17卷5期

• Link 公衛論壇 Public Health Forum
• 對健康保險多元化保險人體制的質疑對健康保險多元化保險人體制的質疑
• 宋鴻樟
  Fung-Chung Sung
• 無
  none
• 無
  none
• 371 - 372
• 10.6288/CJPH1998-17-05-01

• Link 綜論 Review Article
• 風險校正：健康保險市場的效率與公平之關鍵Risk Adjustment: A Key to Efficiency and Equity in the Health Insurance Market
• 張睿詒、江東亮
  Ray-E Chang, Tung-Liang Chiang
• 風險校正 ； 健康保險市場 ； 健康保險改革
  risk adjustment ; health insurance market ; health care reforms
• 在傳統的健康保險市場，醫療效率與就醫公平是二個相互衝突的目標，多年來學者與政策制定者均致力於研究如何設計兼顧公平與效率的健康照護制度。近期在解決此一難題的發展，是建立於風險校正的設計。理論上，風險校正藉由風險平?基金的機制使保險人得收取風險計價之保費，而被保險人則是依其財務能力繳交保費。目前，一些西方國家已將風險校正應用於其市場導向之醫療改革上；台灣值此全民健保朝多元化保險人體制發展之際，實有必要對風險校正加以深入探討。在檢視風險校正理論以及國際實施風險校正經驗之後建議：(1)經修正後之荷蘭風險校正模式或可適合台灣全民健保體制改革之需要，以及(2)台灣應立即加強風險校正相關議題之本土研究，以為制訂醫療改革政策之參考。
  Efficiency and equity are conflicting objectives under the traditional health insurance market, and for many years researchers and policy makers have striven to achieve both goals at the same time. Recent developments to resolve this dichotomy have been based on risk adjustment. In principle, risk adjustment works through the mechanism of equalization fund so that health plans are able to collect risk-adjusted premiums while the contribution of the insured is in accordance with their abilities to pay. Some Western nations have already introduced risk adjustment to their market-oriented health care reforms. In Taiwan, where market-oriented health insurance proposals are under consideration by the government, it is timely to open the debate on the issue of risk adjustment prior to being implemented. After reviewing the theory of risk adjustment and international experiences on the application of risk adjustment, we recommend: (1) Netherlands' model may be modifiable and adapted to meet the need of Taiwan's health care reform, and (2) more indigenous efforts should be immediately undertaken to study issues related to the introduction of risk adjustment in Taiwan.
• 373 - 380
• 10.6288/CJPH1998-17-05-02

• Link 綜論 Review Article
• 青少女之生育問题Adolescent Childbearing in Taiwan
• 李孟智
  Meng-Chih Lee
• 青少年 ； 生育 ； 性
  adolescents ; childbearing ; sexuality
• 台灣15~19歲青少女年齡別生育率在近十年皆維持在千分之17左右，居亞洲已開發國東之冠，而1994年相同年齡層有偶青少女年齡別生育率更超越美國，高達千分之726，乃因決定繼續懷孕的青少女中85%會在生產前結婚所致。台灣既往研究結果顯示：青少女懷孕會導致多重不良後果；包括非志願結婚、婚姻不穩定、在青少年期重複生育，以及高比率的低出生體重兒、早產兒、及新生兒死亡率。本土研究亦顯示；青少女生育之相關因素包括性知識不足而性態度和性行為卻日趨開放，對青少年之避孕服務不普及，青少女家庭屬低社會經濟階層，以及青少女過早離家在外居住。此外，台灣青少女之男伴年齡普遍偏高且教育程度偏低，其相互結合進而生育的過程及機轉值得進一步探討，其中性侵犯為可能的原因之一。青少女生育防制之道在於加強政府組織及民間組織之性教育功能，提供青少年避孕服務和生涯發展輔導，及對高危險群施予重點防制。若青少年性行為的確不可能禁絕，則避免其懷孕生子應為務實的努力方向。
  In Taiwan, the age-specific fertility rate for adolescent women aged 15-19 years has remained at 17/1000 in recent 10 years, which is the highest among developed countries in Asia. Moreover, There was a surprisingly high age-specific fertility rate for married women aged 15-19 years at 726/1000 in 1994, which was even higher than that of the United States. This figure could be explained by the fact that more than 85% of pregnant adolescents who decided to carry their pregnancy to term got married prior to delivery. Previous studies in Taiwan indicated that adolescent childbearing causes a lot of adverse outcomes including unwanted and unstable marriage, repeated childbearing during adolescence, and increased risks of having low birth weight and preterm births, and neonatal mortality. Studies in Taiwan also showed that adolescent childbearing is associated with their poor knowledge but open attitude and behavior on sexuality, inadequate contraceptive services for the adolescents in need, and low socioeconomic status of adolescents families. In addition, many fathers of infants born to adolescent women were adults with a low educational level. The large age difference between the adolescent mothers and their partners could be due to sexual assault. The effective strategies for adolescent childbearing prevention range from sex education to the direct provision of contraceptive supplies, and to life options programs, especially for the adolescents with high risk. It is believed that reducing the incidence of adolescent childbearing is more important and practical than prohibiting adolescent sexual activity.
• 381 - 387
• 10.6288/CJPH1998-17-05-03

• Link 原著 Original Article
• 臺灣醫療區跨區住院比例之變遷，1985-1995Changes in the Proportion of cross-region Admissions in Taiwan, 1985-1995
• 洪維河、鄭守夏、張睿詒、江東亮
  Wei-Her Hong, Shou-Hsia Gheng, Ray-E Chang, Tung-Liang Chiang
• 醫療網 ； 跨區住院 ； 計畫評估
  medical care network ; cross-region admission ; program evaluation
• 自1985年衛生署推動醫療網計畫以來，不但資源缺乏醫療區的醫院設施已明顯增加，而且醫院病床地理分布不均的現象亦不再惡化。本研究旨在以跨區住院比例為指標，檢視過去十年來住診可近性的改變情形。本研究假設跨區住院比例會隨著醫院病床供給及地理分布情形之改善而降低；研究資料則取自衛生署傷病調查資料庫、內政部臺閔地區人口統計，以及其他官方出版品。研究結果顯示，(l)1985到1995年間，雖然全國跨區比例已從19.9%降低至17.9%，但醫療區跨區住院比例的變異係數則從50.0%增加為57.9%；(2)對任一研究年度而言，跨區住院比例均與人口密度存在弱相關，與醫院病床供給存在強相關；(3)控制醫療區的區域醫院和醫學中心家數後，跨區住院比例與人口密度和醫院病床供給的相關變為不顯著；以及(4)跨區住院比例的改變與人。密度和醫院病床供給的增加，呈現弱負相關。根據以上結果，本研究建議衛生政策必須考慮區域醫院與醫學中心的角色，以改善臺灣住診服務的可近性。
  Since the implementation of the Medical Care Network program in 1985, the supply of hospital facilities in disadvantaged medical regions has substantially increased and the geographic distribution of hospital beds in Taiwan has been improved. This study aims to examine changes in access to inpatient care as measured by the proportion of cross-region admissions for the last decade. It was hypothesized that the proportion of cross-region admissions has decreased following the improvement in the supply and geographic distribution of hospital beds. The data for the analysis came from Hospital Discharge Surveys, Demographic Fact Books, and other governmental publications. The results of this study showed that: (1) Between 1985 and 1995 regional differentials in the proportion of cross-region admissions in terms of coefficient of variation have increased from 50.0% to 57.9% though the national proportion of cross-region admissions has slightly decreased from 19.9% to 17.9%; (2) For each study year the proportion of cross-region admissions was weakly associated with population density but strongly associated with the supply of hospital beds; (3) After controlling the number of regional hospitals and medical centers in a region, the proportion of cross-region admissions had little to do with population density and supply of hospital beds; and (4) Change in the proportion of cross-region admissions was negatively and weakly associated with increasing population density and increasing supply of hospital beds. This study thus concludes that the important role of regional hospitals and medical centers should be well taken into account in order to improve geographic access to hospital care in the future.
• 388 - 394
• 10.6288/CJPH1998-17-05-04

• Link 原著 Original Article
• 病人候診時間之模擬研究－以某醫學中心家庭醫學科為例Using Simulation Method for Waiting Time analysis-take Family Medicine Deparement of a Medical Center as an Example
• 蘇喜、李敏禎
  Syi Su, Ming-Gen Lee
• 門診 ； 等候 ； 模擬
  outpatient department ; waiting time ; simulation
• 本研究以一家醫院中心的家庭醫學科為研究場所，藉由現場時間的記錄，瞭解病人實際等候的狀況，經由看診作業模式的建立，擬改善候診時間的問題，經模擬後，瞭解各種改善方案實施後的結果，並據以建議可改善的方案。本研究實料蒐集的時間有二次，第一次是1994年12月19日至24日收集初診診間（初診病人）的現場時間，第二次是1995年l月12日至24日收集一般診間（複診病人）的現場時間。經模擬後，研究結果發現可改善的方案是：(1)設定醫師的看診量；(2)縮短預約病人到診的間隔時間；(3)提昇預約比率；(4)減少病人遲到的比率。在不改變看診作業及增加人力、設備成本的情況，可以做以上的改善。
  This research takes the family medicine department of a medical center as the subject. Onsite observation of outpatient operation was conducted to explore the basic parameters and statistics that could be lent to simulation experiments. Data were collected in two periods. The first run was conducted between Dec. 19-24, 1994 for first-visit patients. The second run was conducted between Jan. 12-24, 1995 for repeated-visit patients. Simulation analysis was performed to describe the actual situation and to explore potential improvement schemes. The following alternatives were found to be helpful in improving the outpatient departments operation: (1) Setting a maximum amount of patient visits for each section. (2) Lessening the interarrival time for pre-registration patients. (3) Increasing the pre-registration rate. (4) Discouraging patients from arriving late.
• 395 - 403
• 10.6288/CJPH1998-17-05-05

• Link 原著 Original Article
• 影響自然生產醫療費用之相關因素研究－以某軍方教學醫院為例A Study on the Factors Associated with Normal Delivery Medical expenses-a Case Study at a Military Teaching Hospital
• 溫信財、陳立昇、陳惟華、高森永
  Hsyien-Chia Wen, Lih-Sheng Chen, Wei-Hwa Chen, Sen-Yeong Kao
• 論病例計酬 ； 論量計酬 ； 自然生產
  case payment ; fee for service ; normal delivery
• 全民健保於84年3月1日起實施，且隨即在當年7月1日要求各級醫院之「自然生產」個案，須以「論病例計酬」方式中報，此舉顯示健保局嘗試將醫療費用支付方式，從原先之「論量計酬」改變為「論件計酬」前瞻性付費之全圖，當醫療給付不再是以往的「多做多得」時，對產科醫師、醫務管理及費用申報單位均有相當大的衝擊。醫院如何在控制醫療支出下，提供適當的服務品質，是一大挑戰。本研究收集某教學醫院產科84年5月至85年4月自然生產555名產婦之費用申報資料，並有以下發現，(1)在不同身份別產婦住院費用及住院日數之比較上，軍眷均高於健保，且達統計上之顯著意義，但自84年12月以後已有明顯下降。(2)產婦之住院費用及住院天數會受年齡影響，且以40歲以上產婦之平均值最高。(3)某些醫師會因產婦身份不同而有診療行為之差異。(4)住院費用之主要影響因素為：住院天數、代號為4、6、9、15之醫師，其解釋能力R square值為0.6092。(5)住院費用高於「論病例計酬」支付金額之原因與產婦之診斷、住院天數、使用無痛分娩、特殊檢查及用藥等變項有關。
  The National Health Insurance (NHI) was implemented in Taiwan on March 1, 1995. The Bureau of NHI later requested all hospitals’ normal deliveries be paid by case payment afetr July 1, 1995. This shows that the Bureau of NHI wants to change the ”Fee for Service” payment system to the Prospective Payment System (PPS). Maintaining quality of care with a set cost will be a challenge of obstetricians and hospital administrators. We collected and analyzed the expenses of 555 wowen who delivered babies at a military teaching hospital from May, 1995 to April, 1996, and found: (1) Military dependents total expense were higher and length of stay (LOS) was longer than NHI insured. (2) The woman's age affects the total expenses and LOS. (3) Some physicians medical behavior was influencd by the woman's identity. (4) According to the multiple regression that LOS, Doctor.4, Doctor.6, Doctor.9, Doctor. 15 are important factors that effect total expenses. (5) The reasons that the woman's expenses are higher than the NHI case payment were attributed to diagnoses, LOS, epidural anesthesia, special exams and drugs.
• 404 - 411
• 10.6288/CJPH1998-17-05-06

• Link 原著 Original Article
• 影響居家癌病患者家庭照顧者需要因素之研究Needs among Family Caregivers of Cancer Patients Who Lived at Home
• 陳惠津、李怡娟、吳肖琪
  Heuy-Jin Chen, I-Chuan Li, Shao-Chi Wu
• 居家照護 ； 癌病 ； 照顧者 ； 需要 ；
  home care ; cancer ; caregivers ; needs
• 為能瞭解癌病患者家庭照顧者之需要及其影響因素，本研究以台北二所區域以上之醫院癌症（腫瘤）治療中心，在民國85年4月29日至5月28日接受門診治療之癌病患者其家庭照顧者為對象，採結構式問卷面訪，共訪樣本115人。結果發現六項家屬照顧需要中，其重要性依次為資訊、協助照顧病人、靈性、心理、個人及家務處理。由複?歸分析的結果姿現息者教育程度愈高、照顧者本身年齡愈輕、照顧者有宗教信仰者，照顧者之總需要愈高。息者為放射線治療者、照顧者年齡愈輕、照顧者教育程度愈高、且有信仰者其對資訊的需要較高。家務處理需要與治療狀況、照顧者年齡及與患者之關係有關。協助照顧病人需要方面與患者教育程度、癌病轉移情形、照顧者性別、年齡、與信仰有關。個人需要及心理需要，皆受照顧者年齡及信仰影響。在靈性需要方面則僅受照顧者是否有宗教信仰影響。建議未來醫療供給者能針對息者與家屬不同的特性，提供不同需要上的協助。
  The purpose of this study was to describe the needs of caregivers of cancer patients who lived at home. Subjects were from two out-patients cancer departments at two regional hospitals in metropolitan Taipei. We selected 115 caregivers of cancer patients. A structured questionnaire was used to collect data from Apr 29 to May 281996. The research results revealed the following six dimensions of needs for cancer patients: information needs, patient care needs, spiritual needs, psychological needs, personal needs and household needs. The results of multiple regression analysis indicated that overall caregiver needs were higher in cancer patients with higher educational level, younger caregivers and caregivers with religious beliefs. In the information needs dimension, higher caregivers' needs were associated with patients receiving radiotherapy, younger caregivers, caregivers with a higher educational level, and caregivers with religious beliefs, Household needs had significant correlation with the cancer patients' radiotherapy and chemical therapy, the caregivers' age and the relationship between patients and caregivers. Patient care needs had significant correlation with the patients' educational level, cancer metastasis, and caregivers' gender, age and religious beliefs. Personal needs and psychological needs were influenced by caregivers' age and religious beliefs. Spiritual needs were influenced by caregivers' religious beliefs. Recommendations are that health care providers consider the different needs based on the characteristics of patients and caregivers addressed by this study. Results indicate that caregivers with lower educational levels demands a special level of concern and assistance by the health care delivery system.
• 412 - 422
• 10.6288/CJPH1998-17-05-07

• Link 原著 Original Article
• 喪偶對社區老人身體、精神及社會功能之影響The Effect of Widowhood on Physical, Mental, and Social Functioning of the Community Elderly
• 邱亨嘉、謝穎慧、陳正宗
  Herng-Chia Chiu, Ying-Hui Hsieh, Cheng-Chung Chen
• 喪偶 ； 老人 ； 健康狀況 ； 功能評估 ； 世代研究
  widowhood ; elderly ; health status ; functional assessment ; cohort study
• 本研究之主要目的在檢視喪偶事件對於老人健康的影響，及其影響程度是否因喪偶時間長短而有差異。本研究採用縱貫性世代研究法；測量工具為中文版多元功能評估問卷(CMFAQ)；共有511社區老人成功完成三個時間點之訪問。比較喪偶組與非喪偶組發現，其在簡式精神量表評分、自覺精神健康及抓單程度三項功能指標，兩組在喪偶一年內呈現統計顯著差異；然除孤單程度外，兩組在喪偶後第三年並無顯著差異。另，僅針對喪偶一組之功能變化進行探討，結果發現喪偶者在喪偶一年內，其自覺身體健康狀況變差且覺得較孤單；但在喪偶後第三年該效應並無統計顯著差異。本研究發現喪偶事件的確影響社區老人之身體、心理以及社會功能：且此影響程度隨時間而遞減。故建議對於剛喪偶者，建立相關之社會心理支持系統，以協助減少該事件對喪偶者身心之影響。
  The major purpose of this study is to examine the effect of widowhood on health status of the community elderly; furthermore, to explore the time effect on health status of the widowed group. A panel cohort study was conducted; the measurement instrument was the Chinese-version Multidimensional Functional Assessment Questionnaire (CMFAQ). In total, 511 community elderly were interviewed through three time periods (1994, 1995, 1997). The results indicated that the widowed and non-widowed groups were statistically different in the score of Short Psychiatric Evaluation Schedule (SPES), perceived mental health status, and the degree of loneliness at 1995. However, the found significant differences between the two groups were declined from 1995 to 1997, except the degree of loneliness. Focusing on the widowed group only, the widowed elderly perceived worse physical health status and felt lonely more often within the first year of widowhood 1996; however, such findings were not found at 1997. In conclusion, the findings indicate the significant effects of widowhood on physical, mental, and social functioning of the community elderly. However, the effects of widowhood were decreased with the time. The present study suggests more psychosocial supportive programs should be developed to minimize the effect of widowhood on the community elderly.
• 423 - 431
• 10.6288/CJPH1998-17-05-08

• Link 研究紀要 Research Brief
• 臺北市發展遲緩兒童早期療育醫療資源調查Medical Resources for Early Intervention in Children with Developmental Delays in Taipei City
• 邱怡玟、黃秀梨
  Yi-Wen Chiu, Hsiu-Li Huang
• 發展遲緩 ； 早期療育
  children with developmental delay ; early intervention
• 發展遲緩兒童的早期療育應包括治療及特殊教育的早期介入二部份，本研究的目的在調查台北市各醫療院所發展遲緩兒童早期療育資源的現況，從通報、鑑定、療育三方面著手，以期能作為日後規劃早期療育資源網路的參考。本研究結果發現：台北市目前尚無嚴謹而完整的通報及轉介服務系統，85.3%的醫療院所願意在發現發展遲緩兒童時進行通報；41.2%的醫院依各縣市政府社會局（課）之殘障鑑定表提供發展遲緩兒童之殘障鑑定工作，但僅有11.8%的醫療院所提供發展遲緩兒童之整體性專業診斷與評估，而近九成的醫院無專門負責發展遲緩兒童治療及復健的部門及人員。
  Early intervention in children with developmental delays should include both treatment and special education. The purpose of this study was to survey the medical resources for early intervention in developmentally delayed children in Taipei City. The findings can be used as a reference by health authorities to formulate proper resources for early intervention against developmental delay. The results indicate that there are still very few resources for early intervention in Taipei City. Of the hospitals investigated, 85.3% indicated that they would take action to refer developmentally delayed children in the future, 41.2% offered handicap identification by using the handicap identification form from the Bureau of Social Affairs, and only 11.8% offered holistic review for developmentally delayed children. Nearly 90% of hospitals have no specific rehabilitation departments and staffs for developmentally delayed children.
• 432 - 437
• 10.6288/CJPH1998-17-05-09