15卷6期

• Link 原著 Original Article
• 血液透析單項成本分析之探討－以某醫學中心為例The Cost Analysis of Hemodialysis in a Medical Center
• 陳琇玲
  Hsiu-Ling Chen
• 成本分析 ； 血液透析 ； 醫學中心
  cost analysis ; hemodialysis, haemodialysis ; medical center
• 中央健康保險局有意實施洗腎定額給付制，北市某醫學中心為了確實了解透析之成本，並提供腎臟學會成本數據，以爭取合理醫療給付，乃進行血液透析單項成本分析研究，探討血液透析單項成本分析的方法，並求取該醫學中心單次血液透析之成本數據。本研究將血液透析單項成本架構細分為變動人力成本（有主治醫師、護理人員、菜事服務費），直接材料成本（有藥品、醫材），因定人力成本（有住院醫師、護理站書記、服務員、清潔服務員），間接材料成本（有口服藥、EPO分攤、及感冒藥）、檢查檢驗成本（分為新透析病患及例行透析病患檢查檢驗成本分攤）、機器設備折舊與保養費、其他支出、分攤成本等大類，並計算每一細項成本。研究結果顯示，其成本數據為每次透析成本3,767元。以保險給付每次透析4,000元，則樣本醫院有6%之利潤，遠低於一般之估計。若包含口服藥、EPO分攤、及感冒藥，則每次透析成本為3,943元，幾乎無利潤。
  The Bureau of National Health Insurance is planning to implement the case payment system for hemodialysis. Since reasonable reimbursement is possible only when actual cost data are fully incorporated, our study was conducted in a medical center in Taipei to investigate these costs. This study aimed to determine the cost per dialysis in the medical center. All possible costs related to the dialysis procedures were included and the time span was for the year 1993. Cost items collected were then divided into eight categories: (1) variable personnel. (2) fixed personnel. (3) direct materials. (4) indirect materials. (5) medical examinations and laboratory tests. (6) depreciation and maintenance. (7) overheads. and (8) allocations. First of all, variable personnel costs included those of physicians , nurses, and drug dispension related manpower. Fixed personnel, on the other hand, included residents, nursing station clerks, attendants, house-keeping staff. Direct materials included drugs and other medical supplies. Furthermore, indirect materials may involve oral drugs, EPO allocations, medicine for cough, etc. Costs originated from medical examinations and laboratory tests were calculated on a per patient basis: differentiation was further made between new patients and routine patients. As for depreciation and maintenance, overheads, and allocations, these were costs with usual accounting definitions. The results of the study showed that the cost per hemodialysis was NT3, 767 in the medical center. Comparing with insurrance payment of NT4,000 per dialysis, there was only 6% profit rate for the hospital, far away from the expectation of the administrators. If oral drugs, EPO allocations, and medicine for cough were included, the cost was raised to NT3,943 per dialysis, with almost no profit for the medical center.
• 497 - 503
• 10.6288/CJPH1996-15-06-01

• Link 原著 Original Article
• 病歷成長量及所需空間計算－以臺大醫學中心為例Estimating the Increment of Medical Records Volume and Space
• 范碧玉、劉岱瑋、 陳榮基
  Bih-Yuh Fan, Tai-Wei Liu, Rong-Chi Chen
• 病歷 ； 病歷空間 ； 病歷保存
  medical record ; medical record storage ; medical record retention
• 本研究主要目的在了解臺大醫院病歷數量的成長及所需空間，並探討影響病歷成長的相關因素。經由病歷成長數量及所需空間之估算，妥善規劃病歷空間的有效利用，並對病歷保存方法及期限提出建議。 本研究結果顯示： 1．在病歷增加張數方面，每人次門診、急診、住院病歷增加張數分別為0.82、5.24、36.55張。 2．影響門診病歷增加張數的因素中，以初複診別的影響最大。至於急診及住院病歷增加張數的影響因素方面，則以留、住院日數最重要。 3．病歷空間成長方面，全年門診、急診及住院病歷增加厚度分別為232.49、70.97、149.75公尺。 4．全年病歷厚度共增加453.21公尺，須要病歷檔案櫃132座，換算為檔案空間約36.8坪。預估下年度病歷厚度增加510.74公尺，須要病歷檔案櫃149座，換算為檔案空間約40.94坪。 由於醫療法規定：病歷至少須保存十年。且目前尚有延長至二十年之議。為確保未來病歷保存之品質，兼顧醫療院所空間成本之負擔，推廣縮影病歷或光碟病歷保存方式，並立法取得合理保障，實為當前刻不容緩之要務。
  The aim of this study was to examine the increment of medical records volume and space in National Taiwan University Hospital. Factors influencing the increment of medical records were also mentioned. Through estimating the volume increased and space occupied, we can manage our medical record space more efficiently. Some issues about the methods and duration of storage of medical records were also discussed here. Several findings were noticed: (1) The average increment of medical records for outpatient?emergency and inpatient services are 0.82?5.24?36.55 pages per visit, respectively. (2) For outpatient service, the most important factor for the increment of medical records depends on whether the patient visits first or not. Among factors influencing the increment of medical records, the most important one for emergency and inpatient services is length of stay. (3) The annual increment of medical record thickness for outpatient?emergency and inpatient services are 232.49?70.97 and 149.75 meters, respectively. (4) Total annual increment of medical record thickness is 453.21 meters which need 132 open-shelved filing closets. It occupies the space equal to 121.65 square meter. It is predicted that total annual increment of medical record thickness will be 510.74 meters next year, 149 open-shelved filing closets will occupy 135.33 square meter. Medical records must be stored legally in paper form for ten years. Since the quality of storage is questionable and the increas-ing cost of hospital space, storage of medical record in microfilms and optic disks will be potential alternatives. However, legislative approval will be the most important step.
• 504 - 516
• 10.6288/CJPH1996-15-06-02

• Link 原著 Original Article
• 我國以技術轉移建立現階段進口疫苗生產技術之成本分析Cost Analysis of Establishing the Capability of Producing MMR, DTaP, HBV, and OPV Vaccines in Taiwan
• 張博論、廖明一、 楊均梅、 何美鄉、李丞華、陳宜民(、洪其壁
  Po-Lun Chang, Ming-Yi Liau, Chun-Mei Yang, Mei-Shang Ho, Cheng-Hua Lee, Yi-Ming A. Chen, Chi-Byi Horng
• 疫苗政策 ； 疫苗自製 ； 成本分析
  Vaccine Policy ; Vaccine Production ; Cost Analysis
• 本研究從成本分析的角度與衛生決策單位的立場，評估相較於現行外購政策，我國是否值得以技術轉移方式建立麻疹／德國麻疹／腮線炎三合一疫笛(MMR)、口服小兒痳痹疫苗(OPV)、白喉／百日咳／破傷風三合一疲苗(DPT/DTaP)、及B型肝炎疫苗(HBV)的生產技術。評估的方案有四種，分別是由衛生署預防醫學研究所引進技衍生產、由民間疫苗廠引進生產、由預研所引進後轉移民間生產、與維持現狀。結果顯示政府衛生防疫單位在未來八十三至九十二年若繼續維持外購政策，對於MMR、OPV、DPT/DTaP、和HBV四種疫苗，總採購經費若以八十三年幣值為塞準，共需43.4億元。而三種自製方案對於衛生單位未來十年的相關支出，皆少於目前維持外購的方式。差距從預研所主導的減少8.9億元，到由民間自行引進的減少2.4億元。不過敏感度分析結果顯示，若未來實際技術取得成本增加或經營效率祇使得產銷費用過高，則自製方案便反而會增加衛生單位的經費支出。
  We conducted this cost-effective analysis comparing the future alternatives of procurement vs. domestic production of vaccines from the governmental perspective. Three alternatives were considered to build up domestic capacity for vaccine production: (1) strengthening the National Institute of Preventive Medicine(NIPM) of vaccine production capacity, (2) strengthening the private industry of vaccine production capacity, or (3) strengthening the private industry of vaccine production capacity, but with assistance of NIPM in research & development. Under the current baseline policy which imports vaccines from abroad, the total expenditure of purchasing MMR, OPV, DTaP, and HBV vaccines for public sector from 1994 to 2003 was calculated to be NT$ 4.34 billion in 1994-dollar. Over the incoming 10 years, all three alternatives, would result in a saving of vaccine expenditure, ranging from NT$ 0.24 billion less by the second alternative to NT$ 0.89 billion less by the first one. However, the sensitivity analysis indicates that the most important determinant factor would be the cost of technology transfer as well as that of sales & distributions of vaccine in the future which would greatly alter the results of our analysis in which higher cost might incur with the self-production of vaccine.
• 517 - 524
• 10.6288/CJPH1996-15-06-03

• Link 原著 Original Article
• 跌倒對社區老人健康生活品質的影響The Impact of Fall on Health-Related Quality of Life among the Elderly in Community
• 徐慧娟、吳淑瓊、江東亮
  Hui-Chuan Hsu, Shwu-Chong Wu, Tung-Liang Chiang
• 老人 ； 跌倒 ； 健康生活品質
  elderly ; fall ; health-related quality of life
• 本研究目的在建立路徑分析模式，探討跌倒對老年人的身體功能、心理憂鬱、與自評健康等向度的直接與間接影響。資料來源為台大公共衛生研究所吳淑瓊主持之「老人長期照護調查研究」於1992年收集之第一波資料，該研究樣本由設籍台北縣市四社區65歲以上老人抽樣而得，完訪樣本數共454人。結果發現：(1)13.7%的老人自述過去一年曾跌倒。(2)在控制人口特性與疾病症狀數後，路徑分析結果顯示跌倒對身體功能有顯著的直接影響。(3)跌倒對憂鬱和自評健康的影響主要來自間接影響，即跌倒影響身體功能，再經由身體功能影響憂鬱與自評健康。由此顯示跌倒至少對健康生活品質當中的身體功能、憂鬱、自評健康各有直接與間接影響，政策上應加強老友跌倒的防治工作。
  The purpose of this study was to propose and evaluate a path model of the effect of falls on the health-related quality of life among the community elderly. In the model, health-related quality of life was measured by physical function, depression, and self-rated health. The cross-sectional data came from 1992 Long-Term Care Survey involving 454 respondents aged 65 and over living in 4 communities around Taipei Area. The result showed (1) 13.7% of the respondents had at least one fall in the year prior to the survey; (2) After controlling demographic characteristics and self-reported chronic conditions, fall has exerted a significantly direct effect on physical function; (3) Indirect effects of fall on depression and self- rated health were found through the direct effect of fall on physical function. It showed that fall had the direct and indirect effects on physical function, depression, and self-related health. The policy on prevention of fall for the elderly should be strengthened.
• 525 - 532
• 10.6288/CJPH1996-15-06-04

• Link 原著 Original Article
• 功能評估在估計台灣社區老人長期照護需要之應用Application of Functional Assessment in Estimating Long-Term Care Need among Non-Institutionalized Elderly Adults in Taiwan
• 吳淑瓊、徐慧娟、莊媖智、 張明正
  Shwu-Chong Wu, Hui-Chuan Hsu, Ying-Chin Chuang, Ming-Chen Chang
• 日常生活活動 ； 工具性日常生活活動 ； 認知功能 ； 長期照護 ； 估計
  activities of daily living ; ins trumental activities of daily living ; cognitive functioning ; long-term care ; estimation
• 本研究設計五種功能評估標準估算台灣社區老人的長期照護需要。五種評估標準依篩選範圍從小到大依序為：(1)三項或以上ADLs障礙、(2)二項或以上ADLs障礙、(3)至少一項ADLs障礙、(4)至少一項ADLs或IADLs障礙、(5)至少一項ADLs或IADLs或認知功能障礙。對2,892位台灣65歲以上社區居家老人人口的代表性樣本進行功能評估發現，在最小篩選範圍的標準下，台灣社區老人中具三項或以上ADLs障礙且需人幫忙的重度功能障礙人數約在四萬人左右；若將功能障礙指標放到最大篩選範圍，即凡具ADLs、IADLs、或認知功能障礙且不一定需人幫忙者，則長期照護需要人數大增到27萬左右，此需要人口將於四十年後漲為目前的四倍。由此可知，台灣勢將面對老人長期照護需要暴漲的壓力。本研究因為不包含目前已經利用機構式長期療養的老人，故以上估算數字應只代表老人對居家式或社區式的長期照護的需要。
  Five various functional assessment criteria were applied in this study to estimate the size of non-institutionalized elderly population eligible for long-term care services in Taiwan. The five criteria from the most restrictive to the least restrictive were: (1) three or more ADLs disability, (2) two or more ADLs disability, (3) any ADLs disability, (4) any ADLs or IADLs disability, (5) any ADLs or IADLs or moderate cognitive impairment. Functional evaluation of an islandwide representative sample with 2,892 noninstitutional respondents aged 65 and over showed that the size of the eligible elderly population ranged from about 40,000 persons under the most restrictive disability criterion (human assistance required with three or more ADLs) to 270,000 persons if the least restrictive criterion (instrument or human assistance required with any ADLs, IADLs or moderately cognitive impairment) was applied. The estimate is going to increase 4 times 40 years later. Because the analysis was based on a sample of community elderly, the estimate derived from this study was not including the elderly who have already resided in an institution. The estimate represented the elderly population who were in need of home- or community-based long-term care.
• 533 - 545
• 10.6288/CJPH1996-15-06-05

• Link 原著 Original Article
• 孕婦接受台南市某二區域醫院羊膜腔穿刺術諮詢前後之認知與擔憂研究Exploration of Women's Knowledge and Concerns before and after Amniocentesis Counseling in Tainan
• 黃美智、吳翠雲、林秀娟
  Mei-Chin Huang, Tuesy-Yun Wu, Shio-Jean Lin
• 羊膜腔穿刺術 ； 擔憂 ； 諮詢
  amniocentesis ; concerns ; pre-amniocentesis counseling
• 本研究以自填結構性問卷追蹤40名孕婦，發現研究對象於台南市某二區域醫院接受羊膜腔穿刺術諮詢前，對此檢查之認知不足且與其擔心程度成負相關。經諮詢後呈現擔心程度減輕、認知情形大幅增加；於得知檢查結果援其認知情形則呈現有知識保留的情形。個案於接受諮詢前、後主要擔心事項包括檢查會傷及胎兒、流產、結果異常及怕痛，做完檢查後則怕傷及胎兒及擔心結果異常。 本研究之結果有助於臨床上提供給孕婦更合宜之遺傳諮詢，並更能掌握其情緒變化及考量。
  Forty women who underwent amniocentesis were administered three self-development questionnaires to explore their knowledge, concerns toward amniocentesis by genetic counseling. Subjects' knowledge about amniocentesis improved after pre-amniocentesis counseling and maintained till the results of the procedure were communicated to the women. The concern scores of subjects were significantly reduced after counseling although the items that they concerned were increased. The major concerns about amniocentesis prior to the counseling were fear of fetal injury, abnormal result of amniocentesis, miscarriage and the during the procedures performed. However, after the counseling they changed to fear of fetal injury and the results of amniocentesis. From the correlation analysis, The subjects' knowledge toward amniocentesis was related to concern level prior to counseling. The findings of this study have important implications for the delivery of pre-amniocentesis counseling for clinical practice.
• 546 - 552
• 10.6288/CJPH1996-15-06-06

• Link 原著 Original Article
• 台灣地區死亡率下降對平均壽命改變之影響Changes in Life Expectancy in Taiwan Area Due to Declines in Mortality, 1981-1990.
• 林正祥
  Cheng-Hsiang Lin
• 平均壽命 ； 死亡率 ； 競爭性死因
  life expectancy ; mortality ; competing causes of death
• 本文探討了民國70年和民國79年?台灣地區十大死因死亡率之消長對平均毒命影專之程度，摒棄了以柱必須假設死因部分去除之百分比以推算平均毒命增加之程度。利用民國70年和79年間各年齡區?中各死因之死亡率來估計部分去除率，藉此推算出十大死因死亡率之消長而對平均毒命貢獻之程度。吾等?現在此十年?，腦血管疾病的種制對國人平均毒命的增加貢默最大，另外，惡性腫瘤在60歲以前的貢獻程度不大但為正值，60歲以後則為負值，又意外災害、肺炎在15~65歲工作年齡群多為負值，而糖床病則在所有年齡層皆為負值。負值意謂這些死因之死亡率在十年?相對於其他死因之死亡率其改答之趨勢有限甚而可能忌化。吾等認為，對十大死因的防治而官，老年人之惡性腫瘤，工作年齡群之意外災害、肺炎及各年齡層之糖尿病則約要積極的加強，期能再提高國人之平均壽命。
  This study investigates the gains in life expectancy due to declines in mortality for the Taiwan population between 1981 and 1990. To substitute the traditionally assumed ”partial elimination rat” of the causes of death for figuring out the gains in life expectancy, this article uses the change of mortality rate in each age interval between 1981 and 1990 as an estimator for the partial elimination rate and computes the relative contribution of the ten leading causes of death on the gains in life expectancy in different age intervals. We find out that most of the contribution comes from Cerebrovascular disease, a small contribution from the Malignant Neoplasm before age 60, while it turns out to be negative after age 60; In addition, the contributions from Accident, Pneumonia are negative for working age group (15~65 years old) and the contribution of Diabetes is negative in overall age groups. Negative contribution means the mortality of some causes of death is getting worse during this 10 year period. Obviously, based on the standpoint of prevention and control of the ten leading causes of death in Taiwan, we must pay special attention to the Malignant Neoplasm in old age group, Accident and Pneumonia in working age group and Diabetes for all age group.
• 553 - 561
• 10.6288/CJPH1996-15-06-07

• Link 原著 Original Article
• 台灣北部地區三縣市學齡兒童行人傷害之流行病學調查研究The Epidemiology of Pedestrian Injury among School-Aged Children in Three Counties (Cities) in Northern Taiwan
• 盧成皆、史麗珠、陳端杰、麥薛提
  Sing-Kai Lo, Lai-Chu See, Ray-Jade Chen, Mark Stevenson
• 學齡兒童 ； 行人 ； 事故傷害 ； 流行病學
  school-aged children ; pedestrian ; injury ; epidemiology
• 本研究旨在探討學齡兒童行人事故傷害情況及危險因子。自83年起於北部地區三縣市（基隆市、台北縣及桃園縣）抽取國中及國小各五所，對7~15歲學童進行個案對照式調查訪問，並往事故現場觀察有關地形、環境及交通狀況等。受傷的213名個案中以男生佔多數，要生率則以小學4-6年級最高，並以往返家／學校／補習班為最普遍，下午三時至七時及暑假前複較多；事故地點則以直路、路轉角／十字路。最常見，另有百分之十的事件發生在斑馬線或人行道上。事故發生時兒童正在橫過馬路者不及一半，有不少正在走路或在路上玩耍嬉戲。傷者以四肢受傷最多，主要為裂傷、擦傷及挫傷等。肇事的交通工具以機車最多，但若與同時期註冊車輛的數目比較，則大卡車、小型貨車及計程車撞到行人的比例較高。駕駛人犬部份為男性，多為21-40歲。個案及對照之現場觀察，整體來說，個案事故現場之車流量較大，平約車速則與對照組現場與明顯差異。此外，個案現場的路邊停車及攤販數目較多，而馬路兩邊都有人行道的比率卻低於對照現場。
  To study the epidemiology of pedestrian injuries, 213 school children aged 7-15 who had been injured as a pedestrian within 12 months before interview, together with the same number of controls matched on gender and class, were interviewed in detail. The incident sites and sites along the routes where controls have to take for similar purposes were also inspected. Male, grade 4-6 students were found to be at higher risk. Most injuries occurred while the students were traveling between home, school and supplementary classes. More than 1/3 of the incidents happened between 3:00 and 7:00 pm, and 47% during the summer months. Most injuries occurred in straight roads or near street corners, and 10% of the collisions occurred on zebra crossings or on sidewalks. At the time of the collision, less than half of the children were crossing the road. A third of them were just walking but some were playing in the street. Injuries were mainly to the four limbs. Motor-cycles were the most common type of colliding vehicle reported. However, when compared to the number of registered vehicles, there were significantly more trucks, light commercial vans and taxis involved in these incidents. Drivers were primarily males of age 21-40. The volume of traffic was marginally heavier at case sites, but average speeds of vehicles were similar between case and control sites. There were more illegal parking and venders on case sites. On the other hand, the proportion having pedestrian side-walks in both sides of the streets was higher in control sites.
• 562 - 571
• 10.6288/CJPH1996-15-06-08