26卷2期

• Link 原著 Original Article
• 台灣癌症病患的健保安寧療護利用情形與費用分析Utilization of and Expenditures for Palliative Care for Cancer Patients under the National Health Insurance in Taiwan
• 劉嘉年、楊銘欽
  Chia-Nien Liu, Ming-Chin Yang
• 癌症 ； 全民健保 ； 安寧療護 ； 醫療利用度 ； 醫療費用
  Cancer ; National health insurance ; Palliative care ; Health care utilization ; Health care expenditure
• 目標：分析台灣癌末病患對健保安寧療護的利用度、費用以及使用者特性。方法：以2001-2004年全民健康保險資料庫之門、住診資料，篩選符合癌症診斷且曾經接受過健保安寧療護服務者為研究對象，分析其整體住院安寧病房與居家安寧門診的人次與費用，及其在病患性別與年齡別的差異。結果：台灣癌症病患每年使用居家、住院安寧療護或兩者皆使用的人數，自2001年的4,633人逐年增加為2004年的6,426人，佔各年因癌症死亡人數的14.0%-17.7%之間，健保給付安寧療護服務的總費用，自2001年的2.14億逐年增加到2004年的2.83億，並以支付住院安寧療護為主佔89.2%-94.0%。使用安寧療護服務最多的前五項癌症診斷為肺癌、結腸直腸癌、肝癌、口腔癌、胃癌。醫學中心與區域醫院是癌症病患主要的求醫場所，合計的門診與住院人次分佔總人次的70.5%與92.3%，80%的安寧療護費用支付給6縣市的醫療機構。結論：台灣癌症病人使用安寧療護之比率較國外為低且集中於醫學中心，宜增強安寧療護的資源分布並向病患及家屬宣導，以提昇癌末病患照護品質。
  Objectives: To explore the utilization of and health care expenditures for palliative care and characteristics of palliative care-seeking for cancer patients in Taiwan. Methods: As our sample, we selected cancer patients who had used palliative care from the outpatient and hospital claims data of the Bureau of National Health Insurance (BNHI) between 2001 and 2004. We explored total palliative care use and expenses, age and gender, and differences in in-patient hospice care and outpatient visits of hospice home care. Results: A total of 4,633 persons used hospice or hospice home care in 2001; this increased to a total of 6,426 persons in 2004, representing 14.0%~17.1% of the total number of cancer patients treated between 2001 and 2004 in Taiwan. Total expenditures for palliative care for cancer patients increased from NT$214 million in 2001 to NT$283 million in 2004. Hospice care accounted for 89.2%-94.0% of all palliative care expenses. The five leading cancer diagnoses of palliative care patients were lung, colorectal, liver, oral, and gastric cancer. Medical centers and regional hospitals were major places of palliative care-seeking for cancer patients, accounting for 70.5% of hospice home care visits and 92.3% of hospice admissions. Among all healthcare institutions receiving payment for palliative care expenses, 80% were located within 6 cities or counties. Conclusions: Utilization of palliative care for cancer patients in Taiwan was lower than in other countries and was concentrated in medical centers. In order to improve end-of-life care for cancer patients, we suggest that NHI should encourage hospitals to provide more palliative care resources and educate the general public about the benefits of palliative care.
• 118 - 127
• 10.6288/TJPH2007-26-02-04

• Link 原著 Original Article
• 醫院與衛生所承辦巡迴醫療的經濟評估Cost-effectiveness and cost-benefit Analysis of Mobile Healthcare of Community Hospital and Health Center in Taiwan
• 楊惠娟、李卓倫
  Hui-Chuan Yang, Jwo-Leun Lee
• 巡迴醫療 ； 成本效果分析 ； 成本效益分析
  Mobile healthcare ; cost-effectiveness analysis ; cost-benefit analysis
• 目標：本研究目的在計算健保局巡迴醫療政策的成本、效果與效益，並比較醫院與衛生所執行巡迴醫療在社會成本及結果面的差異。方法：問卷調查以付費卡方式測量台東縣延平鄉民眾的付費意願作為效益面資料，效益面包括一般門診、專科門診(眼科、婦產科)、成人預防保健、婦女子宮頸和乳癌檢查、衛生教育、慢性病防治服務，蒐集醫院與衛生所投入巡迴醫療相關的成本資料，及巡迴醫療相關的效果面資料，效果面包括利用率指標、滿意度指標及可近性指標，以進行成本效果與成本效益分析，評估之依據主要為益本差與益本比。結果：延平鄉巡迴醫療的整體社會效益為每月390,871元，大於延平鄉整體社會成本每月363,351元，益本比為1.076。其中醫院投入延平鄉巡迴醫療的總成本為每月232,123元，效益為每月228,145元，益本比為0.983。而衛生所投入延平鄉巡迴醫療的成本為每月131,229元，效益為每月162,725元，益本比為1.240。結論：整體而言，延平鄉巡迴醫療的整體社會效益大於整體社會成本，因此巡迴醫療是一項值得繼續推行的醫療政策。此外衛生所提供巡迴醫療服務的項目較為單純但提供效率較高，醫院提供巡迴醫療服務的項目較多元，總體社會效益較高但成本也較高，造成提供效率上的損失，因此在政策上有較多改進的空間。
  Objectives: This study aims to analyze and compare the cost-effectiveness and cost-benefit ratio of mobile healthcare provided by a hospital and a community health center in rural Taiwan. Methods: Data were collected in Yan-Ping Township, Tai-Tung County by questionnaire survey, which adopted a payment-card technique to measure subjects' willingness to pay for general and specialized ambulatory care, general prevention and Pap smear, health education, etc. Administrative data of the hospital and community health center were also collected to analyze the cost-effectiveness of mobile healthcare. Results: Effectiveness data indicate that mobile healthcare increases accessibility. Subjects' satisfaction with mobile healthcare is higher than with other general medical care, and its utilization is higher as well. Total cost-benefit per month of mobile healthcare is NTD 232,123 and 228,145 for the hospital; and NTD 131,229 and 162,726 for the community health center. Cost-benefit ratio is 0.983 for the hospital and 1.240 for the community health center, with mobile healthcare delivered by community health center more efficient than that of the hospital. Total net benefit and total cost-benefit ratio for mobile healthcare is NTD 27,519 and 1.076 per month. Conclusions: The mobile healthcare policy for rural areas in Taiwan is justified in terms of efficiency. The Taiwan government should seriously think about allocating more resources to mobile healthcare delivered by community health centers or other primary care clinics rather than by community hospitals.
• 110 - 117
• 10.6288/TJPH2007-26-02-03

• Link 原著 Original Article
• 比較血液透析病患生活品質之心理計量值與效用測量值的差異並探討相關因素Differences between Psychometric and Utility Measures on quality-of-life and Their Associated Factors in Hemodialysis Patients
• 楊樹昌、王榮德、吳麥斯、郭佩雯、蘇喜
  Shu-Chang Yang, Jung-Der Wang, Mai-Szu Wu, Pei-Wen Kuo, Syi Su
• 生活品質問卷 ； 標準賭博法 ； 視覺類比尺度法 ； 血液透析
  quality of life ; standard gamble ; visual analogue scale ; hemodialysis
• 目標：觀察及比較血液透析病患世界衛生組織生活品質問卷台灣簡明版[WHOQOL-BREF(TW)]之生活品質分數，以及標準賭博(SG)法及視覺類比尺度(VAS)法效用值；並探討其影響因素。方法：橫斷調查台北和基隆地區13家血液透析中心共506位長期血液透析病患的生活品質。測量工具為：(1)WHOQOL-BREF (TW)，計算整體生活品質(global QOL)及生理、心理、社會及環境等四範疇之分數；(2)標準賭博及視覺類比尺度效用數值。結果：標準賭博值高於其他測量值，視覺類比尺度值和WHOQOL-BREF (TW)各範疇／項目分數相似。標準賭博值和WHOQOL-BREF (TW)各範疇／項目分數之相關值(0.10-0.20)比視覺類比尺度值和WHOQOL-BREF(TW)各項目分數之相關值(0.22-0.53)低。影響標準賭博值之因素為「教育程度」、「信仰狀況」、「有無併發疾病」、「尿素氮下降率」、「施打紅血球生成素之劑量」；此等因素合起來的整體影響（R^2值0.20）反而比影響視覺類比尺度值或影響整體生活品質分數之因素合起來的整體影響（此2者R^2值都是0.42）少。影響整體生活品質的因素有「地區」、「有無併發症」、及「血紅素」三項。影響視覺類比尺度值的因素有「宗教信仰」及「家庭平均月收入」兩項，R^2為0.42。結論：血液透析病患整體性質的生活品質分數以標準賭博法，視覺類比尺度法或WHOQOL-BREF (TW)問卷的整體生活品質所測有不同，且其影響因素較複雜。
  Objectives: The aim of this study was to compare quality-of-life (QOL) scores from WHOQOL-BERF (TW) and QOL values from the standard gamble (SG) method or visual analogue scale (VAS) method in hemodialysis (HD) patients. Comparisons were also made among associated factors of global scores, SG and VAS values. Methods: A cross sectional survey of QOL was conducted in 506 HD patients from 13 HD centers in Taipei and Keelung areas. Instruments included: (1) WHOQOL-BREF (TW) from which scores of global QOL, physical, psychological, social relationship and environment domains were calculated; (2) QOL values of SG and VAS methods based on utility theory. Results: In HD patients, SG values were significantly higher than VAS values, global score and four domains. In contrast, VAS values were about the same as psychometric scores. Pearson correlations of SG values and peychometric scores (0.10-0.20) were relatively lower than those of VAS values and psychometric scores (0.22-0.53). Associated factors of SG values were education, religion comorbidity, urea reduction rate, erythropoietin dosage, with total R^2 only 0.20. Associated factor of global QOL scores were area, comorbidity and hemoglobin level, with R^2 0.42. Associated factors of VAS values were education and family monthly income, with total R^2 0.42. Conclusion: Total QOL measures of SG, VAS, and global QOL from WHOQOL-BREF (TW) in HD patients were significantly different and their associated factors were complex.
• 99 - 109
• 10.6288/TJPH2007-26-02-02

• Link 原著 Original Article
• 醫師對參與網路線上諮詢之態度Physicians' Attitudes toward internet-based Patient Consultation
• 郭峰淵、柯秀佳、黃莉君、 許瓊文
  Feng-Yang Kuo, Hsiu-Chia Ko, Li-Chun Huang, Chiung-Wen Hsu
• 線上諮詢 ； 醫生態度 ； 醫療不確定性
  Internet-based patient consultation ; physicians' attitude ; uncertainty of health care
• 目標：本研究主要目的為從醫師參與網路線上諮詢的經驗中，探討醫師對線上諮詢的態度、使用時面臨的障礙及困難。方法：研究者採用質性研究方法，透過對36位醫師的深度訪談，了解醫師參與線上諮詢與民眾進行互動的經驗。結果：本研究發現大多數醫生不認為透過線上諮詢的文字互動，即可解決民眾的問題。同時，醫師認為線上諮詢無法滿足需即時溝通的醫療諮詢過程以及望聞問切的社會文化場域，並增加了醫病互動的模糊性與不確定性。此外，醫院政策未強化醫生參與的動機，以及政府法律未給予醫生對等的智慧財產權保護，均會影響醫生參與線上諮詢的意願。結論：本研究建議目前線上諮詢的效用在於讓有網路使用能力及有時間資源的醫生傳遞情感的支持予病人。然而，未來醫院或政府欲設立線上諮詢服務民眾時，亦應正視醫生參與線上諮詢所面臨的困難與問題。
  Objective: This paper reports results of a study on physicians' attitudes toward internet-based patient consultation. Methods: This study employs the qualitative research method, interviewing a total of 36 physicians to investigate physicians' attitudes toward internet-based patient consultation. Results: The study reveals that, in general, physicians do not think favorably toward internet-based patient consultation that lacks face-to-face communication between physicians and patients. It also shows that internet-based consultation cannot fulfill most physician-patient communication requirements, and cannot satisfy the culturally rich diagnostic method of ”watch, listen, ask and touch.” As a result, internet-based patient consultation may raise levels of obscurity and uncertainty for physicians who wish to communicate with patients through the internet. Finally, the lack of support by hospital policies and the absence of laws protecting physicians' intellectual property rights may further diminish physicians' willingness to engage in internet-based patient consultation. Conclusions: This research suggests that, at present, for physicians who are competent in using the internet and have sufficient time resources, internet-based consultation services could be useful for communicating with patients needing ad-hoc emotional support. However, either healthcare institutions or the government must carefully consider the barriers and problems faced by physicians if they plan to set up internet-based consultation services in the future.
• 89 - 98
• 10.6288/TJPH2007-26-02-01

• Link 原著 Original Article
• 非營利醫院之董事會結構與社區公益活動Board Structure and Community Benefit Services of not-for-profit Hospitals
• 郭振雄、何怡澄
  Jenn-Shyong Kuo, Yi-Cheng Ho
• 非營利醫院 ； 社區公益活動 ； 董事會結構與組成
  not-for-profit hospital ; community benefit services ; board structure
• 目標：非營利醫院的主要營運目標之一為社區公益活動，董事會結構和組成與其績效有關聯性，我國醫療法規範非營利醫院董事會結構與組成，本研究提供台灣實證資料。方法：採用2000-2004年度36間非營利醫院追蹤資料，分別以教育與研究支出、免費醫療支出，以及社區公益支出作為應變數，對董事會規模、非醫院員工董事比例，以及負責醫師亦為董事進行迴歸分析。結果：董事會規模對免費醫療支出，以及社區公益支出均有顯著的正向影響；非醫院員工董事比例僅對教育與研究支出有顯著的正向影響；院長亦為董事對教育與研究支出有顯著的正向影響，對免費醫療支出有顯著的負向影響。結論：非營利醫院同時具有社會與商業的角色，其董事會根據成立宗旨組成。非營利醫院之董事會結構和組成與其營運目標的關聯性，可作為主管機關制訂規範的參考。
  Objective: To examine if the structure and composition of a hospital Board of Directors can have an impact on the capacity of Taiwan's private not-for-profit hospitals to deliver community benefit services. Method: Using unbalanced panel data collected between 2000 and 2004 through audited financial statements and surveys from 36 private not-for-profits hospitals in Taiwan, this article explores whether Board structure and composition has an impact on education and research expenditures, uncompensated care service expenditures, and community benefit services offered by these hospitals. Results: Our regression analysis data suggest that Board size has a significantly positive relationship with uncompensated care expenditures and community benefit service expenditures. The percentage of outsiders on the Board has a significantly positive relationship with research and education service expenditures. In addition, executives on the Board have a significantly positive impact on research and education expenditures while having a negative impact on uncompensated care expenditures. Conclusions: All private not-for-profit hospitals have the social role to provide community benefit services and the business role to make profits. The Board of Directors is composed according to each organization's established purpose. Results of this research show that board structure and composition are able to affect hospital performance. This board structure and composition effect for not-for-profit hospitals can make normal reference as the competent authority.
• 128 - 139
• 10.6288/TJPH2007-26-02-05

• Link 原著 Original Article
• 台灣地區醫師繼續教育實施之探討Study on Implementation of Physicians' Continuing Medical Education in Taiwan
• 王俊文、葉德豐
  Jiunn-Wen Wang, Te-Feng Yeh
• 醫師繼續教育 ； 提供者 ； 接受者 ； 醫師
  continuing medical education ; providers ; receivers ; physicians
• 目標：2001年醫師法修正後，台灣正式邁向由國家管制的強制性醫學繼續教育制度。本研究之目的乃從教育提供者與接受者的觀點，來評估醫師繼續教育課程內容與成效之差異。方法：本研究對象分為繼續教育接受者及提供者，採自填式結構性問卷，調查其對繼續教育內容之看法與實施成效滿意度。問卷調查以郵寄方式為主，接受者部分採分層隨機抽樣發放問卷600份，提供者部分採全體抽樣發放問卷300份，最後回收結果，接受者部分的有效問卷為403份、提供者則為182份，回收率分別為67.2%與60.7%。結果：在繼續教育辦理方式、動機及成效方面，除少數無顯著差異外，繼續教育提供者之同意程度均顯著高於繼續教育接受者。而在整體實施的滿意度方面二者呈現無顯著差異，但平均分數僅70分左右。結論：醫師繼續教育提供者與接受者間有很大的差異，顯示台灣辦理醫師繼續教育之單位於教育需求的評估並未妥善執行，因而造成許多教育課程流於形式。而提供者與接受者皆最偏好於短時間之專題演講方式，顯示目前的醫師繼續教育制度仍是零碎的，甚至於僅是應付學分的取得。主管機關必須思考如何提供醫師參與較長時間、且具有連慣性與互動性的繼續教育課程。
  Objectives: After implementing ”The Physician Law” in 2001, Taiwan launched a mandatory continuing medical education (CME) system for physicians. The purpose of this study was to explore the perspectives of providers and receivers toward the CME system's contents and performance. Methods: Study samples were divided into CME providers and receivers. Subjects were surveyed by a mailed structured questionnaire to evaluate their perspectives and levels of satisfaction regarding the CME system. The questionnaire covered three major factor domains, including program holding pattern, participating motivation, and program effectiveness. A stratified sampling method was used. Six hundred providers and three hundred receivers were selected; validated response rates were 67.2% (403) and 60.7% (182), respectively. Results: CME providers showed significantly higher agreement in most factor domains than did CME receivers except for program holding pattern, purpose, and effectiveness. Overall satisfaction between the two sampled groups was unanimous but the average score was just about 70 over 100. Conclusions: Few factors between CME providers and CME receivers were undisputed. Most factors showed significant differences between the two groups, revealing that the CME system is not conducted appropriately and practically. Most CME providers and receivers favored short-period-pattern seminars but not systematic series courses. Consequently, CME system authorities should design and conduct more appropriate systematic-series with providing connected and interactive continuing education programs for physicians.
• 140 - 148
• 10.6288/TJPH2007-26-02-06

• Link 原著 Original Article
• 基層醫師對實施品質報告卡之意願與相關因素Willingness of Primary Care Physicians toward Implementation of a Quality Report Card Program and Associated Factors
• 蔡文正、陳慧珊、龔佩珍、吳守寶、楊志良
  Wen-Chen Tsai, Hui-Shan Chen, Pei-Tseng Kung, Shou-Bao Wu, Chin-Liang Yang
• 品質報告卡 ； 醫療品質 ； 基層診所
  Quality report card ; quality of care ; primary care physician
• 目標：本研究希望能了解基層醫師對健保實施品質報告卡之參與意願及相關態度與認知，同時瞭解醫師對品質報告卡相關指標重要性之看法。方法：針對台灣具健保特約之基層診所醫師，依各縣市家數比例隨機抽取4000位開業醫師。以結構式問卷藉由郵寄方式進行調查，有效回收問卷574份。除了描述性分析外，利用羅吉斯迴歸分析探討影響基層開業醫師是否贊成實施品質報告卡之相關因素。結果：69%的基層開業醫師贊成實施品質報告卡，61%的基層開業醫師願意加入，84%的基層開業醫師表示應以自由加入的方式，並有73%的基層開業醫師認為需要分科別。希望由醫師相關公會來舉辦與公告，並透過網路作為公告管道，而資料更新的週期以一年為佳。對於是否贊成實施品質報告卡之影響因素，包含「小兒科醫師」（勝算比0.54）與「實施後會造成壓力」愈高者（勝算比0.77），其贊成實施品質報告卡的機率顯著較低；醫師對「實施後醫師對病患更用心」（勝算比1.38）、「實施後對醫療或服務品質有助益」（勝算比2.61）、「以品質報告卡的結果為依據給予實質獎勵」（勝算比2.96）之認同程度愈高，其贊成實施品質報告卡的機率顯著較高。結論：由本研究結果可知大部分基層開業醫師贊成實施品質報告卡，認為品質報告卡對醫療服務品質有正面影響認知之基層開業醫師愈贊成實施品質報告卡。
  Objectives: This study aimed to understand the willingness, attitudes, and perceptions of primary care physicians toward implementing a quality report card program and associated factors. We also investigated physicians' opinions about the importance of quality-related indicators. Methods: The studied population comprised primary care physicians who had contracted with the Bureau of National Health Insurance. Four thousand primary care physicians were randomly sampled according to numbers of clinics in counties/cities. Structured questionnaires were mailed out and a total of 574 valid questionnaires were returned. Besides description statistics, we used multivariate logistic regression to analyze underlying factors affecting attitudes of primary care physicians toward supporting implementation of a quality report card program. Results: Sixty nine percent of physicians agreed that a quality report card program should be implemented, and 61% agreed to participate in the proposed program. Eighty four percent agreed that physicians should have free choice to participate. Furthermore, 73% thought the quality report card should be designed based on different medical departments and that the program should be administered by physician associations with reports updated annually and published on the Internet. Regarding associated factors supporting implementation of the quality report card program, pediatricians (OR=0.54) and physicians who agreed that implementation would increase stress (OR=0.77) were less supportive. Physicians who agreed that implementing a quality report card program would influence doctors to pay more attention to patients (OR=1.38), or who believed that program implementation would improve the quality of care and services (OR=2.61), or who agreed to receive financial incentives according to results of quality report cards (OR=2.96) were more supportive. Conclusions: Most primary care physicians agreed with implementing a quality report card program. Physicians with positive perceptions of the influence of quality report cards on medical service quality tend to be more supportive of implementing the quality report card program.
• 149 - 160
• 10.6288/TJPH2007-26-02-07

• Link 原著 Original Article
• 台灣西醫基層診所聯合執業的變化：1998年與2003年Changes of Private Western Clinics' Group Practices in Taiwan: 1998 and 2003
• 楊涵妃、文羽苹
  Han-Fei Yang, Yu-Ping Wen
• 診所 ； 執業型態 ； 聯合執業 ； 全民健康保險學術研究資料庫
  clinics ; practice mode ; group practice ; National Health Insurance Research Database
• 目標：描述私立西醫診所的執業規模、科別組合等變化，分析影響診所聯合執業的因素。方法：利用1998年(n=8,544)與2003年(n=8,571)「全民健康保險學術研究資料庫」，採用對數迴歸，分析地區人口數、競爭程度等因素對診所是否聯合執業的影響。結果：台灣私立西醫診所以單獨執業為主要型態，1998至2003年聯合執業的比例由17%增加至23%，且平均規模略為上升。控制其他變項之影響後，人口數愈多，65歲以上人口比例愈低，競爭程度愈高的地區，診所為聯合執業的機率愈高。骨科、耳鼻喉科、眼科等聯合執業的機率較高。結論：診所執業型態的轉變可視為基層診所努力擴充資源、提升競爭力的表現，相較於一般基層醫師參與聯合執業意願調查結果，雖然高達62%醫師有意願參與聯合執業，真正付諸行動的卻佔少數，顯示聯合執業的實施仍有相當障礙。
  Objective: To profile the practice modes of privately-owned clinics, in particular the average changes in scale and specialty mix, and to analyze factors associated with group practice. Methods: Data from the 1998 (n=8,544) and 2003 (n=8,571) National Health Insurance Research Database were used. Logistic regressions were used to examine whether local population and competition are significantly associated with establishment of group practice. Results: Single practice has been the major mode of practice in Taiwan. However, the proportion of group practice increased from 17% in 1998 to 23% in 2003, along with a slightly larger average scale. Controlling for other factors, greater population, younger population, and higher competition are positively and significantly associated with the probability of group practice. Specialties such as orthopedics, otolaryngology, and ophthalmology are more likely to form group practice than is general medicine. Conclusions: We consider the changes in practice modes as clinics' ways to expand resources and to gain an edge over competitors. Compared to documented willingness as high as 62% to participate in group practice, physicians in Taiwan have yet to transfer that willingness into action. Barriers to group practice still remain.
• 161 - 168
• 10.6288/TJPH2007-26-02-08