43卷6期

• Link 政策論壇 Policy Forum
• 從照護稀缺的角度看安樂死合法化之爭議 On legalization of euthanasia: from the perspective of care scarcity
• 楊秀儀
  Hsiu-I Yang
• 積極安樂死；安樂死合法化；照護稀缺；關係自主
  active euthanasia; legalization of euthanasia; care scarciry; relational autonomy
• 本期政策論壇主題為從照護稀缺的角度看安樂死合法化爭議，國際間討論之安樂死皆指基於自主意願的自願安樂死，而目前在臺灣醫師提供積極安樂死的行為將觸犯刑法，作者認為討論積極安樂死合法化前應先緩解照護稀缺之問題，以保障關係自主、避免衍生倫理爭議。
  The article discusses the debate on the legalization of euthanasia from the perspective of care scarcity. International discussions on euthanasia generally refer to voluntary euthanasia based on the individual's autonomy. Currently, physicians who provide active euthanasia in Taiwan are in violation of the criminal law. The author argues that before discussing the legalization of active euthanasia, the issue of care scarcity should first be addressed to safeguard relational autonomy and avoid ethical disputes.
• 513-515
• 10.6288/TJPH.202412_43(6).PF06

• Link 公衛今與昔 Public Health Now and Then
• 台灣原住民醫療的歷史演變 The historical evolution of medical care for Taiwan's Indigenous peoples
• 蔡篤堅、陳秀娟、李孟智
  Duu-Jian Tsai, Hsiu-Chuan Chen, Meng-Chih Lee
• 無none
  無none
• 無none
  無none
• 516-526
• 10.6288/TJPH.202412_43(6).113039

• Link 綜論 Review Article
• 居家醫療病患使用遠距醫療與遠端監控之系統性文獻回顧：慢性病管理與住院風險 Effects of telemedicine and remote monitoring on hospitalization among home health-care patients: a systematic review
• 楊蕙如、曾偉哲、謝雨蓁、林青青、陳炳仁、廖容瑜
  Huei-Ru Yang, Wei-Zhe Tseng, Yu-Zhen Hsieh, Ching-Ching Claire Lin, Ping-Jen Chen, Jung-Yu Liao
• 居家醫療；在宅醫療；遠距醫療；遠端監控；慢性病
  home healthcare, hospital at home, remote patient monitoring, telemonitoring, patients with chronic diseases
• 隨著全球高齡化，居家醫療成為醫療照護系統另一種選擇，針對使用居家醫療的慢性病患者，搭配遠端監控進行慢性病健康管理，是否能有效降低醫療資源利用，目前尚無定論。因此，本研究以50歲以上且罹患慢性病的病患為對象，回顧實證研究，以了解居家醫療結合遠端監控介入對於降低慢性病患者住院頻率的效果。本研究使用PubMed、Scopus與Embase三個資料庫進行關鍵字搜尋，自1996年開始搜尋居家醫療下使用遠端監控之50歲以上的慢性病患者，經過排除重複文獻、篩選文獻後，納入符合條件之文獻。本研究共納入13篇文獻，共有4,528名患者，女性患者多於男性患者，遠端監控介入時長為12個月內。過去多數文獻為針對心臟衰竭之患者，多為使用居家醫療+遠端監控的治療方式，而對於住院的改善影響為部分支持。不同的遠端監控居家醫療介入模式，相較於單一居家醫療介入，可能具有更高的潛在成效，需要有政策以及技術的支持讓遠端監控可以帶給慢性病患者更高品質的照護。
  With the aging of the global population, home health care (HHC) has become a feasible alternative within health-care systems, particularly for patients with chronic diseases. However, the effectiveness of implementing remote patient monitoring (RPM) in HHC for reducing health-care resource utilization among patients with chronic diseases remains unclear. This systematic review examined the effects of various RPM interventions on health-care resource utilization for HHC patients aged 50 years and older with chronic diseases. Keyword searches were conducted in PubMed, Scopus, and Embase for studies published from 1996 onwards on RPM interventions for HHC patients aged 50 years and above with chronic diseases. Following the removal of duplicate studies and a thorough literature screening process, eligible studies were included for analysis. A total 13 studies involving 4,528 patients, predominantly women, were analyzed. The durations of all RPM interventions were within 12 months. Most of the included studies focused on patients with heart failure and implemented HHC+RPM as a treatment. These interventions often incorporated multiple strategies to reduce hospitalizations and readmissions. RPM interventions significantly reduce readmission rates. Utilizing RPM models in combination with HHC interventions appears to be more effective than HHC alone in reducing hospitalizations and readmissions.
• 527-536
• 10.6288/TJPH.202412_43(6).113072

• Link 綜論 Review Article
• 經濟合作暨發展組織國家或區域與台灣健康公平指標之文獻回顧 Literature review of health equity indicators among Organisation for Economic Co-operation and Development countries or regions and Taiwan
• 劉禮慧、鍾國彪、賴嬿竹
  Li-Huei Liu, Kuo-Piao Chung, Yen-Chu Lai
• 健康公平；公平指標建立；健康照護；經濟合作暨發展組織；國際比較
  healthcare equity, equity indicators development, healthcare, OECD, international comparison
• 消弭健康不平等為聯合國永續發展及臺灣2020國民健康白皮書目標之一，它涉及社會、政治、環境等多面向。本文聚焦健康照護體系可改善之層面，除探討健康照護公平性外，向前延伸至初級預防風險因子及健康照護體系之結果公平性。以國家衛生研究院《縮短臺灣健康不平等之政策研議》報告為基礎，綜覽國內外健康照護公平相關監測指標，回顧與比較經濟合作暨發展組織國家及我國健康公平指標的現況及提供發展方向建議。研究結果與國際相較，我國尚缺乏整合性健康監測系統或報告。本文提出整體建議：第一，臺灣目前尚未確立在地健康公平測量指標，未來如欲發展，方法學可參考美國及以色列，以重要性、可行性、公眾關注等作為選擇標準，比較群體間差異，呈現上建議可參考英國、澳洲、加拿大建立指標監測儀表板，盤點現有資料及歷年趨勢，視覺化呈現，並強化資料管理機制，定期更新追蹤；第二，須依政策需求定出比較公平的分層類別，並呈現分層間差異，儘管分層資料非必定完整呈現在所有年度，但未來資料管理也利於對症下藥、精準補充。
  Eliminating health inequality is a core objective of the United Nations Sustainable Development Goals and Taiwan's 2020 National Healthy People initiative. Achieving this objective necessitates addressing social, political, and environmental dimensions. This review focused on equity in the health-care system and its outcomes as well as primary prevention risk factors that could be mitigated through targeted interventions. On the basis of the ""Policy Discussion on Shortening Health Inequality in Taiwan"" report, this study reviewed and compared health equity indicators between Organisation for Economic Co-operation and Development countries and Taiwan and provided recommendations for future development. The findings indicated that compared with other countries, Taiwan lacks a comprehensive health equity monitoring system or report. In response, the following recommendations are proposed: (a) Taiwan should establish localized health equity indicators by adopting methods from the United States and Israel; selection criteria such as importance, feasibility, and public concern could be used for determining differences between groups. Moreover, Taiwan could adopt presentation models from the United Kingdom, Australia, and Canada to incorporate existing data and historical trends into visualized monitoring dashboards, thereby enhancing data management mechanisms and ensuring regular updates. (b) Policies should define and present standardized equity stratifiers to compare health outcomes between distinct population groups. Although trends in these categories may not be available for all years, these metrics can serve as benchmarks for future enhancement of interventions.
• 537-550
• 10.6288/TJPH.202412_43(6).113058

• Link 綜論 Review Article
• 各國包裹式支付制度及其對台灣的啟示 Bundled payment systems in different countries and their implications for Taiwan
• 林青青、汪辰陽、郭年真、廖慕理
  Ching-Ching Claire Lin, Chen-Yang Wang, Raymond N. Kuo, Joshua M. Liao
• 支付制度；健康照護模式；包裹式支付；支付制度改革
  payment system, healthcare model, bundled payments, payment reform
• 全世界的保險付費者(payer)正逐漸改變過往以論量計酬(Fee-for-service)為主要付費方式，提出各種替代性支付模式(alternative payment models)，給予醫療提供者(providers)經濟誘因，並使醫療提供者負擔更多財務責任。而隨著人口老化，慢性病人口增多，支付制度改革已經是台灣健康體系關鍵的一環。參考各國照護模式及支付制度，利用包裹式支付(Bundled Payments)提高醫療提供者的責任，在提升照護結果的同時，降低過度醫療與避免片段照護，是可能方向之一。本文將簡述各國實施包裹式支付制度的背景、制度模型、相關實證研究之成效結果，並討論包裹式支付制度可提供我國醫療與健康照護模式精進的借鏡之處。
  Insurance payers around the world are gradually shifting from historical fee-for-service reimbursement toward alternative payment arrangements. These new alternative payment models aim to provide economic incentives and increase financial accountability among healthcare providers. With an aging population and increasing prevalence of chronic conditions, payment reform has become a crucial component of Taiwanese healthcare system. Drawing from international care models and payment systems, bundled payments could be a potential approach for increasing healthcare provider accountability and enhancing care outcomes while reducing excessive medical interventions and fragmented care. This study outlines the background, institutional models, and the outcomes from implementation of bundled payment models in various countries. This study also discusses how bundled payments can provide insights for improving Taiwanese healthcare and medical care models.
• 551-563
• 10.6288/TJPH.202412_43(6).113052

• Link 原著 Original Article
• 子宮頸癌與乳癌篩檢之城鄉差距探討 Rural–urban differences in cervical and breast cancer screening service utilization in Taiwan
• 戴晨芝、林青青、程劭儀、董鈺琪
  Chen-Chih Tai, Ching-Ching Claire Lin, Shao-Yi Cheng, Yu-Chi Tung
• 城鄉差距；子宮頸抹片檢查；乳房X光攝影；癌症篩檢；預防醫療利用
  urban-rural difference, pap smear, mammography, cancer screening, preventive care
• 目標：台灣目前針對女性提供的癌症篩檢補助服務，包括子宮頸抹片檢查及乳房X光攝影檢查，雖為公費補助之篩檢項目，但是台灣有醫療資源分布不均之現象，癌症篩檢服務是否能觸及所有符合篩檢條件的女性乃是一值得探討的問題。本研究探討偏鄉婦女與城市婦女之乳癌與子宮頸癌篩檢情況是否存在差異。方法：本研究採用回溯性世代研究法（Retrospective Cohort study），利用全民健保資料庫進行次級資料分析。研究對象為2017年滿30歲及以上女性（子宮頸癌篩檢）及2017年45-69歲女性（乳癌篩檢）。利用承保檔中投保單位地區、保險單位類別、被保人身份、呼吸道感染門診就醫紀錄等推估居住地，之後再進行居住地城鄉劃分，並針對研究對象居住地（城/鄉）與篩檢情況進行雙變項卡方檢定及多變項羅吉斯迴歸分析，探討居住地不同是否造成癌症篩檢利用情況差異。結果：本研究發現，偏鄉地區婦女較城市婦女更可能進行子宮頸癌（OR = 1.017， p < 0.01）和乳癌篩檢（OR = 1.038， p < 0.01）。隨著年齡或地區教育程度增加，接受子宮頸癌篩檢之勝算比越低，但接受乳癌篩檢勝算比越高；而投保金額較高者，相較於投保金額低的組別，進行子宮頸癌篩檢與乳癌篩檢的勝算比均較高。結論：本研究發現2017至2019年，台灣婦女在子宮頸癌及乳癌篩檢利用上確實存在城鄉差距，但是偏鄉之篩檢狀況並不比城市差，反而出現城市篩檢狀況不及偏鄉的狀況。年齡、投保金額、地區教育程度及共病症情形也均為可預測研究對象篩檢行為之相關因素。本研究亦發現子宮頸癌及乳癌的篩檢率整體偏低，子宮頸癌篩檢率為8.02%，乳癌篩檢率為38.86%，與國家癌症防治計畫目標之間仍有差距，應設法國家提高整體篩檢率。
  Objectives: Taiwan currently provides subsidized cancer screening services, including pap smears and mammograms, for women under its national health-care system. However, the uneven distribution of medical resources in Taiwan raises concerns about these services' accessibility for all eligible women. Few studies have explored the differences in utilization rates of cervical and breast cancer screening services in Taiwan between women residing in urban and rural areas, and the extent to which these differences exist remains unclear. This study investigated variations in the utilization of breast and cervical cancer screening services among women residing in urban and rural areas in Taiwan. Methods: This study employed a retrospective cohort design and utilized secondary data from the National Health Insurance Research Database. The sample for cervical cancer screening comprised women aged 30 years and older, with data 2017-2019 analyzed; the sample for breast cancer screening comprised women aged 45–69 years, with data from 2017-2018 analyzed. The Registry for Benefciaries fle was used to estimate place of residence on the basis of the insurance unit’s region, the insurance unit type, the benefciary’s identity, and outpatient records for respiratory infections. Places of residence were categorized as urban or rural. Chi-square tests and multivariate logistic regression analyses were conducted to examine differences in cancer screening utilization by place of residence (urban/rural). Results: We have investigated 6,754,863 women in total, with 6,244,533 from urban area and 510,330 from rural area. The overall screening rates were low, being 48.02% for cervical cancer screening and 38.86% for breast cancer screening. Women in rural areas had higher odds of undergoing cervical cancer (OR = 1.017, p < .01) and breast cancer (OR = 1.038, p < .01) screening than those of women in urban areas. A higher age or education level was associated with lower odds of undergoing cervical cancer screening but higher odds of undergoing breast cancer screening. Additionally, individuals with higher insurance coverage had higher odds of undergoing both cervical and breast cancer screening than those of individuals with lower insurance coverage. Conclusions: This study identifed differences in cervical and breast cancer screening utilization between urban and rural residents from 2017 to 2019. The fndings reveal that women living in rural areas exhibited slightly higher screening rates than those of women living in urban areas. Factors such as age, insurance coverage, regional education level, and comorbidity status were associated with screening behaviors. However, the overall screening rates for cervical and breast cancer were below the targets set by Taiwan's National Cancer Control Program, underscoring the need for initiatives to improve these rates.
• 564-576
• 10.6288/TJPH.202412_43(6).113065

• Link 原著 Original Article
• 加壓裝置於預防透析中低血壓之成效—系統性文獻回顧暨統合分析 Effectiveness of compression devices in preventing intradialytic hypotension: a systematic review and meta-analysis
• 曾芃廩、徐禮平、曾瑞慧、蘇祐瑩、陳素華、朱淑媛、郭嘉琪
  Peng-Lin Tseng, Li-Ping Hsu, Jui-Hui Tseng, Yu-Ying Su, Su-Hua Chen, Shu-Yuan Chu, Chia-Chi Kuo
• 血液透析；加壓；透析中低血壓
  hemodialysis, compression, intradialytic hypotension
• 目標：透析中低血壓為血液透析治療常見且嚴重的併發症，將導致生理不適、器官缺血性損傷、透析通路栓塞、加速心血管功能惡化與增加死亡風險。本文旨在探討加壓裝置於預防透析中低血壓之成效。方法：依循Joanna Briggs Institute系統性文獻回顧指引，搜尋台灣期刊論文索引系統、華藝線上圖書館、CINAHL、Cochrane Library、Embase、ProQuest、PubMed、Web of Science共八個中英文資料庫2024年5月以前文獻，鍵入血液透析、加壓、低血壓之MeSH term與同義詞，以布林邏輯、切截字及限制隨機控制試驗等進階檢索技巧，篩選後共納入6篇文獻，以JBI 2023年的隨機控制試驗查核表評讀文獻品質，以Review Manager 5.4版軟體進行統合分析。結果：血液透析中使用加壓裝置之加壓組比常規組有顯著較佳的透析前後收縮壓差(MD = 9.02， p = .02)及透析後心輸出量(MD = 1.13 L/min， p = .01)，透析中低血壓發生率幾近顯著差異(RR = 0.73， p = .06)。結論：現有證據僅來自樣本數偏少的6篇研究，證據力薄弱，建議臨床可針對高風險族群導入加壓裝置，密切評估個案反應，調整與決策最佳氣動加壓方案。
  Objectives: Intradialytic hypotension is a common and severe complication of hemodialysis treatment. It can result in physiological discomfort, ischemic organ damage, dialysis access thrombosis, accelerated cardiovascular functional decline, and an increased risk of mortality. This study evaluated the effectiveness of compression devices in preventing intradialytic hypotension. Methods: In accordance with the systematic review guidelines of the Joanna Briggs Institute (JBI), a comprehensive search was conducted across eight databases: the Index of the Taiwan Periodical Literature System, Airiti Library, CINAHL, Cochrane Library, Embase, ProQuest, PubMed, and Web of Science. Articles published before May 2024 were retrieved using MeSH terms and synonyms for ""hemodialysis,"" ""compression,"" and ""hypotension,"" along with Boolean operators, truncation, and limits for randomized controlled trials. Identified documents were screened, and six articles met the inclusion criteria. The quality of the included studies was assessed using the JBI 2023 checklist for randomized controlled trials, and a meta-analysis was performed using Review Manager 5.4 software. Results: The compression group exhibited a significantly greater systolic blood pressure difference (MD = 9.02, p = .02) and higher postdialysis cardiac output (MD = 1.13 L/min, p = .01) compared with the control group. Additionally, a near-significant reduction in the incidence rate of intradialytic hypotension was identified (RR = 0.73, p = .06). Conclusions: Although the evidence of this study was derived from a limited sample of six studies, it suggests that compression devices may benefit patients at high risk of intradialytic hypotension. Therefore, clinical implementation should involve careful monitoring of individual responses and adjustments to identify the optimal pneumatic compression strategy.
• 577-586
• 10.6288/TJPH.202412_43(6).113059

• Link 原著 Original Article
• 探討40個國家中青少年霸凌行為的兩項決定因素：肢體衝突與國家兇殺率的影響 Two determinants of bullying behavior among adolescents in 40 countries: physical fighting and national homicide rates
• 陳柔伊、林文旭
  Rou-Yi Chen, Wen-Hsu Lin
• 學校霸凌；暴力環境；肢體衝突；兇殺率；多層次
  bullying, violent environment, physical fighting, homicide rate, multilevel
• 目標：霸凌可能源於個人特徵(如犯罪)與社會(如暴力文化)之間影響。本研究旨以跨國視角探討探討個人肢體衝突、國家兇殺率與青少年霸凌行為之關聯。方法：納入2017/18學齡兒童健康行為調查(HBSC)，並整併2018世界衛生組織(WHO)兇殺率資料。排除缺少霸凌或飲酒調查且未記錄在WHO兇殺率國家(n = 6)，及未完整回覆變項資料之青少年(n = 21,695)後，分析樣本來自40個國家或地區約180,000名青少年(n = 179,097)。霸凌行為與肢體衝突以二分法分類(0 = 無；1 = 至少一次以上)，採用多層次羅吉斯回歸進行分析。結果：各國霸凌盛行率差異顯著(6.62% - 51.70%)。空模型顯示，青少年霸凌行為存在國家差異(ICC = 0.11)。隨機截距模型發現，霸凌行為常見於有肢體衝突之青少年(AOR = 2.96， 95% CI = 2.88-3.04)，且居住在兇殺率較高的國家也會增加霸凌行為風險(AOR = 1.22， 95% CI = 1.12-1.34)。結論：個人肢體衝突與國家兇殺率皆會影響青少年霸凌行為，針對個人和社會背景之預防措施對防止霸凌行為和創造更安全、具包容性環境非常重要。
  Objectives: Adolescent bullying may result from a combination of traits, such as delinquency, and sociocultural influences, such as a culture of violence. This study examined whether physical fighting and national homicide rates were associated with adolescent bullying using a multinational sample. Methods: Data were sourced from the 2017/2018 Health Behaviour in School-Aged Children study and linked to the 2018 World Health Organization national homicide rates. After we excluded incomplete survey responses (n = 21,695) and six countries for which data on adolescent bullying behavior or alcohol use were unavailable, we obtained a final sample involving 179,097 adolescents from 40 countries/regions. Data on bullying behaviors and physical fighting were dichotomized (0 = never, 1 = at least once) for ease of interpretation. Multilevel logistic regressions were also conducted. Results: Bullying prevalence varied significantly across countries (6.62%–51.70%). The null model revealed country-level differences in adolescent bullying behaviors (intraclass correlation coefficient = 0.11). The random intercept model indicated that adolescents who reported physical fighting had a higher likelihood of engaging in bullying behaviors (adjusted odds ratio [AOR] = 2.96, 95% confidence interval [CI] = 2.88–3.04). Living in countries with higher homicide rates was associated with an increased likelihood of engaging in bullying behaviors (AOR = 1.22, 95% CI = 1.12–1.34). Conclusions: Physical fighting and national homicide rates are risk factors for adolescent bullying. These findings highlight the requirement for intervention programs targeting both individual behaviors and broader social contexts to prevent bullying and promote safer environments.
• 587-606
• 10.6288/TJPH.202412_43(6).113067

• Link 原著 Original Article
• 不同尼古丁替代療法與六個月戒菸成功相關之實施研究 Association between different nicotine replacement therapy regimens and 6-month smoking cessation success: an implementation study
• 陳駿瑩、吳嘉玲、李商琪、郭鈞瑋、陳全裕、林靜蘭、李中一
  Chun-Ying Chen, Jia-Ling Wu, Shang-Chi Lee, Chin-Wei Kuo, Chuan-Yu Chen, Esther Ching-Lan Lin, Chung-Yi Li
• 戒菸計畫；尼古丁替代療法；戒菸治療
  smoking cessation program, nicotine replacement therapy, smoking cessation treatment
• 目標：利用我國二代戒菸服務資料進行「實施研究」，探討在真實世界中，不同尼古丁替代療法(NRT)與戒菸成功之關聯性。方法：納入2020/01/01到2022/06/30首次使用NRT之療程資料，透過傾向分數配對得到1:1:1樣本。暴露變項為單獨使用長效型(長效型)、單獨使用短效型(短效型)NRT、及長效型合併使用短效型(合併型)NRT，結果變項為六個月點戒菸成功與否，使用廣義線性估計方程式之羅吉斯迴歸。結果：納入26，604個NRT療程，六個月點戒菸成功率為19.86%。校正干擾因素後，與長效型NRT相比，短效型NRT(勝算比=1.16， 95%信賴區間：1.07-1.25)及合併型NRT(勝算比=1.21，95%信賴區間：1.12-1.31)均有較高戒菸成功勝算，然而短效型口腔吸入劑並未達統計顯著(勝算比=1.03，95%信賴區間：0.85-1.25)。年齡與NRT種類有顯著交互作用，合併型及短效型效果優於長效型，且在18-44歲使用者中更為明顯。結論：本研究結果與過去部分隨機對照試驗相同，合併型NRT效果優於長效型NRT。但不同之處在於本研究發現短效型NRT效果也優於長效型NRT，而此現象在18-44歲使用者中更為明顯。
  Objectives: To conduct an implementation study by using data from Taiwan's Second Generation Smoking Cessation Service to explore the associations between different nicotine replacement therapy (NRT) regimens and smoking cessation success in the real world. Methods: Data on initial NRT treatment sessions from January 1, 2020, to June 30, 2022, were included. Propensity score matching was applied to obtain a 1:1:1 sample. The exposure variables were three NRT types: long-acting NRT alone, short-acting NRT alone, and combined long-acting and short-acting NRT. The outcome variable was smoking cessation at the 6-month mark. Logistic regression was performed using generalized estimation equations. Results: A total of 26,604 NRT treatment sessions were included. The 6-month cessation prevalence was 19.86%. After adjustment for potential confounders, short-acting NRT alone (odds ratio [OR] = 1.16, 95% confidence interval [CI]: 1.07–1.25) and combined NRT (OR = 1.21, 95% CI: 1.12–1.31) were both associated with higher odds of cessation success when compared with long-acting NRT alone. However, the short-acting oral inhaler did not reach statistical significance (OR = 1.03, 95% CI: 0.85–1.25). A significant interaction was detected between age and NRT type; compared with long-acting NRT alone, short-acting NRT alone and combined NRT were more effective in users aged 18–44. Conclusions: The finding that combined NRT is more effective than long-acting NRT alone is consistent with the results of previous randomized controlled trials. However, this study also revealed that short-acting NRT alone is more effective than long-acting NRT alone, particularly among users aged 18–44 years. This work was funded by the Health Promotion Administration, Ministry of Health and Welfare. The content of this research may not represent the opinion of the Health Promotion Administration, Ministry of Health and Welfare.
• 607-618
• 10.6288/TJPH.202412_43(6).113069