33卷5期

• Link 公衛論壇 Public Health Forum
• 台灣醫療觀光發展困境之省思 Reflections on Development Dilemmas of Taiwan's Medical Tourism
• 許碧峰
  Pi-Fem Hsu
• 無
  none
• 無
  none
• 455 - 458
•  10.6288/TJPH201433103054

• Link 綜論 Review Article
• 台灣地區論人計酬試辦計畫之評估—以醫院忠誠病人模式為例Evaluation of the Capitation Payment Pilot Program in Taiwan- Using the Hospital's Loyal Patient Model as an Example
• 羅紀琼
  Joan C. Lo
• 論人計酬 ； 忠誠病人 ； 差異中的差異模型 ； 全民健保
  capitation payment ; loyal patient ; Difference-in-Differences model ; National Health Insurance
• 目標：本文以健保署2012年開始試辦的論人計酬支付制度中的醫院忠誠病人模式為基礎，嘗試探討三家試辦醫院是否達到了促進民眾健康、減少醫療浪費的目標。方法：採用差異中的差異（Difference-in-Differences）模型分析試辦醫院與對應醫院忠誠病人2010年7月至2013年6月全民健保門、住診利用與費用；且以傾向分數配對（Propensity Score Matching）模型篩選對應醫院的忠誠病人。醫院的忠誠病人為試辦前一年在該院門診就診次數達該病人門診就診次數的一半以上。結果：試辦計畫對所有試辦醫院之門診利用皆有顯著減少的成效；然而由於試辦醫院A與C之住院費用顯著提升，以致總醫療費用在試辦醫院A與B沒有顯著變化，但在試辦醫院C則呈顯著增加。結論：目前論人計酬試辦計畫僅僅觀察試辦醫院的忠誠病人在試辦前後的醫療費用，並據以衡量試辦計畫成效的作法，因同期間另有影響醫療費用的總體因素存在，以致試辦前後醫療費用的差異並非僅由試辦計畫所造成。在試辦計畫的成效指標中，適度納入總體因素的考量，應是當行的修正。
  Objectives: The aim of this study was to determine if the capitation payment pilot program beginning in 2012 reached its designed target of promoting patient health and reducing medical waste. Methods: We employed the Difference-in-Differences model to study the healthcare expenditures by National Health Insurance in the study group (pilot hospital's loyal patients) and the control group (corresponding hospital's loyal patients), for the periods from July 1, 2010 to December 31, 2011 and January 1, 2012 to June 30, 2013. The Propensity Score Matching method was used to select the final control group. A hospital's loyal patient was defined as one who made more than half of his/her outpatient visits in that particular hospital. Results: Patients' outpatient visits in all three pilot hospitals were significantly reduced, while the inpatient expenditures were significantly increased in hospitals A and C. This resulted in significantly higher total healthcare expenditures in hospital C but not in hospitals A and B. Conclusions: The current tool for the evaluation of the capitation payment pilot program is patients' healthcare expenditures before and after the pilot program. However, since there were other influential factors in existence during the same time period, the expenditure difference observed was not affected solely by the pilot program. Taking those external factors into evaluation consideration is a must.
• 463 - 475
• 10.6288/TJPH201534104009

• Link 綜論 Review Article
• 台灣髖部骨折病人手術失敗率之分析—以人口為基礎的世代研究The Surgical Failure Rates for the Patients with Hip Fractures in Taiwan- A Nationwide Population-Based Cohort Study
• 吳啟明、李淑芬、李美文、何清治、洪錦墩
  Chi-Ming Wu, Shu-Fen Li, Mei-Wen Lee, Chin-Chih Ho, Chin-Tun Hung
• 髖部骨折 ； 金屬內固定術 ； 人工髖關節置換術 ； 手術失敗率
  hip fracture ; internal metal fixation ; artificial hip replacement ; surgical failure rate
• 目標：本研究探討60歲（含）以上老年人發生髖部骨折後，接受金屬內固定術或人工髖關節置換術治療後，於二年內發生失敗機率的比較。方法：運用國家衛生研究院2004年至2008年全民健保資料庫進行分析，並以SPSS17.0進行描述性統計、t檢定及邏輯斯迴歸分析。結果：2004年至2008年發生股骨頸、股骨轉子間、股骨轉子下及整個髖部骨折且住院的人數分別為40,051、35,130、2,767及77,948人；經排除手術後兩年內退保或死亡者及未手術者後，其接受金屬內固定術的失敗率分別為11.6%、6.5%、13.7%及8.0%；人工髖關節置換術的手術失敗率則分別為3.8%、6.4%、4.8%及3.9%，影響髖部骨折手術失敗風險因素有性別、年齡別、疾病共病症、骨折部位及醫院等級等。結論：不管是股骨頸、股骨轉子間、股骨轉子下或是整個髖部骨折的病人其接受金屬內固定術的失敗率皆比接受髖關節置換術的病人為高。
  Objectives: This study explored the failure rates of internal metal fixation surgery and artificial hip replacement in older adults who underwent either surgery (age ?60 y) within 2 years of a hip fracture. Methods: Data from 2004 to 2008 were obtained from the National Health Insurance Research Database of Taiwan for an analysis. SPSS Version 17 was used to conduct a descriptive statistical analysis, t test, and logistic regression analysis. Results: The number of inpatients experiencing fracture in the femoral neck, intertrochanteric bone, subtrochanteric bone, and the overall hip were 40,051, 35,130, 2,767, and 77,948, respectively. After the patients who withdrew from the National Health Insurance program or died within 2 years of surgery and unreceived hip surgery were excluded, the failure rates for patients who underwent internal metal fixation surgery due to a femoral neck fracture, intertrochanteric fracture, or subtrochanteric fracture, or all hip fractures were 11.6%, 6.5%, 13.7%, and 8.0%, respectively. The corresponding failure rates for patients who underwent an artificial hip replacement were 3.8%, 6.4%, 4.8%, and 3.9%. Factors influencing the failure risk of hip fracture surgery included sex, age, comorbidity status, fracture position, and hospital level. Conclusions: Regardless of the fracture position of hip, patients who underwent internal metal fixation surgery exhibited higher failure rates compared with patients who underwent an artificial hip replacement.
• 476 - 490
• 10.6288/TJPH201534103132

• Link 原著 Original Article
• 請不要看到我的“缺口”：口腔癌患者罹癌歷程與因應之探討Please Do Not Look at "My Mouth": The Process of Seeking Health Care by Patients with Oral Cancer and Their Coping Strategies
• 龍紀萱、李依臻
  Chi-Hsuan Lung, I-Jhen Lee
• 口腔癌 ； 罹癌歷程 ； 因應
  oral cancer ; health care seeking process ; coping
• 目標：口腔癌發生率逐年攀升且以青壯年男性為主，其治療過程漫長又擔心有復發的危險，且因治療或副作用恐造成臉部外觀與口腔功能異常。本研究目的為探討口腔癌病患之罹癌歷程以及因應。方法：本研究為質性研究法，採立意取樣的方式，針對13位罹患口腔癌個案進行面對面深度訪談，將訪談資料轉成逐字稿進行內容分析。結果：將口腔癌患者之罹病歷程分為：診斷期、治療期、以及追蹤期等三個歷程，並分析其求醫歷程與因應。結論：建議醫院的工作者面對口腔癌個案應評估其所處階段，分別提供所需之服務與資源，以協助病患本身與家屬因應罹患癌症之求醫歷程。
  Objectives: The incidence of oral cancer rises annually, and new patients are primarily young men. The treatment for oral cancer is a lengthy process and this disease is prone to recurrence. In addition, the treatment and its side effects often result in an abnormal facial appearance and oral dysfunction. This study investigated the process of seeking health care by patients with oral cancer and their coping strategies. Methods: Adopting a qualitative research design, we used a purposive sampling method to conduct in-depth face-to-face interviews with 13 patients with oral cancer. The interview data were later converted into transcripts for content analysis. Results: The course of seeking health care was divided into 3 stages: initially seeking health care, treatment, and follow-up. We then analyzed the process in terms of patient condition and coping strategies during these 3 stages. Conclusions: We recommend that hospital employees be educated to provide assistance in evaluating the stage of patients with oral cancer in order to meet the needs of these patients and their families appropriately.
• 491 - 504
• 10.6288/TJPH201534104027

• Link 原著 Original Article
• 台灣青少年吸菸及家庭二手菸暴露相關影響因素及菸害防制新法效益之探討The Risk Factors Related to Smoking Behavior and Secondhand Smoke Exposure among Adolescents after Implementation of the 2009 Taiwan Tobacco Hazards Prevention Act
• 朱美貞、陳珮青、張麗娟、李玉春
  Mei-Chen Chu, Pei-Ching Chen, Li-Chuan Chang, Yue-Chune Lee
• 青少年吸菸 ； 家庭二手菸暴露 ； 菸害防制新法
  adolescents smoking ; secondhand smoke exposure ; Taiwan Tobacco Hazards Prevention Act
• 目標：台灣有吸菸經驗的青少年約有25%變成穩定吸菸者，青少年吸菸已成為重要公共衛生議題。本研究探討2009年菸害防制新法實施，對台灣青少年吸菸及家庭二手菸暴露之效益，並探討影響青少年吸菸與家庭二手菸暴露之因素。方法：運用2004－2011年青少年吸菸行為調查（GYTS）資料庫，包含國中及高中生，以多變項邏輯式迴歸進行分析。結果：國中生與高中生吸菸率分別為7.1與13.7%，二手菸暴露率分別為46.66%與44.45%；多變項分析結果顯示新法顯著降低高中生家庭二手菸暴露風險26%－32%，高中生吸菸風險亦顯著降低65%；但國中生吸菸與家庭二手菸暴露可能性均無顯著差異。眾多影響因素中，同儕吸菸、對吸菸為正面意向的青少年較容易吸菸及暴露於家庭二手菸，而父母吸菸也使青少年家庭二手菸暴露風險升高。結論：菸害防制新法減少高中生吸菸風險與家中暴露於二手菸的風險。建議未來若欲減低青少年吸菸率，可著重於減輕青少年來自同儕、父母、及媒體構成之正面吸菸意向。
  Objectives: Previous studies have found a downward trend in the age of onset of adolescent smoking in Taiwan. Among those adolescents who had tried smoking, one fourth became regular smokers. This study investigated the risk factors associated with adolescent smoking behavior and secondhand smoke (SHS) exposure at home after the implementation of the 2009 Taiwan Tobacco Hazards Prevention Act. Methods: The study utilized data from the 2004 -2011 Taiwan Global Youth Tobacco Survey. Multiple logistic regression analyses were performed to examine the impact of the 2009 Taiwan Tobacco Hazards Prevention Act and to identify the risk factors for adolescent smoking and SHS exposure at home. Results: After the Act was implemented, the risk of smoking by senior high students decreased by 26%-32%; the risk of their SHS exposure at home decreased by 65%. Peer smoking and holding positive beliefs about smoking were the key factors in adolescent smoking; parental smoking was also a key factor in adolescent SHS exposure. Conclusions: This study provided evidence that the 2009 Taiwan Tobacco Hazards Prevention Act reduced the risks of senior high students smoking and SHS exposure at home. The results suggested a need to lower the adult smoking rate and to control the positive attitude about smoking encouraged by peer smoking, parental smoking and the media in order to lessen the risk of smoking and SHS exposure.
• 505 - 519
• 10.6288/TJPH201534104040

• Link 原著 Original Article
• 評論：台灣青少年吸菸及家庭二手菸暴露相關影響因素及菸害防制新法效益之探討Commentary: The Risk Factors Related to Smoking Behavior and Secondhand Smoke Exposure among Adolescents after Implementation of the 2009 Taiwan Tobacco Hazards Prevention Act
• 吳岱穎
  吳岱穎
• 無
  none
• 無
  none
• 520 - 520
• none

• Link 原著 Original Article
• 劑量與效應反應的統合分析之應用：以血糖值與牙周病間的關係為例Application of Dose-Response Meta-Analysis to the Relation between Glucose and Periodontal Disease
• 謝宗穎、呂雅媛、杜裕康
  Tsung-Ying Hsieh, Ya-Yuan Lu, Yu-Kang Tu
• 血糖值 ； 糖尿病 ； 牙周病 ； 統合分析
  glucose ; diabetes ; periodontal disease ; meta-analysis
• 目標：使用劑量與效應反應的統合分析之方法來檢視血糖值與牙周病風險之間的劑量與效應關係。方法：本研究使用三種資料庫：Pubmed、Medline、Embase進行系統性文獻回顧以搜尋血糖值與牙周病之間證據，最後進入統合分析部分之文獻為23篇。在統合分析部分，先是以傳統統合分析方法探討高血糖為牙周病的危險因子，接著使用Greenland和Longnecker的廣義最小平方法，進行劑量與效應反應的統合分析。結果：高血糖為牙周病的危險因子，而血糖值與牙周病風險之間存在著劑量與效應非線性關係。隨著血糖值的上升，牙周病的風險增加；而當血糖值上升至一個程度（血糖值約為160 mg／mL）時，牙周病風險會趨於平緩，藉由劑量與效應反應的統合分析結果顯示並沒有一個血糖值範圍對於牙周病是安全的。結論：以劑量與效應反應的統合分析探討血糖值與牙周病間的關係，發現血糖值與牙周病間確實存在著劑量與效應的關聯性，對於糖尿病患的照護亦應特別重視口腔保健並定期追蹤及檢查。
  Objectives: The aim of the study was to undertake a systematic review and dose response meta-analysis to evaluate the relationship between glucose levels and the risk of periodontal disease. Methods: We first carried out an electronic search of three databases: Pubmed, Medline, Embase, to examine the relation between glucose and periodontal disease. In total, 517 studies were identified. After screening titles and abstracts, we retrieved the full texts of 147 articles, with 23 articles included in the meta-analysis. We first undertook a traditional meta-analysis on the risk of developing periodontal disease between subjects with high or low glucose levels. The generalized least squares method proposed by Greenland and Longnecker was then used for the dose-response meta-analysis. Results: People with a high glucose level were more likely to have suffered periodontal diseases than those with a low glucose level (odds ratio 2.61, Confidence interval: 2.00 to 3.41). The dose-response meta-analysis showed that glucose level had a nonlinear relation with the risk of periodontal disease. When glucose level reached 160 mg/dl, the risk of developing periodontal disease gradually reached a plateau. Our meta-analysis suggested that there is no safe level of glucose for periodontal disease. Conclusions: Our dose-response metaanalysis found a nonlinear relation between glucose level and an increased risk of periodontal disease. Diabetic patients should pay attention to oral health care and receive regular oral examination.
• 521 - 533
• 10.6288/TJPH201534104010

• Link 原著 Original Article
• 台灣毒劇藥品相關法令及管理改進芻議An Initiative to Amend the Regulation and Management of Poisons and Dangerous Drugs in Taiwan
• 廖怡清、游雯淨、 李志恒
  Yi-Ching Liao, Wen-Jing Yu, Jih-Heng Li
• 毒劇藥品 ； Kappa係數檢定 ； 管理規範
  poisons and dangerous drugs ; Kappa coefficient ; regulations
• 目標：確保用藥安全為公共衛生的優先議題，本研究探討台灣毒劇藥品項及管理規範是否符合時代需求。方法：先檢視美國、澳大利亞、英國、歐盟、台灣、日本、中國大陸、香港及新加坡相關法規，進一步以中華藥典102項毒劇西藥品為基準，比較台、日、中、港、星毒劇性藥品定義、品項及管理措施，並利用百分比一致性及Kappa係數檢定品項相似性。結果：台灣與日本百分比一致性最高（64.7），其次依序為新加坡、香港及中國大陸（47.1、40.2及4.9）。日本毒劇藥品有明確定義及審定基準，台灣的毒劇藥品項與日本之一致高（Kappa=0.63, p＜0.05），品項收載及分類亦符合日本毒劇藥審定基準。日本之毒劇藥品包括近期抗癌藥、免疫製劑及抗病毒藥，其品項數（148、39及39）較台灣多（3、0及0），而台灣的毒劇藥品近20年未增修，有些臨床少用的列載藥品在日本並未收載。有關毒劇性藥品管理規範，台灣缺少明確毒劇字樣標籤及貯存之規定，但相關紀錄留存時間較其他國家久。結論：台灣毒劇藥品之管理有改善空間，日本毒劇藥品管理相關規範可作為台灣之參考。
  Objectives: Ensuring that drugs are used safely is a major priority in public health. The aim of the study was to investigate whether the listed items and related regulations for poisons and dangerous drugs (PDDs) in Taiwan were appropriate and timely. Methods: We initially evaluated the drug toxicity-related regulations in the United States, Australia, United Kingdom, European Union, Taiwan, Japan, China, Hong Kong and Singapore. The definitions, items and regulations related to PDDs were further compared among those in Taiwan, Japan, China, Hong Kong and Singapore. Based on the 102 items of western medicine considered to be PDDs in Taiwan, the item differences among countries were determined as percent agreements and kappa coefficients. Results: Taiwan and Japan showed the highest percent agreement, followed by Singapore, Hong Kong and China (64.7, 47.1, 40.2 and 4.9, respectively). Taiwan and Japan had substantial agreement (Kappa=0.63, P < 0.05) about PDD items. The regulations of Japan have criteria for judging whether a drug is poisonous or dangerous, and seem to be generally in line with the PDD items in Taiwan. The numbers of antineoplastic drugs, immunologic agents and antiviral agents listed as PDDs in Japan (148, 39 and 39, respectively) were much higher than those in Taiwan (3, 0 and 0, respectively). The list of PDD items in Taiwan has not been amended for almost 20 years, and some without current clinical use were not included in the Japanese regulations. Compared to other countries, the regulations in Taiwan lacked definite label and storage requirements for PDDs, but the period of record-keeping was longer than that in other countries. Conclusions: The Japanese PDD-related regulations could serve as a reference for Taiwan in improving the management of PDDs.
• 534 - 547
• 10.6288/TJPH201534104020

• Link 原著 Original Article
• 食品安全－事件觀、系統觀Food Safety- Viewpoints from Issues and Systems
• 莊秀文、林怡淑
  Sheu-Wen Chuang, Yi-Shu Lin
• 食品安全 ； 系統思考 ； 消費文化 ； 企業經營理念
  food safety ; systems thinking ; consumer culture ; business philosophy
• 目標：近年食安問題延燒不斷，各界人士在媒體上陸續表達對於此問題的投書，然而這些意見尚缺乏有系統地整理，本研究目的即為分析民眾對於食安問題之看法，並提出食品安全的整體系統觀。方法：本研究收集2014年九、十月四大平面媒體，在此期間對於食安事件的投書，並應用主題分析法解析讀者觀點，其次，依據系統理論，設計食安各層面向的系統架構圖。結果：本文共收集519則讀者投書，研究發現大多數的投書，對於食安問題的發生原因與改善觀點較為零散，且侷限於與事件直接有關的各別單一層面的肇因，其中又以因為政府之監督與管理的不當比例最高（77%），其次是對企業之信任（12.6%），相對較少以整體的觀點說明造成食安事件的完整性系統原因，尤其是較少從消費者自身角度與食品相關企業觀點出發，思考大眾消費文化的缺失，例如不理性的消費癖好，以及企業經營理念的失衡。結論：食品安全的維護有賴系統內相關成員共同的運作與合作，而非個別成員所能獨立促成。對於食品安全的促成，除政府已強化其執行功能與能力之外，進一步的做法是需要將所有相關成員的狹隘事件觀轉化為整合與縝密思考的系統觀。
  Objectives: There have been a large number of letters to media editors to advocate readers' thoughts on food safety because of recent food industry scandals. Yet, no systematic analysis for these letters has been reported. We conducted a systemic analysis for these opinions and proposed the concept of food safety. Methods: We screened 4 major newspapers in Taiwan for all letters to the editors, about the food safety scandals, published in the media in September and October 2014. These opinions were summarized thematically based on the contents, followed by developing a model food safety management system based on systemic theory model. Results: We identified 519 readers’ letters from the media. Most of the letters provided one-sided viewpoints fragmentally focusing on the direct causes relating to food safety events. Approximate 77% of readers thought the problem of food safety was associated with the gaps of government supervision and administration, followed by the trust in the food industries (12.6%). However, lacking of an integrative thinking to elaborate the systemic causes of the food scandal events was indicated. These opinions suggested especially an inadequate consumer culture, i.e. unreasonable propensity to food products inherent in consumers, which was not coherent with the business philosophy of food industry corporations. Conclusions: Food safety relies on the cooperation and collaboration among all stakeholders in the food production, marketing and consumption chain rather than independent efforts of individuals. The government has to refine their functions and capacities to supervise the food industries to ensure safe food operation. In addition, the food industries and consumers need to take a further step shifting narrow viewpoints of issues to integrate their thought into deliberate systems toward a safe operation in food supply chains.
• 548 - 556
• 10.6288/TJPH201534104046