31卷4期

• Link 綜論 Review Article
• 美國癌症登記及老人醫療保險資料庫之發展與應用－論台灣癌症登記與健康保險聯結資料庫之可行性Development of the TCDB-NHIRD Linked Database: What Can We Learn From The SEER-Medicare Database In The United States?
• 潘憶文、簡君儒、施雅真
  I-Wen Pan, Chun-Ru Chien, Ya-Chen Tina Shih
• 癌症登記 ； 醫療保險 ； 行政申報資料庫
  Cancer Registry ; Medicare ; Claim database
• 根據美國國家癌症研究中心的統計，到2011年1月止，運用美國癌症登記（Surveillance, Epidemiology, and End Results Program，簡稱SEER）及老人醫療保險（簡稱Medicare）行政申報資料庫連結資料庫發表在同儕審查期刊的文章已超過650篇以上，在癌症醫療品質及成本相關的研究有卓著的成果。我國全民健康保險自1995年開始辦理，全民健康保險資料庫業已廣泛應用，另一方面我國癌症登記資料庫也漸趨成熟。若能將兩者結合，應可發揮相當程度的綜效。本文的目的是希望藉由他山之石，提供我國未來整合癌症相關資料庫供臨床、學術研究應用及政策評估之參考。本篇文章將針對以下內容作介紹：資料蒐集之行政層級及架構、資料庫的結構、附加應用軟體及程式介紹、資料庫驗證（Validation）與申請費用、資料庫的使用限制與病人個別資料保護，並以乳癌為例，說明該資料庫在臨床研究、醫療品質及癌症治療成本研究方面之應用，並提供建議。
  In the United States, the SEER-Medicare data link cancer patients in the SEER (Surveillance, Epidemiology, and End Results) Program with Medicare enrollment to identify cancer patients who are eligible for Medicare and to provide Medicare Claims for these patients. Statistics from the National Cancer Institute show that there are over 650 peer-reviewed publications using the SEER -Medicare database. This database has been the primary data source for health services research in oncology since its inception, and it has made tremendous contributions to policies related to cancer control, treatment, and surveillance in the United States. The National Health Insurance Research Database (NHIRD), established at the initiation of the Taiwan's National Health Insurance program in 1995, is a claims database. The Taiwan Cancer Database (TCDB), based on the Taiwan Cancer Registry, was established in 2002. The creation of a TCDB-NHIRD linked database could produce a SEER-Medicare-like database and has the potential to become an invaluable resource for cancer as well as policy researchers in Taiwan. This paper introduces the SEER-Medicare database, including data collection, software, applications of the database, data elements, structure, validation, the data request and application process, limitations of the database, and privacy and confidentiality issues. We then use a previously published breast cancer study to demonstrate the procedures involved in generating research from the SEER-Medicare database, followed by recommendations for the future development of a database that links TCDB to the NHIRD.
• 299 - 310
• 10.6288/TJPH2012-31-04-01

• Link 評論 Commentary
• 評論：台灣癌症登記與全民健康保險連結資料庫之可行性Commentary:Development of the TCDB-NHIRD Linked Database: What Can We Learn From The SEER-Medicare Database In The United States?
• 賴美淑
  Mei-Shu Lai
• 無
  none
• 無
  none
• 311 - 313
• 10.6288/TJPH2012-31-04-02

• Link 綜論 Review Article
• 全民健康保險補充財源初探A Pilot Study on Supplemental Revenue Sources for National Health Insurance
• 郭振雄、何怡澄、林翠芳
  Jenn-Shyong Kuo, Yi-Cheng Ho, Tsui-Fang Lin
• 全民健康保險 ； 補充財源
  National Health Insurance ; supplemental revenue sources
• 本文藉由回顧文獻及討論相關法令研修議題，尋找全民健康保險可能之補充財源，並探討這些財源的可行性與合理性。本文建議政府考慮開徵或加徵有害物質健康福利捐。此外，將部分奢侈稅稅收做為全民健康保險之補充財源有劫富濟貧的作用，與社會保險之重分配目標不謀而合。最後，考量肥胖、博弈及汙染活動對健康產生的醫療外部成本，將肥胖稅、博弈稅與健康相關之汙染稅收專用於日益成長的醫療費用，有其合理性。在面臨調整保費費率不易，保險給付範圍不斷擴大的情況下，尋求補充財源為規劃我國全民健康保險財務政策不可避免的趨勢。
  The aim of this paper was to explore potential sources of revenue for National Health Insurance (NHI). Potential revenue sources considered were earmarked taxes on various substances including cigarettes, alcoholic beverages and betel nuts. A fat tax, a green tax, a luxury tax and a gambling tax were also considered. We reviewed the literature in this area of research, examined relevant financing policies in other countries, and discussed the benefits and costs associated with the proposed revenue sources. We suggest that the government raise the tax rates on tobacco and alcohol consumption to finance NHI. In addition, the government can tax sin goods such as betel nuts and sugar-sweetened beverages. In light of the negative externalities associated with gambling and pollution activities, the government can use parts of the green tax and the gambling tax to finance NHI. Finally, a luxury tax is also a good financing alternative due to its redistributive nature. We contend that, due to NHI's growing financial burden, it is imperative to find supplemental sources of revenue.
• 314 - 325
• 10.6288/TJPH2012-31-04-03

• Link 原著 Original Article
• 青少年性騷擾受害經驗與身心適應之相關－以基隆市國中學生為例Psychological Distress and Experiences with Sexual Harassment among Junior High School Students in Keelung City
• 簡苑珊、陸玓玲、李鴻森、洪百薰
  Yuan-Shan Chien, Dih-Ling Lun, Hung-Sheng Li, Bai-Syuan Hurng
• 性騷擾受害經驗 ； 身心適應
  sexual harassment victimization ; psychological distress
• 目標：瞭解基隆市國民中學在學學生之性騷擾受害經驗，並探討性騷擾受害經驗與身心適應之關係。方法：以自行發展之結構式問卷為工具，針對基隆市國民中學，以班級為單位隨機抽出75班，由訪員至班級教室施測，學生以不具名方式填答，回收1,846份有效問卷為本次分析樣本。性騷擾受害經驗係依據美國大學婦女協會(簡稱AAUW)之建議分別詢問八種性騷擾狀況，「曾發生性騷擾事件且覺得不舒服」視為有性騷擾。以BSRS-5測量身心適應狀況(分為良好、輕度、中度、重度情緒困擾四類)。使用多分類邏輯斯迴歸進行統計分析。結果：（1）過去一年至少發生過一項以上的性騷擾受害經驗之整體比率為46.9%，沒有性別差異；（2）整體而言，調整性別、因應方式及其他壓力狀況後，性騷擾受害經驗者發生輕度及重度情緒困擾之比率分別是無性騷擾受害經驗者1.65及2.28倍，性騷擾受害經驗與身心適應狀況之關係因性騷擾類型及性別而異。結論：將近半數國中學生自述在過去一年曾有過性騷擾受害經驗，且此經驗與其身心適應有顯著相關，建議公共衛生及教育單位應關心性騷擾受害學生後續之身心適應狀況，並適時提供相關之輔導。此結果可作為衛生及教育單位進行性騷擾防治計畫之參考。
  Objectives: The purposes of this study were to determine the prevalence of sexual harassment victimization (SHV) among junior high students and to analyze the relationship between SHV and psychological distress. Methods: Trained interviewers went to randomly selected junior high school classrooms in Keelung City, and administered a structured questionnaire to collect data anonymously. A total of 2,282 students took the survey but 1,846 were excluded due to incomplete data. Sexual harassment was defined as a situation with sexual overtones that felt uncomfortable (American Associaction of University Women, AAUW). The BSRS-5 was used to measure coping strategies and to classify psychological distress as none, mild, moderate, or severe. Polytomous logistic regression was used to analyze the data. Results: Almost half (46.9%) of the students experienced at least one episode of sexual harassment in the previous year. There was no gender difference in this. After adjustment for gender, coping style, and other stressful conditions, victims of sexual harassment had higher rates of mild and severe psychological distress, 1.65 and 2.28 respectively, than did the non-victims. The relationships between SHV and psychological distress varied with SHV type and gender. Conclusions: Nearly half of junior high students in Keelung City experienced sexual harassment in the previous year and there was a significant relationship between sexual harassment and psychological distress. Health and education authorities need to develop effective strategies to prevent sexual harassment in the schools.
• 326 - 335
• 10.6288/TJPH2012-31-04-04

• Link 原著 Original Article
• 家戶主要清潔者的蟲媒相關知識與環境風險知覺－高雄市不同登革熱流行程度社區之比較Vector-Related Knowledge and Environmental Risk Perceptions among Household Hygiene Keepers - A Comparison of Communities with Different Levels of Dengue Attack in Kaohsiung City
• 李芳盈、蔡瑜珍、丁志音
  Fang-Ying Li, Yue-Chen Tsai, Chih-Yin Lew-Ting
• 登革熱 ； 環境風險知覺 ； 孳生源 ； 殺蟲劑使用 ； 戶外環境
  Dengue ; Environmental Risk Perception ; Breeding Sites ; Pesticide Use ; Outdoor Environment
• 目標：本研究之目的為瞭解並比較不同登革熱流行程度社區之居民對登革熱相關的認知與環境風險知覺。方法：本研究為一橫斷性的調查。首先將高雄市所有的里按登革熱的流行程度區分為高、中、低三種層次的組別，之後再以等距抽樣於三組中各抽出兩個里進行家戶資料收集，並特別挑選家戶主要清潔者進行面訪。結果：總計訪問598個家戶。研究結果顯示，高流行程度社區的居民對登革熱相關蟲媒知識有一定程度的了解，且對於登革熱的流行與被感染的可能有所意識，然而他們卻仍低估家戶外環境不佳將導致的風險。相對的，低流行社區的居民雖然自覺最不受到登革熱的威脅，但仍最為戒慎恐懼，且認為疾病防治需同時從環境與自我防護著手。而中流行社區之民眾的知識最差，對登革熱的流行也最不憂心，且他們在疾病防治上相當依賴政府的噴藥措施。結論：處於登革熱流行程度不同社區之民眾，對登革熱蟲媒相關認知與環境風險知覺確有不同，登革熱的預防與控制應該設計因地制宜的介入方案。
  Objectives: To examine and compare vector-related knowledge and the perceptions of environmental risk among residents living in communities exposed to different levels of dengue attack. Methods: This study was a cross sectional survey. The magnitude of the dengue epidemic was calculated for all communities (Li, the basic administrative unit) in Kaohsiung City and was further differentiated into three levels (low, medium, and high). Two communities were selected from each level by systematic sampling. Interviews were carried out with the person responsible for domestic hygiene in each household. Results: A total of 598 valid household interviews were conducted (low=194, median=200, high=204). Residents with a high level of dengue attack were knowledgeable about dengue vectors. They were also conscious of the possible adverse effects of dengue infection; however, they tended to pay inadequate attention to the outdoor environment. In contrast, residents in low magnitude communities perceived the least threat of dengue, but they were the most alert, and believed in the dual necessity of environmental management and self-protection to prevent dengue. For respondents residing in communities of a medium magnitude of epidemic risk, their vector-related knowledge was the poorest and they had the least anxiety about dengue infection. They also believed that the use of pesticides by the government was the most efficient strategy for fighting against dengue. Conclusions: Vector-related knowledge and the environmental risk perceptions for dengue varied with the severity of neighborhood dengue epidemics. Strategies for dengue prevention and control should be developed and tailored to the needs of residents based on the risk of dengue attack.
• 336 - 346
• 10.6288/TJPH2012-31-04-05

• Link 原著 Original Article
• 「西醫基層總額分科計畫」實施前後門診醫療利用差異之研究Differences in Healthcare Utilization before and after Implementation of the Departmental Clinics Global Budget Program
• 陳文意、李卓倫、林玉惠
  Wen-Yi Chen, Jow-Leun Lee, Yu-Hui Lin
• 總額預算 ； 醫師行為 ； 差異中取差異
  Global Budgeting ; Physician's Behavior ; Difference-in-differences
• 目標：本研究的主要目的在於評估中區健保分局實施「西醫基層總額分科計畫」前後門診醫療利用的差異，藉以探討基層醫師因應此項醫療政策的行為。方法：本研究的資料來源為全民健康保險研究資料庫的2005年承保抽樣歸人檔，為了釐清「西醫基層總額分科計畫」對醫療利用的影響，我們將樣本分為普通個案與高價個案兩個族群。我們使用差異中取差異法，針對「西醫基層總額分科計畫」實施前後的醫療利用差異進分析。結果：實證結果顯示「西醫基層總額分科計畫」僅對高價個案的每次門診給藥日數有顯著的抑制效果，但對於普通個案的各項醫療利用（每次門診申請金額、藥費、部分負擔以及給藥日數）的影響卻不降反升。結論：「西醫基層總額分科計畫」由不同專科別醫師的同儕制約力量，藉以控制醫療費用的效果應屬有限。健保局應針對某些特定指標（包括病患當月就診次數、給藥日數、藥費、部分負擔）進行監控，藉以抑制基層醫師回應支付制度改變的醫療行為。
  Objectives: To evaluate the differences in healthcare utilization before and after implementation of the Departmental Clinics Global Budget Program (DCGBP), and to investigate physicians' behavior in response to the DCGBP. Methods: Data were obtained from the 2005 Longitudinal Health Insurance Database. In order to determine the impact of DCGBP on healthcare utilization, the samples were separated into two groups, a high utilization group and a low utilization group. We used the difference-in- differences method to analyze the difference in healthcare utilization before and after implementation of the DCGBP. Results: Our empirical results showed that the DCGBP decreased drug days per visit in the high utilization group, but it impacted healthcare utilization (such as claimed expenditure, drug expenditure, co-payment, and drug days) positively in the low utilization group. Conclusions: The Bureau of National Health Insurance should monitor specific indices such as the numbers of outpatient visits per month, drug days, drug expenditure, and co-payment per visit to determine if physicians' behaviors change in response to change in the payment system.
• 347 - 360
• 10.6288/TJPH2012-31-04-06

• Link 原著 Original Article
• 影響家長讓小孩接種肺炎鏈球菌疫苗之相關因素：網路調查之應用An Internet Survey of Factors Related to Parental Decisions Regarding Pneumococcal Vaccination for Preschool Children
• 廖彩涵、楊銘欽
  Tsai-Han Liao, Ming-Chin Yang
• 侵襲性肺炎鏈球菌感染症 ； 幼童肺炎鏈球菌疫苗 ； 健康信念模式
  Invasive pneumococcal disease ; Pneumococcal vaccination ; Health Belief Model
• 目標：本研究在探討影響家長讓幼童接種肺炎鏈球菌疫苗接種之認知、態度等相關因素。方法：本研究以健康信念模式自擬結構式網路問卷，透過親子網站，邀請平時會於網路上搜尋相關醫療資訊，且育有五歲以下幼童之家長，上網填答。調查時間為2011年4月20日至5月10日，有效樣本566份。資料先以卡方、威爾克森符號等級、克-瓦二氏單因子等級檢定分析後，再以羅吉斯迴歸分析檢定影響家長是否讓小孩接種疫苗的相關因素。結果：566位家長完成有效樣本，其中382位（68%）已讓小孩接種肺炎鏈球菌疫苗；多數家長對疾病知識有一定程度的了解，但是對於疫苗效價和政府補助方案較不清楚；疾病知識分數高、自覺行動利益高、自覺行動非經濟障礙低、自覺行動經濟障礙低、小孩滿一歲、家長年齡介於30至34歲、曾有醫療人員建議或曾看過院所宣傳單者，較傾向讓小孩接種疫苗。結論：本研究顯示家長對於肺炎鏈球菌疫苗之認知，以及對於接受疫苗接種的自覺障礙，皆與幼童是否接受疫苗有關，研究結果可供主管機關規劃相關政策時之參考。
  Objectives: This study analyzed parental attitudes and behaviors related to pneumococcal vaccination for their preschool children. Methods: We first developed a structured questionnaire based on the Health Belief Model (HBM) and then invited those who were used to searching for medical information on the internet and were raising children younger than 5 to answer the questionnaire. A total of 566 web-based questionnaires were completed from April 20th to May 10th, 2011. Hypotheses were tested using Chi-squares, Wilcoxon rank sum tests and Kruskal-Wallis tests. Factors associated with pneumococcal vaccination were identified with multivariate logistic regression analysis. Results: Of the 566 parents who completed a valid questionnaire, 382 (68%) had taken their children for vaccination against invasive pneumococcal disease (IPD). Most of these parents had acquired knowledge about IPD but few of them understood the vaccination subsidy program. Parents who had a greater understanding about IPD and perceived more benefits and fewer barriers to vaccination, were between 30 and 34 years old, advised by medical staff, had read an IPD information sheet at a hospital, or had children one year old or older tended to have their children vaccinated. Conclusions: Parental knowledge about self-perceived barriers to pneumococcal vaccination were significantly associated with whether their children were vaccinated or not.
• 361 - 370
• 10.6288/TJPH2012-31-04-07

• Link 原著 Original Article
• 花蓮縣偏遠與非偏遠地區民眾對於基層醫療保健服務的使用與需求之比較A Comparison of the Utilization of and Needs for Primary Healthcare Services among Residents in Non-Remote and Remote Areas of Hualien County
• 葉婉榆、陳志聖、鄒欣縈、劉宜華、吳柏樺、曹雅琪、呂佳容
  Wan-Yu Yeh, Chih-Sheng Chen, Xin-Ying Zou, Yi-Hua Liu, Bo-Hua Wu, Ya-Chi Tsao, Chia-Rong Lu
• 偏遠地區 ； 基層醫療衛生保健 ； 服務需求 ； 需求評估
  remote area ; primary health care ; service needs ; needs assessment
• 目標：探討並比較花蓮縣偏遠與非偏遠地區民眾對基層醫療保健的使用情形及服務需求。方法：運用量性調查問卷詢問人口背景、基層醫療使用情形、醫療／預防保健／衛生教育服務之需求程度和原因，於花蓮縣偏遠地區選取六個鄉鎮，非偏遠地區選取三個鄉鎮民眾參與，共回收573份有效問卷（回收率97%）；另邀請10位偏遠／非偏遠村里代表參與訪談，收集質性資料。結果：偏遠民眾對醫療資源充足度有49.3%認為「不足」，非偏遠民眾僅佔16.6%。鄉鎮應強化之醫療科別，偏遠民眾首需「眼科」，非偏遠民眾則為「家庭醫學科」。鄉鎮應加強之醫療服務，偏遠民眾首需「巡迴醫療」，非偏遠民眾則為「降低醫療自付費用」。訪談另發現，村里長積極程度對村里醫療資源多寡影響極大。結論：本研究發現偏遠與非偏遠地區至基層醫療據點的可近性差異不大，但偏遠民眾的服務滿意度明顯較低，建議衛生主管機關對於偏遠地區醫療保健資源的規劃，在服務項目與服務品質方面需考量民眾需求來實質提升。
  Objectives: This study compared the utilization of and requirements for primary healthcare services for residents living in remote and non-remote areas of Hualien County. Methods: We used quantitative questionnaires to survey 6 townships in remote areas and 3 townships in non-remote areas of Hualien County. The questionnaire gathered data about demographics, utilization of primary healthcare services, and the needs for medical care, preventive care, and health education services. A total of 573 valid questionnaires were retrieved for a response rate of 97%. In addition, 10 village heads of villages in remote/non-remote areas were invited to participate in qualitative interviews. Results: The results indicated that 49.3% of residents in remote areas thought that medical resources were inadequate, while only 16.6% of the residents in non-remote areas held the same opinion. Results also showed a need to strengthen various departments of healthcare services in villages and townships. Ophthalmology was the most needed medical service in remote areas, while family medicine was the most needed in non-remote areas. Mobile medical services were also needed for residents living in remote areas, while those living in non-remote areas emphasized a need for the reduction in payments for medical care. The qualitative in-depth interviews showed that the attitudes of village or neighborhood leaders were highly correlated with the availability of medical resources. Conclusions: Access to primary health care centers was similar in remote and non-remote areas; however, the residents in remote areas had a relatively lower level of satisfaction with health care services. We suggest that healthcare authorities consider specific service items and quality when determining the deployment of health care services in remote areas.
• 371 - 387
• 10.6288/TJPH2012-31-04-08

• Link 原著 Original Article
• 雪山隧道通車對宜蘭縣急性心肌梗塞病患救治結果之影響Did The Treatment Outcomes for Yilan's Acute Myocardial Infarction (AMI) Patients Improve after the Opening of the Hsuehshan Tunnel?
• 林宜靜、李淑芬、蔡偉德
  I-Ching Lin, Shu-Fen Li, Wei-Der Tsai
• 雪山隧道 ； 急性心肌梗塞 ； 死亡率 ； 再住院率
  Hsuehshan Tunnel ; Acute Myocardial Infarction ; Mortality ; Readmission
• 目標：本研究旨在分析2006年6月雪山隧道開通，對宜蘭縣急性心肌梗塞病患的短期死亡率與再住院率之影響。方法：以2004年6月至2008年6月之宜蘭縣急性心肌梗塞住院病患資料，利用羅吉斯特迴歸模型分析雪隧通車是否影響宜蘭縣急性心肌梗塞病患的醫療結果；並以花蓮縣病患為對照組，利用差異中的差異分析方法，比較宜蘭縣與花蓮縣病患救治結果的平均差異。結果：雪隧通車後，宜蘭縣急性心肌梗塞病患的出院後30天內死亡率顯著降低；相較於花蓮縣，雪隧通車後宜蘭縣急性心肌梗塞病患死亡率確實獲得改善；但對再住院率則無顯著影響。結論：透過重大交通建設縮短交通距離與時間，有助於提升醫療資源與人力流動的便捷性，最終使病患的救治結果獲得正向影響。
  Objectives: The purpose of this paper was to investigate whether there was an improvement in the treatment outcomes for AMI patients in Yilan County after the opening of the Hsuehshan Tunnel on June 16, 2006. The Hsuehshan Tunnel connects Taipei City with Yilan County and substantially cuts down the traveling time between the two regions. It may facilitate the migration of medical manpower between the two regions and increase accessibility to medical center hospitals for Yilan's inhabitants. Methods: By using the 2004-2008 National Health Insurance Database, we estimated the changes in the 30-day mortality rate and readmission rate of Yilan's AMI patients via the logistic regression model and difference-in-differences. Results: We found that 30-day mortality rates for AMI patients in Yilan County did decline after the opening of the Hsuehshan Tunnel. This finding persisted when AMI patients in Yilan County and Hualien County were compared via difference-in-differences. There was also a decline in the readmission rates; however, it was not statistically significant. Conclusions: The treatment outcomes for Yilan's AMI patients did improve after the opening of the Hsuehshan Tunnel. Transportation facilities have a positive effect on the treatment outcomes for AMI patients living in less accessible areas because of the migration of medical manpower to regions with improved transportation.
• 388 - 397
• 10.6288/TJPH2012-31-04-09