20卷6期

• Link 綜論 Review Article
• 全球化之下工作壓力對職工身心健康之影響及整合性的對策Globalization, Workplace Pressures and Mental Health At work: Challenges and Sustainable Strategies
• 朱明若、李姣姿
  Cordia Chu, Chiao-Tzu Lee
• 工作壓力 ； 全球化 ； 身心健康 ； 整合工作場健康管理
  workingplace pressures ; globalization ; mental health ; integrative workplace health management.
• 近二十年來。國際間的工作人群健康已成為漸受關注的一個領域。世界經濟與快速科技發展的全球化改變了勞動及職業型態，使員工暴露於新的健康風險中。這對於各國的工作機構帶來了嚴峻的挑戰，所以對關心職場健康的有關單位及學術研究與專業人士，探討如何有效地維護與促進員工的健康是一個非常重要的課題。 本文探討全球化與工作及就業型態的改變下，對職工健康與安全的影響；並且在處理影響工作場所與職工健康的多種因素方面，提出一套全盤性工作場所健康管理的模式，最近這套模式已發展為國際工作場所健康促進的重要方法。本文首先從近來全球化趨勢及科技發展的背景來探討變化中的工作型態及其對員工的健康影響。尤其本文更強調出與工作場所壓力增加有關的心理健康方面的問題。最後，本文則加以說明整合性工作場所健康管理(Integrative workplace health manage是包含健康促進、疾病預防、安全管理與組織發展等全面性的計劃）模式並討論此模式在國際間的發展與成果。
  The health of the international workforce has been an increasing area of concern for the last two decades. Globalization of the world economy and rapid technological changes continue to change the nature of work and employment practices, exposing employees to new and serious health risks. These challenges are inescapable in any workplace, therefore it is critical that work organisations examine how they can best protect and promote the health and well being of their employees. This paper examines health and safety implications for workers in the context of globalization and the changing world of work. It suggests that a sustainable strategy for employers to deal with the multifaceted workplace pressures and health impacts on employees is to implement an integrative holistic model of workplace health management, which has emerged from the latest developments in the settings approach to workplace health promotion. This paper will first examine the changing world of work and the implications on employee health in the current climate of globalization and technological changes. In particular, it will highlight mental health issues associated with the emerging epidemic of work stress from increased workplace pressures. Finally, it will explain the integrative workplace health management model and discusses its international development and successes.
• 413 - 422
• 10.6288/TJPH2001-20-06-01

• Link 綜論 Review Article
• 以經濟學觀點探討非法性藥物濫用之危險因子與防制措施Study the Risk Factors and Control Measures of Illicit Drug Abuse- an Economic Approach
• 張宏浩、賴麗華、唐麗慧、黃旐濤、陳國東
  Hung-Hao Chang, Li-Hua Lai, Li-Hui Tang, Chao-Tao Huang, Kow-Tong Chen
• 非法性藥物濫用 ； 需求面 ； 危險因子 ； 管制策略
  illicit drug abuse ; demand side ; risk factor ; control measure.
• 目前國內對於非法性藥物濫用之研究大多以生物醫學或流行病學觀點。探討非法性藥物濫用行為對人體生理及心理的傷害及其危險因子，雖然這些研究提出了許多防制方法，但禁者恆禁、用者恆用，政策成效有限。我們不禁要問是否有其他吸引使用者的因素，促使濫用者不顧生理、心理的健康繼續使用？經濟學供需的理論是我們思考的方向之一，不過就我們所知國內以經濟學觀點探討非法性藥物之研究甚少。本文之目的擬以文獻回顧方式，由供給面與需求面角度詮釋非法性藥物濫用行為及其危險因子，並提出防制策略建議。長久以來各國政府對於防制非法性藥物濫用，大都採取以供給面為主之管制政策，花費龐大但政策效果不彰，未來在擬訂藥物濫用防制借施時應加入需求面的理念，以使防制成果更有成效。
  Most previous studies of illicit drug abuse are based on medical or epidemiological approaches, discussing health impacts and health risk factors. Although many control measures have been applied, the prevalence of illicit drug abusers is still increasing. There may be Some unknown factors to trigger the desire of illicit drug abuse. In order to curb the use of illicit drugs, an economic approach may be more effective. Unfortunately, very few studies have been done in this field. The objective of this paper was to review the behavior and risk factors of illicit drug abuse from the view of supply and demand, and highlight some recommendations of control measures. The government's exclusive focus on supply side policy has been costly and generally ineffective in the past. In order to improve effectiveness of illicit drug abuse control, the control strategies should consider toward demand side.
• 423 - 432
• 10.6288/TJPH2001-20-06-02

• Link 原著 Original Article
• 鋼鐵業勞工聽力損失評估Assessment of Hearing Loss Among Steel Manufacturing Workers
• 張淑如、宋鴻樟、江宜庭、陳秋蓉
  Shu-Ju Chang, Fung-Chang Sung, Yi-Ting Chiang, Chiou-Jong Chen
• 噪音 ； 聽力損失 ； 鋼鐵業
  noise ; hearing loss ; steel manufactories.
• 目標：工作場所噪音造成的聽力損失，是重要的勞工安全衛生議題，鋼鐵業勞工噪音暴露特別高，但未曾有過系統的探討。本研究收集國內鋼鐵廠勞工聽力檢查資料，評估分析其聽力損失概況。方法：本研究調查獲得13家鋼鐵廠同意提供聽力健檢資料，其中12家依「勞工健康保護規則」規定保存了10年的資料，乃取其1997和1998年可供分析之員工資料，計有7160個案。利用我國勞工聽力常模值，校正年齡因素的影響後，分析由噪音所造成的聽力損失，特別是4kHz和6kHz之聽力損失，並比較其符合勞工噪音健康管理級別的程度。結果：從事噪音作業勞工較差耳的4kHz聽力損失達40分貝以上的有29％，6kHz的聽力損失更達31％，顯示鋼鐵業為噪音作業中較嚴重的行業之一。各年齡層的4kHz和6kHz的聽力損失均嚴重，由噪音和其他因素造成的聽力損失皆高達14分貝，年齡50歲以上甚至高達20分貝。依據醫院判定之健康管理級別區分，只有1人判為第三級管理。結論：鋼鐵業勞工聽力損失與職業噪音管理級別不具相關性，實為嚴重低估，顯示噪音作業勞工聽力損失指標不宜使用三分法或四分或六分法。鋼鐵業應確實實施「勞工聽力保護計畫」保護勞工聽力，以免聽力損失更形嚴重。
  Objectives: Hearing loss in the workforce, due to noise exposure, has attracted attention for decades in Taiwan. However, studies on this issue remain scarce. This report describes hearing loss for steel factory workers. Methods: Steel factories in Taiwan are required to comply with ”Workers Health Protection Regulation” by establishing records of routine hearing examinations for workers exposed to noise. We obtained, from 12 factories, 7160 workers' records of hearing examinations conducted in 1997 and 1998. Age-adjusted hearing acuity, particularly in the frequencies of 4kHz and 6kHz, was compared against ”National Labors' Hearing Normal Distribution”. This Was used as a standard for estimating hearing impairment for each worker. Results: Hearing impairment was found for study subjects of all ages. Workers younger than 50 years had an average hearing loss of at least 14 decibels. Workers 50 years of age and above had an average loss of 20 decibels. Approximately 29% of workers had an average loss of 40 decibels or above in 4kHz and 31 % workers had a similar level of hearing loss in 6kHz. Among all steel industrial workers in this study, almost none were classified for hearing protection management level 3. Analysis also' revealed that using the three-, four- or six-distribution method for assessing hearing loss for steel manufacturing workers underestimates their hearing impairment. Conclusions: The steel industries fail to protect workers from hearing loss. This industry must be in compliance with the ”Hearing Protection Project for Workers” act to halt the decline of hearing acuity for their employees.
• 433 - 439
• 10.6288/TJPH2001-20-06-03

• Link 原著 Original Article
• 健保支付制度對全髖及全膝關置換手術療利用情形之影響Impact of NHI Payment on Medical Utilization of Total Hip Replacement and Total Knee Replacement
• 張佳琪、黃文鴻
  Chia-Chi Chang, Weng F. Hung
• 論病例計酬 ； 醫療利用 ； 全髖關節置換手術 ； 全膝關節置換手術 ； 全民健保
  Case Payment ; Medical Utilization Total Hip Replacement ; Total Knee Replacement ; National Health Insurance.
• 目標：本研究目的在瞭解全髖及全膝關節置換手術之住院日數、醫療費用及診療處置行為；並比較不同支付制度對住院日數、醫療費用、診療處置行為之影響。方法：以全民健保86年11月實施論病例計酬前後半年之全髖及全膝關節置換手術的住院病人為研究對象；以健保總局之住院費用及醫令清單明細檔進行資料分析。結果：1.全臗及全膝關節置換手術之平均住院日數分別為11.4天、12.6天，平均醫總用分別為131,766.8元、150,501.1元，醫令種數分別為81.7種、87.0種醫令使用率分別為510.2 次、570.2次。2.兩手術在住院日數、醫療費用、醫令種類數、醫令使用率等指標上，論病例計酬與論量計酬間幾乎都呈現統計顯著之差異。結論：全髖及全膝關節置換手術之整體住院醫療利用情形，在論病例計酬支付制度實施之後呈現醫療資源耗用下降的情形，且使利用情形、醫師行為更趨一致。
  Objectives: This study analyzed and compared the length of stay, medical costs, and treatment behavior for total hip replacement (THR) and total knee replacement (TKR) in fee-for service and case payment of the NHI payment system. Methods: As the Bureau of National Health Insurance has implemented the case payment for THR and TKR since November 1997, the study subjects comprised of all THR and TKR patients under NHI coverage during May 1997 to April 1998. Results: The average length of stay in THR/ TKR are 11.4 days and 12.6 days, while the average medical costs are NT$ 131,766.8 and NT$ 150,501.1 respectively. The category quantity of medical order for each replacement are 81.7 and 87.0, and the number of medical orders are 510.2 and 570.2 respectively. The indicators of these two surgeries, such as length of stay, medical costs, category quantity and utility rate of medical order showed a statistically significant difference between fee-far-service and case payment. Conclusions: Medical utilization indicators declined after the case payment implementation for total hip replacement and total knee replacement. It is obvious that medical utilization trends produce a converging effect after the implementation of case payment.
• 440 - 450
• 10.6288/TJPH2001-20-06-04

• Link 原著 Original Article
• 台灣成年民眾於死亡前三個月健保醫療費用支出之影響因素分析Factors Affecting the Expenditure of NHI by Adult Beneficiaries in Their Last Three Months of Life in Taiwan
• 劉嘉年、楊銘欽、楊志良
  Chia-Nien Liu, Ming-Ching Yang, Chih-Liang Yaung
• 臨終成本 ； 醫療費用 ； 全民健康保險
  Cost of dying ; Health care expenditure ; National health insurance.
• 目標：臨終成本是衛生服務研究的重要課題之一，本研究的目的在探討影響台灣成年民眾於死亡前三個月健保醫療費用支出的因素。方法：採次級資料分析法，由衛生署死因資料檔中，以簡單隨機抽樣的方式，選取一萬名於1999年死亡的20歲以上台灣民眾，以身分證字號連結門診、住院明細檔與醫令檔。經歸戶後共有8.124人為臨終組樣本。並參照Andersen 醫療服務利用的行為模式，從前傾、需要與能力資源三個因素，再加上加護醫療利用因素，共同探究死亡前三個月醫療費用的影響因素。結果：死亡前三個月的醫療費用受到需要、前傾、能力資源、與加護醫療利用因素的影響，整體模型的解釋力高達75.20%：結論：本研究確認出影響臨終醫療費用的重要特質，並建議未來研究應關切臨終照護服務的適切性，並進一步探究年齡、婚姻狀態、地區醫療資源與臨終醫療費用的關係。
  Objectives: The costs of health care at the end of life are a major issue of health services research. The purpose of this study is to examine the factors related to expenditure of NHI in the last three months of life by adult people who died in 1999 in Taiwan. Methods: Ten thousand individuals aged 20 and over who died in 1999 were randomly selected from the Death Certificate data file. To obtain a complete record of the National Health Insurance reimbursement and utilization experience for these deceased individuals, we linked the sample to the inpatient claims and the outpatient claims files provided by the Bureau of the National Health Insurance. Of this sample, 8,124 of the deceased were matched. The logged sum of an individual's last three months expenses was modeled using intensive care utilization variables and variables specified in the behavioral model of health services utilization developed by Andersen. The behavioral model views the use of health services as a function of the predisposing, enabling, and need characteristics of an individual. Multiple regressions were employed for data analysis. Results: The health care expenditure of the last three months was related to predisposing, need, enabling characteristics, and intensive care utilization variables. The multivariable regression model explained 75.20% of teristics related to the expenditure of NHI by adult beneficiaries in their last three months of life in Taiwan. We suggest that the appropriateness of care for terminal patients, and the relationship between dying cost and age, marital status, regional health care resource deserve further study.
• 451 - 462
• 10.6288/TJPH2001-20-06-05

• Link 原著 Original Article
• 中醫醫療利用成長與醫師數增加之關係Relationship Between Chinese Medical Utilization and Growth of Physicians
• 蔡文正、 龔佩珍
  Wen-Chen Tsai, Pei-Tseng Kung
• 醫師誘發需求 ； 供給誘導需求 ； 中醫醫療利用 ； 中醫師數
  Physician-induced demand ; Supplier-induced demand ; Chinese medical care utilization ; Number of Chinese medical physicians
• 目的：全民健保實施後醫療費用不斷上漲，假若民眾之健康情形無明顯之惡化，為何醫療服務量成長速度高出人口成長比率甚多，此一問題值得深入探討。本研究主要探討中醫醫療利用之成長與中西醫師數增加有無關係。方法：本研究以衛生署規劃之次醫療區為觀察單位，以民國85至88年間之資料為研究期間，各區域內之每人每年中醫醫療費與利用次數為依變項。共計236個觀察值。應用固定效果模型(Fixed-effects Mosel)為複回歸統計分析模型，並分為平均費用模型及平均次數模型。結果：每萬人口中、西醫師人數、老年人口比率、幼年人口比率、女性人口比率皆顯著影響中醫醫療利用次數與費用。並計算出，每萬人口中西醫師數增加25%，則因中醫師人數的增加醫療利用次數及費用將增加0.39％。每萬人口西醫師數增加25％，則造成平均中醫醫療利用次數及費用減少0.23%。結論：中醫門診醫療稍微存在醫師誘發需求的現象。且民國85至88年中醫門診醫療費用成長中，有1.69%的成長費用導因於中醫師人數之增加。顯示平均中醫醫療利用受中醫師數或西醫師數之增加影響不大。
  Objectives: After implementation of National Health Insurance in Taiwan, health care expenditure has increased rapidly. If people's general health status has not significantly changed, why has the health care expenditure increased so much? This study examined the impact of the growth of physicians on Chinese medical utilization in Taiwan. Methods: This research used sub-region in health care service network as the observation unit over the period from 1996 to 1999. It contained 236 observation units in total. Average Chinese medical care expenditures per capita per year and average Chinese medical care visits per capita per year were used as the dependent variable. This study applied multiple regression with a fixed-effects model as the means of analysis. Results: Chinese medical physicians per ten thousand population, Western medical physicians per ten thousand population, ratio of aged population (older than 64 years), ratio of young age (less than 15 years), and ratio of female population significantly influence Chinese medical care utilization. If Chinese medical physicians increase 25 percent, Chinese medical care expenditure will increase 0.39 percent. However, if Western medical physicians increase 25 percent, Chinese medical care expenditure will decrease 0.23 percent. Conclusions: Chinese medical care services slightly exhibit a physician-induced demand situation and 1.69 percent increase in Chinese medical care expenditures was caused by the growth of Chinese medical physicians from 1996 to 1999. This implies that the impact of growth of physicians on Chinese medical care utilization is very slight.
• 463 - 474
• 10.6288/TJPH2001-20-06-06

• Link 原著 Original Article
• 牙科處置資源耗用相對價值表之研探A Study on Resource Based Relative Value Scale of Dental Procedures in Taiwan
• 楊志良、 陳琇玲、 溫信財、 黃文駿、 黃意婷
  Chih-Liang Yaung, Hsiu-Ling Chen, Hsyien-Chia Wen, Wen-Jiun Huang, I-Ting Huang
• 牙科 ； 資源耗用 ； 相對價值表 ； 支付標準
  dentist ; practice cost ; relative value scale ; payment system.
• 目標：本研究試圖建立本土牙科處置資源耗用之相對價值表。以發展醫療項目資源耗用的分析模式。方法：本研究結合「牙醫師工作量」、「藥衛材成本」、「操作時間」三種不同基準資料，透過牙科「成本結構」之各項成本占率以及單項處置之「服務量」，轉換為相同基準之相對值，建立牙科處置的資源耗用相對值，作為資源耗用分析模式。並請專家小組成員個別對研究結果進行評估，同時探討與健保支付標準的相關性，再將各項處置之相對值貨幣化後，與健保支付標準進行比較。結果：完成建立79項牙科處置之執業資源耗用為基準相對價值表。牙醫師全聯會推派之專家對研究結果的評估。與本研究所得相對值之間有顯著相關，本研究所得牙科各項處置耗用資源相對價值表與現行健保支付標準之間具有顯著相關，將研究結果相對值貨幣化後所得到牙醫師判定各項處置資源耗用金額，可獲得與健保支付標準之差異值。結論：本研究所得相對值整體為牙科專家認同，顯示健保支付標準大致反應牙科各項處置的資源耗用的相對性。但是部分項目牙醫師判定耗用的資源與健保支付標準之差異大，可作為未來調整支付標準之參考。
  Objectives: The purpose of this study was to investigate the Resource Based Relative Value Scale of dental procedures (D-RBRVS) in Taiwan in order to establish a model of resource-input for medical services. Methods: The formula for our procedure cost was ”D-RBRYS = the RVS of dentists' Workload + the RVS of drug and material costs + the RVS of other operating costs”, We readjusted the three RVSs to a common scale and set up the D-RBRVS by dental cost structure and service volume. We then investigated the opinions of dental specialists and evaluated the correlation between our D-RBRVS and the dentistry payment scheme of the National Health Insurance (NHI). We also adjusted the D-RBRVS in a monetary base and compared with it the AA procedures were established. The views of dental specialists were significantly correlated with Our D-RBR VS. The results also correlated fairly well with the current dental payment schedule of the NHI. However, there were differences between the monetary-base D-RBRVS and the payment scheme of NHI for some services. Conclusions: The high acceptance of our D-RBRVS by dental specialists suggests that the parameters of dentists' workload, cost of medications and supplies, and time required for procedures establishes a reasonable basis for evaluating resources. The current NHI dental fee schedule also fairly well matched the D-RBRVS of the 79 procedures. The monetary-base D-RBR VS can be a reference for adjustment of the NHI dental payment system in the future.
• 475 - 484
• 10.6288/TJPH2001-20-06-07

• Link 原著 Original Article
• 台北市國中生之暴力行為與溝通技巧的關係The Relationship Between Violent Behaviors and Communication Skills Among Students of Junior High Schools in Taipei City
• 吳文琪、李蘭
  Wen-Chi Wu, Lee-Lan Yen
• 暴力行為 ； 溝通技巧 ； 青少年 ； PRECEDE模式
  violent behavior ; communication skill ; adolescence ; PRECEDE Model.
• 目標：本研究目的在瞭解台北市國中生之暴力行為分布及溝通技巧運用現況，並探討溝通技巧與暴力行為關係。方法：研究資料取自1999年台北市國中生危害健康行為調查，共1477個有效樣本。結果：(1)曾有暴力行為的頻率由高到低依序是講髒話、頂撞、生氣時摔東西、打架、破壞公物、性侵害、欺負及勒索；(2)從各類溝通技巧向度來看，經常使用聽的技巧的頻率介於46.7%~73.9%之間，經常使用說的技巧的頻率介於21.5%~77.2之間，經常使用內容結構技巧的頻率介於32.2%~63.7%之間；(3)背景因素中年級、性別、內控傾向、對暴力行為的態度、家人及朋友從事暴力行為的頻率、朋友關係及家人關係，與國中生暴力行為的發生頻率有顯著關係；(4)在控制了前述因素之後，溝通技巧對暴力行為的發生頻率呈現顯著的負相關；(5)在前傾因素中，女生、學業成就高、內控傾向程度高、自我肯定程度高、對暴力行為的態度傾向不贊同、父親教育程度高及父母婚姻狀況愈和諧者，並溝通技巧運用頻率會愈高。結論：溝通技巧在控制其他影響因素之後，對暴力行為有顯著的的預測力，所以建議相關單位研擬暴力行為的預防介入計畫時，可強化溝通技巧的訓練。
  Objectives: The purposes of this study were: (l) to understand the distributions of violent behaviors and the frequency of using communication skills among junior high school students in Taipei City; (2) to find out the relationship between violent behaviors and communication skills. Methods: Secondary data drawn from a study entitled ”The Health Risk Behavior Investigation of Junior High School Students in Taipei City” was analyzed. A total of 1477 students completed the questionnaires. Results: The results included: (l) the prevalence rates of violent behaviors ranking in order were swearing, verbally offending parents or teachers, breaking things when getting mad, fighting, destroying public equipment, sexually assaulting others, and threatening and extorting; (2) among all kinds of communication skills, the frequency of using hearing skills was usually between 46.7% and 73.9%, the frequency of using talking skills was usually between 21.5% and 77.2%, and the frequency of using content constructing skills was usually between 32.2% and 63. 7%; (3) grade, gender, locus of control, attitude toward violent behaviors, violent behaviors of families and friends, friendship, and the relationship with family were correlated with the frequency of violent behaviors; (4) after controlling for other factors, communication skills still had a significant negative relationship with the frequency of violent behavior; (5) among all predisposing factors, students who were female, had a higher academic achievement, higher degree of internal control, higher degree of self confidence, more disagreement with the use of violence, whose father had a higher degree of education, and whose family was more harmonious, had a higher frequency of using communication skills. Conclusion: The frequency of using communication skills was found to be a significant predictor of adolescents' violent behaviors. It was thus suggested that our government and educational department could provide communication skill training in preventing violent behaviors among adolescents.
• 485 - 494
• 10.6288/TJPH2001-20-06-08

• Link 綜論 Review Article
• 管理式醫療介紹Introduction of Managed Care
• 林恆慶、黃子芬、李照軒
  Herng-Ching Lin, Zhi-Fan Huang, Zhao-Shen Lee
• 健康維護組織 ； 管理式醫療 ； 群醫執業
  managed care ; Health Maintenance Organizations ; group practice.
• 在過去二十年中，美國在健康維護組織的納保人口已從1980年時的九百萬增加到1999年時的八千一百萬，管理式醫療機構不但重新塑造了美國健康照護體系，管理式醫療也被公認為是最能控制醫療費用及確保醫療品質的利器，本文的主要目的即是要藉由管理式醫療的介紹讓醫療專業者能對其他國家的健康照護體系有更進一步的瞭解。管理式醫療不僅支配了二十世紀末期的美國健康照護體系，其原理精神也成為世界各衛生政策製定者群起傚仿之對像，例如亞洲國家中的韓國、日本、香港、及新加玻都已將管理式醫療的部份精神融入他們的衛生體系中，而臺灣目前在澎湖、蘭嶼、綠島等離島及對洗腎病患所實行的論人計酬制度也是來自管理式醫療機構用來支付醫療提供者的付費機制，管理式醫療已被許多國家做為控制醫療費用及確保醫療品質的工具。本文敘述了管理式醫療的定義、起源、及發展過程，並且探討了促進傳統保險過渡到管理式醫療的主要因素及管理式醫療對健康照護體系之影響。
  Managed care has dominated the U.S. health delivery system since the end of 20th century. The umber of those enrolled in Health Maintenance Organizations jumped from 9 million in 1980 to 81 million in 1999. Managed care not only reshape the health care delivery system of the United States, but is also considered as the best mechanism to contain costs and to assure quality of medical care. The purpose of this paper is to help health professionals expand their understandings of other countries’ health delivery system through the introduction of managed care. The essence of managed care has been applied by many Asian countries such as Korea, Japan, Hong Kong , and Singapore into their own health delivery systems. The Bureau of Taiwan National Health Insurance also uses the capitation payment method, one kind of managed care payment mechanism, to pay for the health care service in outlying islands, such as Penghu, Lanyu, and Green Island. The adoption of managed care has become a popular strategy for the health industry to contain costs and to assure quality of medical care. This article states the definitions, origins, and developments of managed care. It also explores the major factors which facilitate the transition from traditional fee-far-service insurance to managed care and discusses the influences of managed care on the health care delivery system
• 331 - 336
• 10.6288/TJPH2001-20-05-01