25卷1期

• Link 綜論 Review Article
• 生物有效性體外試驗應用於健康風險評估之問題與展望Problems and Perspectives in the Application of Gastrointestinal Bioavailability in-vitro Test to Health Risk Assessment
• 江舟峰、張芳華、許惠悰
  Chow-Feng Chiang, Fang-Hua Chang, Hui-Tsung Hsu
• 絕對生物有效性係數 ； 相對生物有效性係數 ； 體外試驗 ； 體內試驗 ； 風險評估
  absolute bioavailability factor ABF ; relative bioavailability factor RBF ; in-vitro test ; in-vivo test ; risk assessment
• 本文首先闡述絕對生物有效性及相對生物有效性之意義及各種計算公式，接著評析1992-2003年體外生物試驗的重要發展沿革及成果，特別著重不同試驗程序及操作參數比較。本研究建議修改反應槽設計、攪拌方式及溫控設備，以避免開放系統的揮發逸散，並建議評估一階段胃相試驗程序，以簡化操作程序。試驗參數如：樣品前處理、溫度、酵素添加量、pH值與反應時間等，經過歷年的研究，雖然已漸趨一致，但本研究發現仍待釐清的三個問題為：是否應控制氧化還原電位？是否應模擬胃環境之蠕動強度？是否應控制胃之排空比？本研究另發現，不同體外試驗方法仍難相互評比，主要是因為並未建立系統品管基準，本文建議四種管制樣品：空白管制、重複管制、代理參考物質(surrogate reference material，SRM)管制及介質管制(matrix control)，期盼藉由後續實証研究，建立簡化且有效的評估程序，以應用於土壤改良劑、受污土壤、食品、中藥、牙材、玩具等健康風險評估。
  As a methodological review, this paper begins by introducing the concepts and definitions of absolute bioavailability factor (ABF) and relative bioavailability factor (RBF) and the relevant mathematical equations for the bioavailability test of gastrointestinal function. The critical literature review was then concentrated on the historical development of in-vitro test and important outcomes reported during 1992-2003. Based on this review, we suggest modifying the reactor design, mixing method, and temperature control to reduce fugitive emission from the unsealed reactor. We also identified three key issues for the in-vitro test: the control of oxidation-reduction potential (ORP), the simulation of actual mixing intensity in the stomach, and the range of liquid-to-solid ratio. This study further concludes that a set of systematic quality control criteria must be established for the in-vitro test. Four types of control sample are available for quality control test in parallel with the test sample: blank materials, replicated sample, surrogate reference material (SRM), and matrix control. The ultimate goal of this study is to develop a simple but reliable in-vitro bioavailability method for assessing the potential risk of waste recycling materials, such as soil conditioners, contaminated soil, food, Chinese herbs, orthodontic appliances, and toys.
• 1-10
• 10.6288/TJPH2006-25-01-01

• Link 原著 Original Article
• RU486合法化過程意識型態論述分析The Ideological Narratives on the Legitimating Process of RU486 in Taiwan
• 徐佳青、黃文鴻
  Chia-Ching Hsu, Weng-Foung Huang
• 利益團體 ； RU486 ； 合法化 ； 意識型態
  interest groups ; RU486 ; regulatory approval ; ideological narratives
• 目標：RU486在台灣合法化過程，利益團體（婦產科醫學會、藥師公會與藥商）或女權團體扮演不同的角色，本文主要探討在RU486合法化過程中，相關利益或公益團體在意識型態方面的論證觀點。方法：採用質性研究參與RU486合法化過程之關鍵知情人士之訪談，歸納整理相關的訪談研究資料。結果：在RU486合法化過程中，利益相關團體與政府部門在意識形態衝突中包含了專業權威與自主性衝突、身體自主權衝突、對墮胎的認知衝突。墮胎概念上各利益團體與政府都欠缺對討論生命倫理的嚴謹態度；除婦女團體反駁墮胎污名化的現象外，相關團體都有污名化墮胎母體的現象；婦女團體主張國家應尊重其身體自主權，然官方卻仍主張應保留配偶的決定權；而婦女主張身體自主權之概念，也與醫師團體要求專業監控女性服用RU486墮胎有概念衝突。此外，RU486桃戰醫師傳統墮胎技術，使其專業權威受到威脅；而藥師捍衛專業調劑權，形成醫藥專業者間專業自主性之衝突；官方在RU486管理上也因其藥政專業認知與法律解釋而和醫師團體有所不同。結論：任何公共政策的合法化過程，均應建立制度化的利益團體參與和協商管道，擴大與利益相關者、利益團體與政府之對話空間，尊重不同團體彼此之專業自主，重新檢討優生保健法，徹底解決RU486可能誤用問題，並增加墮胎社會學與RU486使用的進階研究。
  Objectives: The interest groups played different roles in the regulatory approval process of the abortion drug RU486 in Taiwan. This article explores the ideological narratives of the interest groups during the RU486 legitimating process. Methods: Qualitative research method was adopted by in-depth interviewing key informants involved in the legitimating process and combined to synthesize this data. Results: The ideological conflicts of RU486 legitimating process among government regulatory agencies and interest groups include ideological conflicts on abortion, conflicts between professional authority and autonomy, and conflicts in body autonomy. On the concept of abortion, all interest groups lack strict attitudes toward the right and ethics to life, and, except for women's rights group, have generally a stigma about on abortion. The women's rights group advocates the state should respect women's body autonomy, which is contrary to the official position of reserving such right to husbands. The body autonomy advocated by the women's rights group is contrary to professional dominance of RU486 use by medical doctors. In addition, RU486 poses a threat to the traditional surgical procedure of abortion, and henceforth threatens the authority of the medical profession. The dispensing of RU486 incurred another professional conflict between the pharmacy profession and medical profession. The health authorities also have different perception and legal interpretation on RU486 administration from the medical profession. Conclusions: Transparent and systemic participation and negotiation channels should be established for any public policy such as RU486 legitimating process; government agencies should expand opportunities for dialogue with interest groups; competing interest groups should mutually respect professional autonomy. Finally, it is recommended that the Genetic Health Law governing abortion should be extensively amended in order to solve the problem of illegal use of RU486; research on the sociology on abortion and RU486 use are also suggested.
• 11-25
• 10.6288/TJPH2006-25-01-02

• Link 原著 Original Article
• 同儕資訊回饋與內科醫師開立TG檢驗次數之關係：一個探索性研究The Relationship between Peer Comparison Feedback and TG Test Ordering among Internists: An Exploratory Study
• 陳端容、鍾國彪、吳麗竹、曾靜瑤、張金堅
  Duan-Rung Chen, Kuo-Piao Chung, Li-Chu Wu, Ching-Yao Tseng, Chin-Chien Chang
• 醫師 ； 同儕比較 ； 資訊回饋 ； 開立TG檢驗行為
  physicians ; peer comparison ; information feedback ; test-ordering behaviors
• 目標：了解同儕資訊回饋對醫師開立TG（三酸甘油脂）檢驗的影響。方法：選取內科共18位門診看診醫師，隨機分派各9位醫師進入實驗組或與對照組。於92年8月起到12月，進行4次資訊回饋，資訊內容為該月門診平約每百張處方箋開立TG次數，將每位醫師開立檢驗的次數依序排列於單張報表中。控制組醫師則未接受任何資訊回饋。以介入前實驗組醫師的門診處方資料（91年12月到92年3月及92年7月與8月）為回饋前的對照基線資料。並於實驗介入結束後半年（93年6月／8月），對實驗組醫師進行深入訪談，以暸解其對實驗介入的主觀看法。結果：實驗介入後，實驗組與對照組醫師平均每百張門診處方箋開立TG檢驗次數無統計顯著差異，但實驗組醫師在實驗介入後，開立TG檢驗次數有降低趨勢，介入後平均值較介入前減少0.134，對照組則有上升趨勢，開立TG檢驗次數較之前平均增加0.504次，與文獻結果符合。就個別醫師的訪談結果，在回饋前檢驗次數平均值偏高的醫師，回饋後檢驗次數平均值則呈下降趨勢，而回饋前檢驗次數平均值偏低的醫師，回饋後檢驗次數平均值則呈上升趨勢，同儕資訊對位於極端值的醫師有影響，支持社會比較理論。醫師對同儕資訊回饋的內容較關切，多數醫師(67%)亦肯定同儕資訊回饋對醫師行為可能產生影響。結論：同儕資訊回饋是否可以做為修正醫師行為的方法，其合理的操作方式或比較基準需要進一步探討。
  Objective: The purpose of this study is to investigate the effects of peer comparison feedback on changing TG test ordering among internists in a teaching hospital. Methods: A quasi-randomized time series controlled trial was conducted. Eighteen physicians were randomly assigned into the experimental and control groups. The experiment was conducted during a period of six months. In-depth interviews with six physicians in the experimental group were carried out afterwards. Results: The results indicate that physicians in the experimental and control groups show no significant difference on the average counts of ordering TG tests per 100 orders. Physicians in the experimental group show a slight decrease in the average counts of ordering TG tests per 100 orders, yet physicians in the control group show otherwise. In-depth interviews show that physicians who have relatively higher or lower average counts of ordering TG tests tend to change their behaviors after intervention. The results support the social comparison arguments. Physicians interviewed indicate positive attitudes toward the effect of peer comparison information feedback on changing physician behaviors, yet show more concerns about the information from feedback. Conclusion: More studies are needed to determine whether or not peer comparison feedback can be used to change physician behaviors.
• 26 - 36
• 10.6288/TJPH2006-25-01-03

• Link 原著 Original Article
• 居家服務使用之相關因素研究Factors Associated with the Use of Home Care Services
• 紀玫如、莊坤洋、吳振龍、吳淑瓊
  Mei-Ju Chi, Kun-Yang Chuang, Chen-Long Wu, Shwu-Chong Wu
• 居家服務 ； 服務利用
  home care ; utilization
• 目標：為檢驗居家服務需要者使用居家服務的影響因素。方法：本研究對象選自「建構長期照護體系先導計畫」實驗社區中有居家服務需要之個案，91年1月到92年2月間共有657名；再以自擬結構式問卷經電話訪問收集資料，最後取得有效樣本數463名個案進行分析。其中由自己決定是否使用服務者178名，由家人決定者285名，以邏輯斯複迴歸分別對這兩類樣本進行相關因素之檢驗分析。結果：全部分析樣本中有44.5%的個案有使用居家服務。對居家服務的預期效用和兩類樣本使用居家服務顯著相關，認為效用高者使用的意願機會較高（自己決定樣本之勝算比為7.53，95%CI為3.20-17.75；家人決定樣本之勝算比為9.54，95%CI為4.87-18.68）；另外在家人決定的樣本中，失能程度越嚴重者（勝算比為2.32，95%CI為1.00-5.43）越會去使用服務；照顧觀念越傳統者（勝算比為0.46，95%CI為0.18-0.94）則越不願意使用服務。結論：對服務的預期效用和照顧觀念是民眾決定是否使用服務的重要相關因素，未來政府推動相關政策時可加強此一部份的宣導和規劃。
  Objective: To examine the effects on home care services utilization by the needy. Method: A total of 657 homecare-needed from the experimental-community of ”Pilot Program for the Development of Long Term Care System” were interviewed by constructed-questionnaire on telephone, and 463 subjects were qualified and completed finally. All subjects were the decision maker of the services use and we separated them into 2 models (”self-decided” were 178 and ”family-decided” were 285) to analyze. Results: There were 44.5% of respondents who had used homecare. Logistic regression showed that, after controlling for other variables, the expect-utility was the significant factor in both models (OR of self-decided=7.53, 95% CI=3.20-17.75; OR of family-decided=9.54, 95%CI=4.87-18.68). Otherwise, more ADL (activity of daily living) disability (OR=2.32, 95%CI=1.00-5.43) and less effect on filial piety (OR=0.46, 95%CI=0.18-0.94) were more likely to use in ”family-decided” model. Conclusions: Expected-utility of services and filial piety are two important factors associated with the use of homecare. Our government should enhance the programming and information when promoting relative long-term care policy.
• 37 - 48
• 10.6288/TJPH2006-25-01-04

• Link 原著 Original Article
• 醫院員工與責任中心制度：分析層級程序法之應用Hospital Staff and Responsibility Center System: Using the AHP Method
• 邱紋絹、 張雅婷、洪燕妮、譚醒朝
  Wun-Jyan Ciou, Ya-Ting Chang, Yen-Ni Hung, Sing-Chew Tam
• 醫院管理 ； 責任中心制度 ； 分析層級程序法
  Hospital management ; Responsibility center system ; Analytical Hierarchy Process
• 目標：責任中心制度是醫院執行管理控制最有效的工具之一，本研究期以實證調查瞭解醫院內不同屬性成員對於責任中心制度實施要件及可行方案之重視程度。方法：本研究應用分析層級程序法(AHP)建立本研究層級架構與問卷，包括責任中心制度六大實施要件與二十二項可行方案，對國內某醫學中心之一、二級主管進行調查分析。結果：共發出157份，回收86份，回收率為54.78%，以84份有效問卷進行分析。在實施要件之重要性排序，不同屬性成員均認同以「績效指標構面」為最重要，但對其他實施要件之重視程度則較不一效。在二十二個可行方案重要程度之整體評估方面，不同屬性成員均認同以「以財務屬性為獎勵」為最重要，而「以實際發生數字與預算做比較為指標」則為第二重要的可行方案，對其他方案則較無一效的看法。結論：本研究發現不同屬性成員對於責任中心制度建置內容有不同的重視程度，此結果可提醒醫療機構在建立責任中心制度時，應考慮將不同屬性部門意見納入制度設計中。
  Objectives: The responsibility center system is one of the valuable managerial techniques for hospital administrators to enhance cost constraint and allocate resources effectively. The purpose of this research is to figure out the viewpoints of different attribute personnel regarding the priority factors in implementing the responsibility center system at one teaching hospital. The analytical results of the critical factors not only provide a reference for this sampling hospital while revising the system but also serve as a reference for other hospitals to ensure the responsibility center system is implemented smoothly. Method: We developed the questionnaire by using the Analytical Hierarchy Process and the questionnaire is composed of 6 critical factors and 22 sub-alternatives. The opinions from department heads of the selected hospital are gathered. Results: 157 questionnaires were delivered and the response rate was 54.78%. Altogether, 84 valid questionnaires were analyzed. The survey data shows that both medical and administrative staff, rank as the first priority of critical factors as ”Performance Indicators Aspect” and the top two sub- alternatives as ”Financial Reward” and ”Performance Indicator-Actual amount vs. Budget” in implementing the responsibility center system. Nevertheless, there were no consensuses on the rankings of other critical factors and sub-alternatives between medical and administrative staff. Conclusion: The result of this study pointed out that the different attribute personnel in a hospital would pay attention to different aspects of the responsibility center system. This finding suggested that opinions from those who are in different departments of a hospital should be taken into consideration while planning or revising the responsibility center system.
• 49 - 57
• 10.6288/TJPH2006-25-01-05

• Link 原著 Original Article
• 全民健保糖尿病門診問題處方之分析－以北台灣為中心之研究Inappropriate Prescriptions Issued to Ambulatory Diabetic Patients in National Health Insurance-A Study Based on Northern Taiwan
• 高淑真、李玉春、黃文鴻、李龍騰
  Su-Cheng Kao, Yu-Chun Lee, Weng-Foung Huang, Long-Ten Lee
• 糖尿病 ； 健保門診 ； 問題處方
  Diabetic mellitus ; NHI ambulatory visits ; inappropriate prescriptions
• 目標：糖尿病病患常使用多重藥物，本研究探討健保糖尿病門診病人可能存在的問題處方。方法：採次級資料分析，以健保局北區分局提供之1997年9月至1998年6月醫療院所門診申報檔，擷取符合糖尿病及糖尿病相關併發症診斷碼之病人，篩選出處方箋中有使用降血糖藥者為研究對象，計有35,981名，處方總數為333,414張，而藥品醫令總數則為17,795,911筆。結果：糖尿病門診病患研究期間換算成每年每人平均看診次數14.6次，平均門診醫療費用11,822元，其中平均藥品費用佔78.6%（9,292元）；平約每處方用藥日數為18.41天，平均用藥筆數為4.1筆。在可判讀之口服降血糖藥處方中，劑量有問題之處方佔4.7%，重複用藥處方佔2.9%，處方出現重度、中度不良交互作用問題者分別佔3.02%與40.02%，整體有45.28%處方有前述三者之任一問題。以對數複回歸比較病人與不同醫院特質，其處方問題之勝算比皆有顯著差異，勝算比從診療科別的其他科1.09（95%信賴區間＝1.06-1.13）到區域醫院的8.39（95%信賴區間＝7.56-9.30）不等。結論：女性、年齡較大及有其他糖尿病慢性合併症的病人，出現問題處方的風險較高；醫院層級亦呈現不等程度的開立問題處方之風險，非醫學中心在超量處方開立的勝算比最高（介於3.83-8.39），相對於公立醫院，財團法人醫院勝算比為3.95（95%信賴區間＝3.66-4.26），和立醫院亦達1.21（信賴區間95%=1.13-1.30）。
  Objectives: Diabetic patients generally are users of multiple medications. This study explored potential inappropriate prescription problems of ambulatory diabetic patients in the National Health Insurance (NHI). Methods: This study applied secondary data analysis based on a claim database (September 1997~June 1998) provided by the Northern Branch of the NHI Bureau by selecting patients diagnosed with diabetes mellitus (DM) and DM complications ICD-9 codes. 35, 981 patients receiving hypoglycemic medications were included, and a total of 333,414 prescriptions with 17,795,911 medicines written in the prescriptions were identified. Results: The diabetic patients in this study had an average of 14.6 ambulatory visits per year, with average medical expenses of NT$11,822, 78.6% (NT$9,292) attributable to pharmaceuticals. The average days per prescription were 18.41 days, and there were 4.1 drugs per prescription. In the valid prescriptions, 4.7% of prescriptions had over-dosage problems, while 2.9% of prescriptions had duplicated hypoglycemic medication. Besides, 40.02% had moderate and 3.02% had severe adverse drug interactions. Overall, there were 45.28% of prescriptions that had one or more kinds of problem prescriptions. After controlling the patient characteristics and types of providers, there was statistical significance in term of odds ratio in written inappropriate prescriptions. The odds ratio varied from 1.09 (95% CI=1.06-1.13) of the other clinical departments versus family medicine to 8.39 (95% CI=7.56-9.30) of metropolitan hospital versus academic medical center. Prescriptions with over-dosage were more likely found among hospitals and clinics than academic medical centers with odds ratios ranging from 3.83 to 8.39. Comparing with public hospitals, the odds ratios were 3.93 (95% CI=3.66-4.26) for non-proprietary hospitals and 1.21 (95% CI=1.13-1.30) for private hospitals. Conclusions: The odds ratio of patients who receive inappropriate prescriptions were higher for females, patients with older age, and patients with DM complications. There were also various risks among different types of providers.
• 58 - 64
• 10.6288/TJPH2006-25-01-06

• Link 原著 Original Article
• 原鄉的家庭暴力及受暴婦女求助行為之探討－比較原漢之差異Ethnic Differences in Domestic Violence and Victimized Women's help-seeking Behaviors
• 陳秋瑩、王增勇、林美薰、 楊翠娟、 宋鴻樟
  Chiu-Ying Chen, Frank T. Y. Wang, Mei-Hsun Lin, Tra-Jang Yang, Fung-Chang Sung
• 家庭暴力 ； 酒癮 ； 原住民 ； 求助行為
  domestic violence ; alcoholism ; ethnicity ; help-seeking behaviors
• 目標：在原鄉地區調查家庭暴力的發生狀況及受暴婦女求助方式。方法：2002年在南投縣信義與仁愛兩鄉分別對600位隨機抽樣的家戶樣本之婦女進行居家的問卷訪視調查，內容包括社會人口特質、過去一年內經驗家暴的類型與次數和受暴者的求助行為等，完成有效問卷的樣本數為432人。本研究針對其中335位31至65歲的樣本資料進行分析。結果：「家庭暴力」及「伴有肢體暴力」的受暴比率分別為31.6% 、13.1%。在兩類受暴比率上原住民皆顯著高於漢人，其勝算比分別為2.8 (95%C.I.=1.6~5.0)與7.6 (95%C.I.=2.3~25.1)。進一步分析發現酒癮及原住民族群是受暴經驗的潛在相關因子。三成多經驗肢體暴力者未採任何求助行為。結論：本研究顯示家暴問題在原住民族群的嚴重性，酒癮防治與健全受暴者的求助體系是防治家暴的重要課題，然實質存在之種族差異亦蘊涵弱勢族群在社會與健康資源上的不平等問題。
  Objectives: To investigate the ethnic difference in domestic violence and the help-seeking behaviors of victims in aboriginal townships. Methods: An in-home survey was conducted in two aboriginal villages of Nan-Tou County in 2002. Complete interviews with 432 women, from 1200 randomly selected households, aged 16-65 years addressed socio-demographics, frequency and types of domestic violence against them, and help-seeking behaviors in the past year. A sample of 335 women aged 31-65 years was analyzed. Results: Overall, 31.6% women experienced domestic violence and 13.1% experienced physical abuse. The rates for the aboriginal group were higher than those for Han; and the odds ratios were 2.8 (95% C.I.=1.6-5.0) and 7.6 (95% C.I.=2.3-25.1), respectively. More than one-third of victims did not adopt any help-seeking behaviors. Conclusions: It appears that aboriginal women are at greater risk of physical violence than their Han counterparts. This study suggests further research on an area of social and health disparity for ethnic minorities.
• 65 - 74
• 10.6288/TJPH2006-25-01-07

• Link 實務 Public Health Practice
• 民眾就醫層級與醫療利用分析：SARS疫情前後的觀察The Analysis of Level of Outpatient Visits and Healthcare Utilization: A before and after Observation of the SARS Outbreak
• 王冠懿、鄭守夏
  Kwan-I Wang, Shou-Hsia Cheng
• SARS；醫療利用；就醫層級
  SARS ; healthcare utilization ; level of outpatient visit
• 目標：台灣民眾就醫次數偏高以及越級就醫情形普遍，一直受到衛生單位關切，本研究利用大樣本的健保資料，描述民眾就醫層級的分佈，並利用2003年SARS疫情造成之就醫恐慌，來檢視民眾醫療利用的改變情形。方法：本研究資料來源為健保局台北分局民眾承保檔及醫療院所點數清單檔，自承保人口抽樣10萬人，依據專業醫師的共識，將門診疾病依特性分為預防保健、慢性病、常見輕病、常見疾病等，並觀察SARS疫情發生期間，樣本人口各疾病類別之西醫門診就醫層級與次數與去年同期之差異。結果：本研究發現各疾病類別在各層級院所間分佈明顯不同，醫學中心看診多為慢性疾病(61%)，基層則以常見疾病為主（約80%）。SARS疫情期間之門診量與去年同期相較，整體約減少23%，醫院層級越高者於SARS期間門診量下降幅度越大（醫學中心降幅達46%，基層院所為12%），在疾病類別方面也有明顯差異，常見輕病在大型醫院之降幅超過六成，在基層下降不到一成五，而慢性疾病在大醫院減少超過三成，在基層則只下降不到5%。結論：民眾選擇到不同層級醫院診所看診，其疾病類別分佈明顯不同，顯示民眾有一定程度的就醫素養。SARS疫情對民眾在不同層級與各種類型疾病的門診有不同影響，本研究也對輕病越級就醫的問題提出討論。
  Objectives: For a long time, people's healthcare utilization, including high frequency of physician visits and upgrades in seeking outpatient service, are of great concern in Taiwan. This study employed the National Health Insurance (NHI) claim data to examine the distribution of disease categories among various hospital/clinic levels and the changes of outpatient visits during SARS outbreak. Methods: Data sources for this study came from the claim files provided by the Taipei Branch of the Bureau of NHI. Disease categories such as preventive care, chronic disease, common minor illness and common illness etc. were established via the consensus of a panel of clinical experts. This study assessed the medical care utilization during the SARS outbreak compared with that in the previous year of a cohort of one hundred thousand residents in greater Taipei area. Results: The distribution of disease categories among various levels of hospitals and clinics varied significantly. Medical centers had the highest proportion of chronic diseases (61%), while the primary care facilities had the majority of common illnesses (around 80%). The SARS outbreak resulted in an overall 23% decrease in outpatient visits. Higher-level medical facilities suffer from a bigger magnitude of volume decrease (46% for medical centers and 12% for primary care facilities). The decrease of service volumes also differed among disease categories. The volume of common minor illnesses fell more than 60% in large-scaled hospitals, while it was less than 15% in primary care facilities. The volume of chronic diseases decreased over 30% in large-scaled hospitals, while it was less than 5% in primary care facilities. Conclusion: The distribution of disease categories varied among different levels of medical care facilities. People showed a certain level of knowledge in making a reasonable selection of medical care providers. Different SARS impacts were observed in the disease categories among the various levels of medical care facilities. The problems of upgrade or overuse of physician visits is discussed in the study.
• 75 - 82
• 10.6288/TJPH2006-25-01-08