26卷4期

• Link 公衛論壇 Public Health Forum
• 台灣職場疲勞問題的社會性台灣職場疲勞問題的社會性
• 鄭雅文、葉婉榆、林宜平
  Yawen Cheng, Wan-Yu Yeh, Yi-Ping Lin
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  none
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• 251 - 253
• 10.6288/TJPH2007-26-04-01

• Link 原著 Original Article
• 血液樣本於不同抗凝固劑與儲存時間對血鉛濃度的影響Effects of Anticoagulants and Duration of Storage on Blood Lead Levels
• 劉紹興、孫建安、董和銳、賴錦皇、鍾蝶起、周雨青、楊燦
  Saou-Hsing Liou, Chien-An Sun, Ho-Jui Tung, Ching-Huang Lai, Tieh-Chi Chung, Yu-Ching Chou, Tsan Yang
• 血鉛濃度 ； 溫度保存狀態 ； 重複分析 ； 穩定性
  blood lead levels ; container type ; repeating analysis ; stability
• 目標：本研究目的是要瞭解血液樣本存放於不同採血管以及儲存時間，對血中鉛濃度之影響。方法：總計有57個血液樣本納入本研究。包括47名鉛作業人員與10名非鉛作業人員。每位研究對象均採用8種不同抗凝固劑之採血管收集血液檢體，並以4℃冷藏直至分析。血鉛濃度比較是以建議血鉛分析使用之採血管，內含Sodium Heparin抗凝固劑之無鉛真空採血管為參考比較組。不同採血管與儲存時間對血鉛濃度的影響採用廣義線性模式GEE(generalized estimating equation)方法來分析。結果：不論在高血鉛值或低血鉛值兩組之血液樣本中，不同採血管血鉛濃度多低於參考比較組，且達顯著差異。其中內含Na2 EDTA、K3 EDTA抗凝固劑之採血管不論在高血鉛值或低血鉛值兩組中，均較參考比較組血鉛濃度為高。而內含Buffered Cit, Na 9:1與Cit, Na-0.129M Silic兩種抗凝固劑之採血管，其血鉛濃度與參考組比較，顯著下降1.616μg/dL and 3.182μg/dL。在各種採血管血液樣本以4℃儲存時間達12個月，血鉛濃度並無太大變化。結論：不同採血管與建議血鉛分析採血管比較，其中內含Buffered Cit, Na 9:1與Cit, Na-0.129M Silic兩種抗凝固劑之採血管，在高血鉛值組，建議不宜做為血鉛分析之採血管，其他採血管對血鉛之影響及長達12個月的儲存時間，雖然血鉛濃度會有所差異，但此種差異在實質上影響甚微。
  To explore the influence of different blood sample collecting tubes and the length of storage times on the measurement of blood lead levels (BLLs). Methods: A total of 57 blood specimens were collected from 47 lead-exposed workers and 10 workers not exposed to lead. For each subject, 8 blood samples were drawn with tubes containing different anticoagulants. All specimens were kept in a freezer at a temperature of 4? until analyzed. By treating tubes containing lead-free sodium heparin as the reference group, the effects of container types and storage times were analyzed by the generalized estimating equation (GEE) model. Results: For subjects with high BLLs, the blood lead measurements obtained from the blood sample tubes containing the other 7 types of anticoagulants were lower than those of the reference group. Among blood samples from both the high BLL and low BLL groups, higher BLLs existed in tubes containing the anticoagulants, Na2 EDTA and K3 EDTA. On average, the BLLs from tubes using the anticoagulants, buffered Cit, Na 9:1, and Cit, and Na-0.129M Silic were lower than those in the reference group by 1.616µg/dL and 3.182µg/dL, respectively. No significant differences existed in the blood lead concentrations obtained from the blood samples stored in a 4? environment and in different types of blood containers for 12 months, whether from the high BLL or the low BLL groups. Conclusions: When collecting blood samples for high BLL analyses, the two anticoagulants (i.e, buffered Cit, Na 9:1, and Cit, and Na-0.129M Silic) are not recommended. However, blood lead concentrations remain stable, even when blood samples have been stored for a period of 12 months.
• 254 - 260
• 10.6288/TJPH2007-26-04-02

• Link 原著 Original Article
• 醫院總額預算對費用單價與服務量的影響初探An Exploratory Investigation of the Effect of Hospital Global Budgeting on Payment Distribution
• 羅紀琼、詹維玲
  Joan C. Lo, Vei-Lin Chan
• 醫院總額 ； 總額預算 ； 醫療費用分配
  hospital global budget ; global budgeting ; payment distribution
• 目標：本研究旨在探討醫院總額預算對費用單價與服務量的影響。方法：以趨勢分析來觀察全體醫院在總額實施前後費用單價與服務量的變化；以涵蓋醫院別固定效果的迴歸分析來探討總額實施前後層級、權屬及分局等特性對費用單價與服務量的影響。資料為健保局提供的各醫院各月的門、住診申報費用、人次及住院人日，涵蓋期間為1996年1月至2005年6月。分析軟體為Stata 9.0。結果：住院次數、每日費用及門診次數長期來說皆有上升趨勢，總額實施前後並沒有顯著新增差異。每次住院平均日數有減少趨勢，然而總額實施使其顯著增加。每次門診平均費用有上升趨勢，總額實施後有顯著新增差異。總額的實施對不同層級、權屬與分局別醫院有不同程度的影響。醫學中心、財團法人醫院，台北、中區及高屏分局醫院申報的費用顯著增加；地區，公立、私立，東部與南部分局醫院申報的費用顯著減少。結論：總額實施後醫療費用更往都市、大型及財團法人醫院集中，主管機關應正視此問題。
  Objectives: To investigate the effect of hospital global budgeting on the distribution of payments. Methods: We conducted a trend analysis to study the effect of hospital global budgeting on health expenditures and services. We also used a panel data model with hospital specific fixed effects to investigate payment distributions among hospitals of different levels, ownership, and locations. The statistical analysis was based on monthly hospital claims from January 1996 to June 2005 provided by the Bureau of National Health Insurance. Results: Global budgeting had no significant effect on the number of outpatient and inpatient visits. Mean expenditures per inpatient day rose over time, as did the length of stay decreased over time, though this downward trend reversed after global budgeting. After the global budgeting period, we observe a significant positive effect on mean expenditures per outpatient visit. Regarding payment distribution, medical centers, not-for-profit hospitals, and hospitals in northern and central areas all gained resources. By contrast, district, public, and private hospitals, as well as hospitals in eastern and southern areas, received fewer resources. Conclusions: After global budgeting was implemented, payments were distributed toward urban, large, and not-for-profit hospitals. The Department of Health should pay attention to this problem.
• 261 - 269
• 10.6288/TJPH2007-26-04-03

• Link 原著 Original Article
• 住院癌末病患照護型態對住院醫療費用與住院天數之影響Effects of Care Patterns in end-of-life Hospitalized Cancer Patients on Hospitalized Medical Expenditures and length-of-stay
• 羅健銘、陳素秋、賴允亮、林家瑾、陳建仁
  Chien-Ming Lo, Su-Chiu Chen, Yun-Liang Lai, Chia-Gen Lin, Chien-Jen Chen
• 安寧療護 ； 癌症病患 ； 醫療費用 ； 住院天數 ； 屬性分數
  hospice ; cancer patients ; medical expenditure ; length-of-stay ; propensity score
• 目標：癌症為國人近年主要死因的第一位。癌末病患除了接受一般急救照護外，另一種照護的選擇為安寧療護。文獻顯示國外安寧療護能降低醫療費用，但國內少有以健保資料庫來分析安寧療護的使用情形。方法：以健保資料庫資料比較癌末病患安寧與非安寧療護之住院天數；並經調整病患使用安寧療護的機率（propensity score，由複邏輯斯迴歸估計）將選擇兩照護型態隨機化後，進一步比較兩照護型態之平均醫療費用。結果：安寧與非安寧療護的平均住院天數分別為15.23天與23.77天，無論何種照護型態病患有接受手術治療會有較高的平均住院天數、肝癌則比其他疾病有較低的平均住院天數；安寧療護病患選擇區域醫院比其他醫院等級有較高的平均住院天數。安寧與非安寧療護之醫療費用比較中，經propensity score方法調整成隨機化後，安寧療護估計可以降低約四萬至二十二萬元的住院醫療費用。結論：癌末病患使用安寧療護估計可降低平均住院醫療費用，但居家安寧療護及其他養護機構照顧並未考量，建議未來衛生主管機關能夠進一步探討並研究安寧療護的品質及存活。
  Objectives: Cancer has been the leading cause of death in Taiwan for years. In addition to curative treatments, patients with cancer can choose hospice care as a medical option. Studies indicate that hospice care could reduce medical expenditures in foreign countries, but little research has been done related to hospice care in Taiwan by using National Health Insurance Databases (NHID). Methods: Length-of-stay was compared between hospice and non-hospice cancer patients by using the NHID. After adjusting for each patient’s probability of hospice care (i.e., the propensity score, as estimated by multiple logistic regression) for randomization, average medical expenditures of two care patterns were further compared. Results: The length-of-stay of hospice and non-hospice care was 15.23 and 23.77 days, respectively. Those who underwent surgery tended to have a longer length-of-stay and those who had liver cancer tended to have a shorter length-of-stay. However, hospice patients who chose to stay in a regional hospital tended to have longer length-of-stay. The medical expenditure of hospice care was estimated to be lower, by approximately NT 40,000-220,000 dollars as compared to non-hospice care, after adjustment of propensity score methods. Conclusions: The average medical expenditure was estimated to be lower when end-of-life hospitalized cancer patients choose to have hospice as their care pattern, but home hospice and other care centers were not considered. Further research is suggested to investigate these issues and the quality and survival of hospice care in the future.
• 270 - 282
• 10.6288/TJPH2007-26-04-04

• Link 原著 Original Article
• 總額支付制度實施後醫院的適應策略分析Adaptation Strategies of Hospitals under the Global Budget System
• 黃國哲、陳怡樺、張蕙芝、張維容、溫信財、邱瓊萱
  Kuo-Cherh Huang, Yi-Hua Chen, Hui-Chih Chang, Wei-Jung Chang, Hsyien-Chia Wen, Chiung-Hsuan Chiu
• 適應策略 ； 市場導向策略 ； 資源基礎策略
  Adaptation strategy ; Market-oriented strategy ; Resource-based strategy
• 目標：本論文旨在探討國內醫院在總額支付制度實施後所採取的適應策略，並分析影響醫院採取不同類型的適應策略之因素。方法：本研究以加入全民健保特約並通過醫院評鑑屬地區醫院層級（含）以上之醫院為研究母群體，合計462家受訪醫院（民國九十三年度的評鑑資料）。研究人員於民國九十四年三月下旬向上述醫院寄發結構式問卷，問卷詢問對象則設定為受訪醫院的院長等高階經營主管，最後的有效回覆問卷數計有194份(42.0%)。結果：依據因素分析的結果將回覆醫院所採取的適應策略分為市場導向及資源基礎策略兩類，累計可解釋總變異量的64.02%。樣本醫院所採取的適應策略是市場導向策略為主流。另一方面，醫院評鑑等級、醫院權屬別及是否屬於教學醫院等變項對於醫院採取市場導向策略則具有顯著性的影響力。結論：實證結果顯示，國內醫院在總額支付制度實施後所採取的適應策略，是以顧客為主的市場導向策略為主，而醫院屬性則對於醫院採取市場導向策略的傾向具有顯著性的影響力。
  Objectives: The current study aimed to explore adaptation strategies utilized by Taiwan's hospitals under the global budget system and examine the factors which influence the types of adaptation strategies among the various hospitals. Methods: The study population included all 462 district (and higher level) hospitals in Taiwan using 2004 data. Structured questionnaires were mailed to the responsible management personnel for the hospitals in late March 2005. After two rounds of mailing, the final effective sample size was 194, with an effective response rate of 42.0%. Results: The results of factor analysis identified two types of adaptation strategies: 1) market-oriented strategy and 2) resource-based. The total explained variance by the two factors was 64.02%. Moreover, the sample hospitals were more likely to execute market-oriented strategies. Predictive factors of a hospital carrying out market-oriented strategies included hospital ownership, the level of the hospital, and the hospital's teaching status. Conclusions: The empirical research has demonstrated that Taiwan's hospitals employ adaptation strategies which are market-oriented and resource-based under the global budget system, and the former strategy is more prevalent. Moreover, hospital characteristics are related to a hospital's adoption of market-oriented strategies.
• 283 - 291
• 10.6288/TJPH2007-26-04-05

• Link 原著 Original Article
• 靜脈注射藥癮者參與減害計畫之意願及影響因子探討Factors Which Influence the Willingness of Injection Drug Users to Participate in the Harm Reduction Program
• 許淑雲、王俊毅、廖宏恩
  Shu-Yun Hsu, Jiun-Yi Wang, Hung-En Liao
• 減害計畫 ； 靜脈注射藥癮者 ； 清潔針具交換計畫 ； 替代療法 ； 愛滋病
  Harm Reduction Program ; injection drug users ; Needle Exchange Program (NEP) ; substitution therapy ; AIDS
• 目標：本研究主要於減害計畫未全面實施前分析靜脈注射藥癮者參與「清潔針具交換計畫」及「替代療法」的意願及其影響因子，並建議減害措施可行模式。方法：95年2至3月以分層隨機抽樣方式選取台中監獄、雲林及嘉義戒治所靜脈注射藥癮者樣本共計1206人，進行橫斷式問卷調查。結果：本研究發現有85.2%藥癮者表達傾向參加清潔針具交換計畫意願；93%的藥癮者表示願意參加替代療法。此外，羅吉斯迴歸分析發現「對清潔針具交換計畫之信念」、「識別卡片保障」、「藥癮同儕影響」及「配偶或性伴侶影響」等變項會影響未來加入清潔針具交換計畫意向；而「對替代療法之信念」、「替代療法自費程度」及「配偶或性伴侶影響」則是未來參加替代療法之顯著影響因子。結論：推動減害措施除應有消除靜脈注射藥癮者對執法人員疑慮的配套措施外，更應宣導減害計畫對降低愛滋病感染之成效及美沙冬治療戒毒之效能，透過藥癮者之社會網絡，推動同儕衛教並減輕自費者參加替代療法之負擔。
  Objectives: The purpose of this study was to analyze the factors which influence the willingness of injection drug users to participate in needle exchange and substitution therapy programs while both programs are still experimental. Methods: The multi-layer random sampling method was used in a cross-sectional survey conducted between February and March 2006, in which 1,206 samples were collected at the Yunlin and Chia-I Drug Abstention and Treatment Center of the Taichung Prison. Results: Of the injection drug users, 85.2% and 93% were willing to participate in needle exchange and substitution therapy programs, respectively. Belief in the program, identification card protection, peer pressure, and their sexual partner's encouragement were the factors which influenced willingness to participate in the needle exchange program, while belief in the program, the affordability of out-of-pocket volunteers, and their sexual partner's encouragement were the factors which determined willingness to participate in the substitution therapy program. Conclusions: Implementing peer education through the social network of high risk groups, propagating the benefits of these programs, eliminating the financial burden of substitution therapy for those out-of-pocket volunteers, and working together with law enforcement officials as a cohesive group may facilitate the overall implementation of the Harm Reduction Program.
• 292 - 302
• ?

• Link 原著 Original Article
• 低出生體重早產兒出生後第一年內再入院研究A Study of Readmission during the First Year of Life among Preterm Infants with Low Birth Weight
• 曾燕雪、李中一
  Yen-Hsueh Tseng, Chung-Yi Li
• 低出生體重 ； 早產兒 ； 再入院 ； 發生率 ； 照護品質
  Low birth weight ; Preterm birth ; Readmission ; Incident rate ; Quality of care
• 目標：本研究旨在探討低出生體重早產兒出生後一年內全病因及呼吸道感染再入院發生率及其預測因子。方法：本研究採回溯性世代研究設計，研究世代成員擷取自全民健康保險住院醫療清單明細檔（以下簡稱住院檔）中於2000~2002年間出生，且在此期間首次住院之出院診斷為ICD-9-CM:765共18，421名低出生體重早產兒；出生後第一年內除首次入院以外之再入院資料則是由2000-2003年之住院檔串聯個案加密之身份證字號獲得。結果：研究對象於出生後第一年內全病因及呼吸道感染再入院之累積發生率分別為37.2%與22.4%，發生密度則分別為167人次／100人年與139人次／100人年。多變量Cox迴歸模式分析結果顯示：男性、出生體重小於1,500公克、妊娠週數小於28週、具先天畸形、首次住院罹患慢性肺部疾病及父（或母）投保金額小於19,200元等因素均為發生再入院之顯著預測因子。結論：為降低低出生體重早產兒第一年之再入院率，應針對再入院高危險群加強實施周產期與新生兒照護分級制度，以提昇新生兒的健康狀態。此外，未來研究也應進一步評估針對早產兒肺部疾病所作照護措施（無法避免早期分娩的產婦於產前注射類固醇，以及產後給予可能發生呼吸窘迫症候群的早產兒肺表面活性物質）之成效，以期利用有效的臨床介入措施進一步降低早產兒之再入院率。
  Objectives: The aims of this study were to estimate the incidences of readmission for all causes and for respiratory infection among preterm low-birth-weight infants during the first year of life and to explore significant predictors for readmission. Methods: For this retrospective cohort study, we enrolled 18,421 infants born and first hospitalized in 2000-2002 because of prematurity or low birth weight (International Classification of Diseases, Ninth Revision, Clinical Modification code 765) at discharge. The infants were identified from inpatient claims of our National Health Insurance. They were linked, by using scrambled personal identification numbers, to 2000-2003 inpatient claims data to identify all possible re-hospitalizations during infancy. Incidences of readmission, incidence density estimates, and predictors of readmission were analyzed. Results: Cumulative incidences of readmission for all causes and for respiratory infection were approximately 37.2% and 22.4%, respectively; respective incidence density estimates were 167 and 139 readmissions/100 person-years. Cox multivariate regression analysis indicated that male sex, birth weight < 1,500 g, gestational age < 28 weeks, congenital anomaly, chronic lung disease, and a parental insurance premium of < 19,200 NT dollars were significant predictors for readmission. Conclusions: To reduce readmission rates among preterm low-birth-weight infants, perinatal and newborn regionalization must be enforced to improve the health of those at increased risk for readmission. Future studies should be performed to assess the effectiveness of healthcare maneuvers, such as administering antenatal steroid therapy to those who will be born early and providing surfactant to premature babies who are vulnerable to respiratory distress syndrome. Effective maneuvers such as these may further reduce readmission rates among infant born preterm.
• 303 - 311
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• Link 原著 Original Article
• 台灣地區單身且有性經驗軍人使用保險套的意向Examining the Intention to Use Condoms among Single and Sexually Active Military Conscripts
• 李思賢、趙運植、吳藹薇
  Tony Szu-Hsien Lee, Yun-Chih Chao, Ai-Wei Wu
• 愛滋 ； 保險套 ； 軍人 ； 結構方程模式 ； 計劃行為模式
  AIDS ; Condom ; Conscript ; Structural Equation Modeling ; Theory of Planned Behavior
• 目標：本文是探討軍人與主要性伴侶性交時使用保險套的意向。方法：受訪者是在台灣某一個軍營中，徵得751位軍人同意參加研究，本文是分析其中518位單身且有性經驗者對於保險套使用的負面態度、主觀規範、冒險及保險套知覺行為控制、與將來六個月內性交時使用保險套意向。資料分析是採用驗證式因素分析（CFA）與結構方程模式（SEM）。結果：研究結果顯示，以CFA測量模式發現測量題項能適切地組成三個潛在變項：保險套使用的負面態度（4個項目）、主觀規範（4個項目）、與冒險及保險套知覺行為控制（3個項目）。SEM分析結果顯示保險套使用的負面態度、主觀規範、冒險及保險套知覺行為控制有顯著的路徑指向未來使用保險套的意向。整體模式結果指出計畫行為理論能解釋未來保險套使用意向38%變異量。結論：本研究結果提供軍人在保險套的使用是受到多元因素彼此互相影響的證據，藉由瞭解這些因素對於男性在使用保險套的影響，可以協助提高保險套使用以及降低性傳染疾病（包含愛滋病）傳染可能性。
  Objectives: The purpose of this study was to examine the intention to use condoms among single and sexually active male conscripts in Taiwan. Methods: The study subjects were 751 conscripts who signed consent forms at a military camp. They self-administered a survey questionnaire regarding their attitudes, subjective norms, adventure and perceived control of using condoms, as well as their intention to use condoms during sex in the next 6 months. Confirmatory factor analysis and a structural equation model were applied. Results: Data from 518 single and sexually active participants were analyzed. The measurement model of attitudes toward condom use (4 items), subjective norms (4 items), and adventure and perceived behavior control (3 items) fit the data well (?^2(38) = 47.8, p = 0.13; CFI = 0.99; RMSEA = 0.02). The final structural equation model showed significant paths from latent constructs of negative attitudes about condom use (ß = -0.47), subjective norms (ß = 0.36), and adventure and perceived control of condom use (ß = -0.48) to the intention of using condoms in the next 6 months. In addition, constructs of the theory of planned behavior accounted for 38% of the variance of intention to use condoms. Conclusions: Understanding how conscripts respond to condom use in the context of identifying multiple pathways to safer sex for men can increase condom use and reduce the incidence of sexually transmitted diseases, including AIDS.
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• Link 原著 Original Article
• 台灣地區大專新生愛滋病知識、態度及行為調查Knowledge, Attitude and Practice on Human Immunodeficiency Virus Type 1 Infection among New Entrant University Students in Taiwan
• 梅達、賴淑芬、 莊紹源、張傳琳、顏璧梅、陳宜民
  Isai Medah, Shu-Fen Lai, Shao-Yuan Chuang, Chuan-Lin Chang, Nancy Pi-Mei Yen, Arthur Yi-Ming Chen
• 愛滋病 ； 知識 ； 態度 ； 行為 ； 大專學生
  HIV/AIDS ; Knowledge ; Attitude ; Practice ; Students
• 目標：台灣愛滋病病毒感染最近幾年明顯上升，此研究以尚未被同儕影響的大一新生為研究對象，調查其愛滋病相關的知識、態度與行為。方法：於2004年9月針對9所大學（包括公立、私立、醫學大學、職業學校）的11,847位新生進行問卷調查。結果：知識問題平均答對分數為86.8%。態度方面，42.2%受訪者會避免與愛滋病患接觸，13.6%受訪者會因家人感染愛滋病而感尷尬。在男女學生群中，知識及態度的相關性係數極低（皮爾森積差相關係數：男學生，0.182；女學生，0.074，p ＜ 0.001）。學校及電視是取得愛滋病相關資訊的主要途徑。受訪者的性取向為：93.3%異性戀，1.1%雙性戀，0.5%同性戀。第一次性行為平均年齡為17.1歲（標準差1.5歲）。在1,179（10%）位性活躍的學生中，只有30.9%同學會在每次性行為時使用保險套，此外，9.9%學生有飲酒的行為，157（1.3%）位曾使用過禁藥，其中10位曾使用過靜脈注射的非法藥物。禁藥的來源包括：朋友（58.6%），酒吧（45.2%）及學校（21.6%）。結論：台灣高中畢業生對於愛滋病的相關知識及態度仍有不正確之處，建議加強高中生的愛滋教育。
  Objectives: By the end of 2004, there were 403 students infected with human immunodeficiency virus type 1 (HIV-1) reported to Taiwan’s Center for Disease Control. The objective of this study was to understand the knowledge, attitudes and practice regarding HIV-1 and acquired immunodeficiency syndrome (AIDS) among new entrant (freshman) university students in Taiwan. Methods: A cross-sectional study was conducted in September 2004. Self-administered questionnaires from 11,847 students of nine universities were collected and analyzed. Results: The mean knowledge score was high-86.8. Regarding attitude, 42.2% of students would avoid contacts with HIV/AIDS patients; and 13.6% felt embarrassed if one of their family members had AIDS. The attitude scores of the students did not correlate with the knowledge scores (Pearson correlation: 0.182 and 0.074 for male and female students, respectively). Students identified both school and television as the main sources of information. The sexual orientations were 93.3% heterosexuals, 1.1% bisexuals and 0.5% homosexuals. The mean age of first sexual intercourse was 17.1 (SD ± 1.5). Among 1,179 (10%) students who had sexual experiences, only 30.9% used condoms consistently. In addition, 9.9% were alcohol consumers and 157 students (1.3%) were illicit drug users which including 10 injecting drug users. Students obtained drugs mainly from friends (58.6%), in pubs (45.2%) and at school (21.6%). This is a significant finding. Conclusions: There were knowledge gaps and many misconceptions about transmission routes of HIV-1. More AIDS education including anti-drug information should be provided to high school students in Taiwan.
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