜，若未 良好控制血糖則會發生大血管、小血管病變，造成嚴重合併症，研究發現糖尿病導致腎病變及洗 腎個案發生率為 45%。爰此，健康署發展以病人為中心之連續性整合照護模式，除在初級預防積 極營造健康環境，強化民眾健康生活型態。在次級預防則落實各式檢查，包括透過成人預防保健 服務，早期發現糖尿病，並在糖尿病前期即予以介入，針對不同程度的糖尿病研擬提供適當的個 人化介入及衛教措施，延緩糖尿病或其合併症發生。在疾病診療及照護上除持續推動糖尿病共同 照護模式，結合健保署以支付誘因鼓勵提供跨專業團隊服務外，強化基層照護服務量能是刻不容 緩的，如何提升基層院所的照護涵蓋率，以符合病人實際的就醫行為，並落實分級照護，這是跨 司署須共同合作處理的重點。另外透過醫病共享決策模式，提升病人及其家屬的照護健康識能， 加強病人參與自我照護之能力，使其能真正參與疾病照護。目前本署正透過試辦計畫，針對糖尿 病合併有 3a 前期慢性腎臟病或其他合併症的病人，藉由提醒臨床醫師加強其對病人之用藥、生 活型態改善等介入措施，發展多重慢性病管理，延緩疾病或合併症發生。期能透過病人參與之連 續性照護，降低醫療經濟之負荷，進而提升個案生活及照護之品質。

DAROC-4 THE HEALTH CARE INSURANCE FROM MEDICAL CENTER TO CLINIC SECTOR: THE FUTURE OF DIABETES CARE

PO-CHANG LEE

National Health Insurance Administration, Ministry of Health and Welfare, Taiwan

According to the IDF Diabetes Atlas Eighth Edition, the global prevalence of diabetes will reach 629 million by 2045. A survey conducted by the Health Promotion Administration in 2013-2015 indicates that the prevalence of diabetes in adults aged over 18 years in Taiwan reaches 11.8%.The number of people living with diabetes has exceeded 2.27 million. Diabetes not only lead to several of serious complications, deteriorate the quality of life, but also rank top five of leading causes of death in Taiwan in recent years. Meanwhile, the burden of treatment and disease management has been substantially increased. However, the diabetes-related complications can be prevented and delayed disease progression through regular follow-up, active control and effective treatment. Therefore, the prevention and treatment of diabetes are important issue in Taiwan.

Pay for performance(P4P) payment model has been advocated as an alternative in many countries recently, while Fee-for-service (FFS) is lack to provide the incentive of improving quality of care. However, quality of care which represents the performance is hard to measure precisely. The difference in disease progression and patient’s characteristics influence the outcome of quality surveillance. Therefore, the main concept of developing P4P in Taiwan is improving the effectiveness and efficiency of disease care to conform the principle of Cost-effectiveness. Focus on diseases which are high expenditure, large population and have room for improvement. To provide financial incentive by paying for care performance, the government has budgeted special fund for P4P implementation from 2001. The special fund which is exclusively used for promoting P4P programs in 2017 is 1.7 billion, for example. At present, the following nine projects have been implemented: Diabetes, Asthma, Breast Cancer, Schizophrenia, Hepatitis B and C Carriers, Early chronic kidney disease, Early Intervention, full-term care of pregnant women and COPD.

The NHIA implemented ‘ The Pay for Performance Program for Diabetes ‘ in 2001, combining ’shared care’ and ‘pay for performance’ mechanism. To provide an integrated care for Diabetes patient, the health care institutions should form “team care system”, including physicians, nurses, dietitians, health staff, and team members who need regular continuing education training. Also, the institutions must establish a complete, rational and structured standardized medical procedure to provide regular outpatient care, examination, health education and follow-up, to reduce and slow down the occurrence of complications in diabetic patients and to enhance the overall quality of care. On the other hands, The NHIA provided transparent information on health care quality, hoping that it would motivate the medical community to improve the quality of medical services offered at every hospital and clinic in

Taiwan. That was also intended to enhance people’s understanding of the NHI system’s quality and treatment options and serve as a reference to help the insured make informed decisions when choosing providers and types of care. It further use as a payment tool. Health care institution could receive extra bonus base on the indicators performance since 2007.

The care rate of DM-P4P program had reached 46% in 2016. Patients who enrolled in the DMP4P program have better compliance for completing follow-up tests such as HbAlc, Funduscopic exam and Microalbumin. Patients with higher HbAlc level between 2005 and 2010 were tracked. Two third of these patients achieved a declination of HbAlc level to normal range after one year.New participants in 2005, after 11 years follow up: HbAlc and LDL test value of the normal proportion of check-ups are growing year by year,. They also have lower incidence rate of dialysis. Patients can get good treatment results if they follow doctor’s advice, receive continuous health education, follow up regularly and change their lifestyle. They can also avoid or delay the occurrence of complications. In 2012, DMP4P program was included in Fee Schedule due to its excellent performance, expanding the number of beneficiaries and improving the quality of care in all aspects.

In July 2013, the NHIA completed the first phase of the patient-centered NHI PharmaCloud System. Through NHI PharmaCloud System, the physicians can inquiry into the latest 3-years prescriptions of DM patients such as medication and examination. We can facilitate patient’s drug safety and reduce duplicate prescriptions.In September 2014, the NHIA completed the “My Health Bank” system. In this system, we also provide hyperlinks of health information. Nowadays, “My Health Bank” has been widely used in health care. Untill September 2016, 1.54 million people had inquired their own medical record. After data visualization, patients can easily inquiry into their medical records and increase their capability to manage their own health.

Institutions’ quality of care is expected to enhance by improving care rate of diabetic patients continuously, tracking and disclosing the outcome of health care quality performance. Another physician can share the medical record through NHI PharmaCloud System to improve patient tracking and management efficiency. Patients can use “My Health Bank” for self-health management. Through the above methods, an integrated and comprehensive diabetic care network will established by cooperation of patient, institution and NHI in the future.

DAROC-4

醫學中心到基層醫療健保：糖尿病疾病照護的未來

李伯璋

衛生福利部中央健康保險署

根據國際糖尿病聯合會 (IDF) 於 2017 年更新的全球糖尿病地圖 ( 第八版 )，估計 2045 年全球 糖尿病人口將高達 6.29 億人，依國健署 2013-2015 年調查：18 歲以上國人糖尿病盛行率也高達 11.8%，糖尿病患者已突破 227 萬人。而糖尿病不僅會引發多種嚴重併發症，惡化病患生活品質， 也是近年國人十大死因前五名，同時更造成醫療花費支出的負擔。但其實糖尿病可透過定期追蹤、 積極控制及有效治療，以延緩病情惡化及晚期併發症的發生。因此，糖尿病的預防及治療是我國 重要的醫療課題。 由於論量計酬無法有誘因提升醫療品質，論質計酬 (pay for performance) 則為近年各國提倡之 改革主流，但醫療品質之衡量不易，同疾病之醫療品質測量亦有極大之差異，如何提昇疾病照護 的效果及效率，達到以最符合成本效益的原則，即為台灣推行論質計酬之主要思考方向。疾病之 選擇主要針對費用大、罹病人數多、照護模式有改善空間之疾病為優先。採取論「品質」付費的 支付方式，提供適當誘因。健保醫療給付改善方案 ( 論質計酬方案 )，自 2001 年起每年編列專款 辦理 ( 以 2017 年為例，編列約 17 億元 )，目前辦理項目除糖尿病、氣喘、乳癌、思覺失調症、B 型與 C 型肝炎帶原者、初期慢性腎臟病、早期療育、孕產婦全程照護外，2017 年更增加慢性阻 塞性肺病 (COPD)，總計 9 項論質計酬方案。 中央健康保險署於 2001 年實施「全民健康保險糖尿病醫療給付改善方案」，主要係結合共 同照護及論質計酬的慢性病照護模式，提供糖尿病患者完整的「團隊照護系統」，包括醫師、護 理師、營養師、衛教人員組成共同照護團隊，團隊人員均須定期接受繼續教育訓練。醫療院所須 建立完整、合理、結構化的標準化醫療流程，提供定期的診察、檢驗、衛教及追蹤，降低及延緩 糖尿病患者併發症的發生，提升整體照護品質。另為幫助民眾能確實掌握醫療院所的醫療品質資 訊，做為就醫參考，利用健保給付資料分析，建立偵測醫療院所醫療品質的指標，並透過品質指 標公開，作為參與院所評比依據，進而不斷提升對患者的照護品質，並自 2007 年依品質指標評 核給予品質加成鼓勵。 「全民健康保險糖尿病醫療給付改善方案」照護人數逐年增加，至 2016 年達到整體 糖尿病患者的 46%。每年參與個案的治療遵循率皆高於未參加者，如 HbA1c、眼底檢查及 Microalbumin。且經追蹤 2005-2010 年初診 HbAlc ＞ 9.5% 的新收個案，1 年後有 66% 個案的 HbAlc 檢驗值下降至正常範圍，另持續追蹤 2005 年參與方案者自 2006-2015 的年底檢查值 :HbAlc 及 LDL 檢驗檢查值正常比例皆逐年成長，上述患者的洗腎發生率亦低於未參加方案者，顯示參 與「全民健康保險糖尿病醫療給付改善方案」的糖尿病患者若遵循醫囑，並持續接受衛教及定期 追蹤，以及自我生活型態改變，皆能得到良好的治療成效，亦可避免或延緩併發症的發生。2012 年因方案執行成效良好，已導入支付標準，擴大受益人數，全面提升照護品質。 2013 年 7 月健保署建置完成以病人為中心的「健保雲端藥歷系統」，醫師可利用雲端藥歷來

管理追蹤糖尿病患者近三年的用藥及檢驗狀況，減少重複用藥的可能，以增進病人用藥安全。另 於 2014 年 9 月起建置「健康存摺」系統，提供各種健康資訊可供使用者自行點閱查詢。健康存 摺的使用人數自推廣以來，已呈現倍數般的成長，統計至 2016 年 9 月已有 154 萬人使用，糖尿 病患者可透過健康存摺做好自我健康管理追蹤。 未來我們希望持續提升糖尿病患者照護率，同時透過追蹤及公開醫療品質指標，以提升院所 提供的照護品質；另醫師可透過電子病歷的雲端分享，提升病患的追蹤及管理效益，糖尿病患者 能運用健康存摺做好自我健康管理。透過上述方式，讓健保、院所及民眾共同合作，建立更完善 的糖尿病照護網絡。