21卷5期

• Link 綜論 Review Article
• 內分泌干擾物質對人體健康之可能影響Potential Effects of Endocrine Disruptors on Human Health
• 李美慧
  MEI-HUI LI
• 內分泌干擾物質 ； 人體健康 ； 生殖影響 ； 天生缺陷 ； 癌症
  Endocrine disruptor ; Human health ; Reproductive effect ; Birth defect ; Cancer
• 在過去十多年來，實驗室的研究及野生動物的調查發現許多人工合成及自然的物質都具有干擾內分泌系統的作用，也使得內分泌干擾物質對人類與野生動物之影響成為目前受到大眾關切的公共衛生及環境問題。目前從人類流行病學研究資料，可發現睪丸癌及乳癌之發生率都有增加的現象。另外，男性的精子數、尿道下裂、隱睪症、女孩性早熟、神經內分泌及行為方面等的問題雖然沒有確切證據顯示有增加的趨勢，但是也有一些研究指出內分泌干擾物質可能與人類生殖及兒童發育方面之問題有關。本文將先介紹內分泌干擾物質的定義，再討論常見內分泌干擾物質作用方式及種類。最後針對內分泌干擾物質所可能造成之人類健康影響做一完整介紹。
  Over the past decade, evidence from laboratory studies and wildlife observations has indicated endocrine disruption effects of many synthetic or natural chemicals. Indeed, the effects of endocrine disruptors in public health and the environment have caused a growing concern among the public. In humans, there is some evidence increases in incidences of testicular and breast. cancers, and concern has also been expressed regarding sperm count, crytorchidism, hypospadias, precocious puberty, neuroendocrine development, and behavioral effects. This review will introduce the definition, mechanisms of action and types of endocrine disruptors, as well as the potential impacts on human health mediated by endocrine disruptors.
• 305 - 320
• 10.6288/TJPH2002-21-05-01

• Link 原著 Original Article
• 婦女抽菸及二手煙暴露和低出生體重嬰兒Maternal Smoking, Environmental Tobacco Smoking and Low Birthweight
• 陳培君、李中一、林瑞雄、宋鴻樟
  PEI-CHUN CHEN, CHUNG-YI LI, PUEY-SHIUNG LIN, FUNG-CHANG SUNG
• 母親抽菸 ； 二手煙 ； 低出生體重
  maternal smoking ; passive smoking ; low birthweight
• 無
  Objectives: Many studies have suggested that maternal smoking is a risk factor for low birth weight (LBW). The effect of environmental tobacco smoking (ETS) on LBW remains controversial. While few studies on these issues have been conducted in Taiwan, we initiated a preliminary study in Hsi Chih. Methods: In the survey on low frequency magnetic field and health effect in Hsi Chih, women aged 15 years and above were interviewed for information about reproductive health and life style in regard to smoking and secondary hand smoking. Risks for LBW were investigated among women who were living in Hsi Chih during the first pregnancy. Results: Among the 2074 eligible women living in Hsi Chih when they were pregnant, 4.9% were smokers and 61.4% were exposed to ETS. Maternal smoking contributed to the elevated risk of LBW but not significant (odds ratio (OR) =1.63, 95% confidence interval (CI) 0.65-4.07). Compared to the women with non-smoking spouses, the OR for having LBW births is 3.16 (95% CI 1.38-7.21) for women with smoking partners who smoke 21 or more cigarettes daily. Conclusion: This study suggests that pregnant women need education to be aware of the fact that heavy ETS exposure is a risk factor of giving LBW infant.
• 321 - 328
• 10.6288/TJPH2002-21-05-02

• Link 原著 Original Article
• 公元1980至1997年本國衛生署死因資料庫準確性之確認與補正Verification and Correction of Error for Death Registration Data of the Department of Health R.O.C. Between 1980 and 1997
• 謝功毅、陳保中、王榮德
  GONG-YIH HSIEH, PAU-CHUNG CHEN, JUNG-DER WANG
• 死亡登記 ； 資料庫 ； 衛生署 ； 內政部
  Death registration ; dataset ; Department of Health ; Ministry of Interior
• 目標：目前國內將死亡診斷書建立成死因資料庫有衛生署及內政部兩個單位。本研究之目的係使用內政部死因資料檔中正確及完整部份來補正衛生署自公元1985至1997年死亡之身分證字號及戶政資料，同時填補衛生署自公元1980至1997年教育及村里兩變項及衛生署自公元1980至1984年之身分證字號，以作為未來相關研究之參考與應用。方法：首先將兩死因資料庫內身分證字號及戶政資料皆相同之個案，先填補衛生署死因資料庫之教育及村里之資料，然後把不可連結之部分以身分證字號或戶政資料各做連結碼，來補正衛生署死因資料庫內缺漏或錯誤之戶政資料或身分證字，及填補教育及村里之資料。同時建立兩資料庫間互相無法連結之個案資料庫。結果：第一部分，自公元1980至1997年以身分證字號與戶政資料為連結碼，經由兩資料庫互連，可連結出1,259,600個個案。連結不上之個案利用身分證字號與戶政資料分別比對後，可補正衛生署之戶政資料有3,168個個案，身分證字號有33,036個個案。另外，兩資料庫可連結之部分，教育及村里變項補正百分比都達98%以上。第二部分，公元1980至1984年，主要填補衛生署身分證字號。以戶政資料包括出生年月日、死亡年月日、縣市代碼、鄉鎮代碼全部變項為連結碼可以填補身分證字號達88.83%。公元1980至1997年，兩資料庫未連結上之個案未作補正者，共有衛生署46,305個個案及內政部63,157個個案，可能是失去追蹤及延遲申報個案。結論：本研究結果可使世代研究及存活分析在使用衛生署的死因資料檔案範圍往前推至公元1980年；研究族群之區域分層只能切割到最小單位鄉鎮，但補正後可使之細分到村里。另外衛生署及內政部未連結上之個案可建立檔案作為延遲申報個案及失蹤建檔個案之參考，以便作為將來研究追蹤死亡個案之依據。
  Objective: Both the Department of Health (DOH) and Ministry of Interior (MOI) of Taiwan have established a computerized death registry based on the death certificates of the dead in Taiwan during the past two decades. The purpose of this study is to verify the accuracy of the dataset of death registration for the DOH with the dataset from the MOL .Because the data of the DOH during 1980-84 lacked the identification number (ID no.), our second objective is to establish guidelines for replacing the missing ID no.. Method: Firstly, decedents in the two datasets linked by same ID no. and demography including dates of birth, death, and places of living between 1985 and 1997 were identified and codes of education and village taken from the MOI were filed in those of the DOH. Decedents that could only be linked by ID no. or demography between 1985 and 1997, were refiled the demography or ID no. after making sure of the correction in the MOI. Secondly, due to the lack of information of ID no. in the DOH for decedents between 1980 and 1984, we linked the two decedents with social demography including dates of birth and death, area codes of detailed address, and then imputed ID no. into dataset of the DOH based on dataset of the MOI. Result: There were 1,259,600 decedents identified from 1985-97 with completely the same ID no. and demographic data. After verification of the data, we refiled the missing demographic data for 3,168 subjects and the missing ID no. for 33,036 subjects into the dataset of the DOH. According to the study results, there were 0.0512% of total subjects with complete overlapping demographic data. Thus, after linking the two datasets with the same complete demographic data, we were able to refile 88.83% of the missing Ids for all the death certificate data of the DOH during 1980-84. There were 46,305 cases in the dataset of the DOH and 63,157 cases in that of the MOI during 1980-97, that were unlinkable. This was probably because they were lost track of or there was a delay in registration. Conclusion: This study corrected many errors, filled in ID no. for 1980-84, and imputed information of education and village into the death registration dataset of the DOH. This can be useful for future studies. Beside, the unlinkable cases in the datasets of the DOH and MOI were identified and a separate dataset files for future usage was built up.
• 329 - 338
• 10.6288/TJPH2002-21-05-03

• Link 原著 Original Article
• 牙醫服務誘發需求可能性之研究Supplier-Induced Demand for Dental Services in Taiwan
• 馬可容、鄭守夏、周穎政
  Ke-Zong Ma, Shou-Hsia Cheng, Yiing-Jenq Chou
• 牙醫服務 ； 誘發需求 ； 追蹤資料 ； 固定效果模型 ； 工具變項
  Supplier-induced Demand ; Panel Data ; Dental Services ; Fixed-effects Model ; Instrument Variable
• 目標：誘發需求是否存在一直是健康經濟學領域中爭議已久的問題，本研究藉由個別醫療服務供給者的層次，分析牙醫師人口比對牙醫師行為的影響。方法：研究設計採追蹤資料型態，研究資料為1997及1998年健保申報資料，牙醫師行為觀察變項包括牙醫師之平均病人數、平均每位病患看診次數、每次看診平均申報金額、平均看診次數及平均申報金額，自變項則以鄉鎮市區為單位計算牙醫師執業地點之牙醫師人口比，分析方法為固定效果模型與工具變項。結果：牙醫師人口比增加會導致每次看診平均申報金額上升，但幅度相當小(彈性均為0.04)，平均看診人次及平均申報金額均隨牙醫師人口比的增加而降低。結論：牙醫師以增加每次看診治療密度的方式來彌補因競爭增加所帶來損失的程度很小。政策上未來應考慮牙醫師人口比增加帶來的其它結果，再評估人力或費用的相關政策。未來研究則可由需求面作分析，並探討競爭程度與牙醫師行為間是否有非線性的關係存在。
  Objectives: The existence of supplier-induced demand (SID) is still frequently being debated in health economics studies. Availability of appropriate research methodologies and econometric tools is a key to solve this mystery. This study aims to investigate the effect of dentist-to-population ratio on dentists' behavior in Taiwan by focusing on the level of individual dentist. Methods: Data of this study mainly came from the 1997 and 1998 National Health Insurance Research Database. The data were analyzed using a panel-instrument approach. Results: The results show that an increase in dentist-to-population ratio causes a slight increase in mean revenue per consultation per dentist, but declines in mean number of consultations and mean revenue per month per dentist. The results imply that dentists might respond to the losses due to a greater competition by increasing treatment intensity per consultation, but the magnitude was limited. Conclusion: Compared to previous reports, our results should be more accurate since we had incorporated the case mix adjustment, and included the panel data as well as instrument variable in our analysis. We suggest that government should use incentives to improve unequal distribution of dentists. Future researches can focus on the issue of demand side and investigate the possible existence of a nonlinear relationship between the level of competition and provider behavior.
• 339 - 348
• 10.6288/TJPH2002-21-05-04

• Link 原著 Original Article
• 以體療品質的觀點探討台灣乳癌之診療型態The Quality Issues in the Diagnosis and Treatment of Breast Cancer in Taiwan
• 林慧淳、葉玲玲、吳仁佑、黃達夫
  Huey-Chwen Lin, Ling-Ling Yeh, Jen-You Wu, Anderew T. Huang
• 實證醫學 ； 診療準則 ； 乳癌 ； 診療型態 ； 台灣
  evidence-based medicine ; practice guideline ; breast cancer ; diagnosis and treatment ; Taiwan
• 目標：本研究旨在以乳癌實證醫學為基礎之診療準則為架構，分析台灣各層級別醫院之診療型態，並探討其對確保醫療品質的意涵。方法：本研究利用1997年1月至1999年11月之全民健保門診與住院申報檔，進行次級資料分析。針對曾為1997年女性乳癌新發個案進行手術治療之醫療院，分析其乳癌診斷、治療與追蹤之三階段診療型態，並比較不同層級別醫院診療型態，呈現出醫療品質現況。結果：(１)乳癌診斷之診療型態中，除荷爾蒙接受體與乳房超音波或造影檢查比率較低外，其他檢查比率達97%；(２)0期病人進行改良型乳癌根除術者高達6成，本研究也顯示乳房保留手術病人術後進行放射治療比率低，且各醫院間差異大；(３)醫學中心與區域醫院之化學治療藥物處方較具一致性，而地區醫院高達6成未符合診療準則之藥物處方型態；(４)追蹤期間乳房超音波或造影檢查比率尚不及5成；(５)荷爾蒙治療前、後所需檢查達成比率偏低，各醫院間差異大。結論：藉由本研究乳癌診療型態分析可知，健保申報資料的分析可作為有效監控醫療照護品質的方式。研究結果亦顯示，若遵照實證醫學診療準則診斷或治療癌症，則可降低醫療資源不當利用的情形。此外，建議健保申報資料應增加影響診療型態的重要變項，如診斷期別，以便對國內醫療品質有更深入的瞭解。
  Objectives: The objectives of this study were two-fold. Using the guidelines based on evidence, we analyzed the patterns of diagnosis and treatment of breast cancer in Taiwan. The second objective was to determine whether the data generated from the analysis could be adopted for assuring quality of care in breast cancer. Methods: We used the claims data of the Bureau of National Health Insurance (BNHI) from hospitals throughout Taiwan between January 1997 and November 1999 for a secondary data analysis. The patterns of diagnosis and treatment were divided into three stages, namely diagnosis, treatment, and follow-up conducted in hospitals when ever mastectomy was performed for the new cases of breast cancer recorded in 1997. The analysis was then made on the differences in the pattern of diagnosis and treatment amongst hospitals in Taiwan. Ultimately, a comparison was made against various quality indicators developed for breast cancer. Results: (1) In the diagnostic area, the rate of cytologic and histologic diagnosis as well as blood tests reached 97%. However this figure was not reached for the ER/PR receptor examination and breast sonography or mammography. (2) More than 60% of the patients with noninvasive carcinomas were still treated with modified radical mastectomy. This study also showed an unexpected low rate of radiation therapy after breast conservation surgery in most hospitals. (3) Medical centers and regional hospitals were consistent in their use of the chemotherapy regimen according to accepted practice guidelines, whereas the inconsistency rates among district hospitals were greater than 60%. (4) In the follow-up period, the breast sonography or mammography was less often ordered (50%) than what the standard required. (5) The rate of examination for ER/PR receptor status before and after initiation of hormonal treatment was low, and the variation among hospitals was also large. Conclusions: Breast cancer claims data of BNHI can be used to determine the quality of care with reasonable accuracy. Our analysis of breast cancer indicated that while certain tests or treatments were consistent with good practice of oncology based on evidences accepted worldwide, some important tests and treatments were carried out at frequencies significantly lower than what was considered to be acceptable. The only significant deficiency in the claims data for analysis of quality standards is the lack of staging information for breast cancer or any other cancer. We urge that such information be added as a requirement for the filing of reimbursement claims by the hospital which treats cancer patients.
• 349 - 362
• 10.6288/TJPH2002-21-05-05

• Link 原著 Original Article
• 西醫基層診所實施總額預算前後之價量變化以臺灣北部地區西醫基層診所為例The Effect of the Global Budget on the Western Medicine Clinics Price and Utilization - Case of Western Medicine Clinics in the Northern Taiwan
• 張益誠、 廖宏恩
  Yi-Cheng Chang, Hung-En Liao
• 總額支付制度 ； 保險申報 ； 基層醫療 ； 全民健康保險
  Global Budget Scheme ; Medical Claims ; Primary Care ; National Health Insurance.
• 目標：本研究主要目的在探討西醫基層總額支付制度實施前後對其醫療費用之初期影響。方法：利用健保局台北分局轄區台北縣市、基隆市、宜蘭縣基層西醫診所一門診醫療費用申報檔」，比較其在89及90年下半年申報費用與件數的變化。結果：總額制度實施半年之後；一、西醫基層診所申請件數顯著下降，單位價格顯著增加。二、預防保健及慢性病等鼓勵部門申請件數和點數顯著增加，上限制部門申請件數及點數顯著減少。三、複迴歸分析顯示，縣市別、城鄉別及權屬別是影響基層診所醫療費用變化的因素。結論：基層總額支付制度實施初期的確對基層西醫診所申請醫費用的行為產生一定程度之影響，但由於總額實施時間未久，本研究僅能分析短期變化情形。在推行醫院總額支付制度前，建議衛生主管機關應持續追蹤監測，並建立點值速算機制，和評估基層診所與醫院合作模式，以瞭解醫師醫療行為或醫院管理模式的改變，是否會影響到民眾就醫的可近性與醫療服務的適當性及品質。
  Objective: The aim of this research is to explore the initial impacts of the Global Budget Scheme on the medical claims among primary Western physician clinics. Methods: Outpatient Medical Expenditure Data file is employed to compare the changes in medical claims among primary Western physician clinics in the same half year before (i.e., 2000/07) and after (i.e., 2001/ 07) the Global Budget Scheme was inaugurated. Results: I. Six months after launching the Global Budget Scheme, the number of cases claimed from primary Western physician clinics dropped sharply with a significant increase in unit price. 2. The number of medical claims categorized in encouraged groups such as preventive health services and chronic diseases increased dramatically, while that in the other categories with expenditure cap appeared to decrease. 3. Our regression model showed that the type of cities, type of townships, and the type of clinics ownerships are significant factors influencing the results of decreasing medical claims and an increasing unit price index. Conclusions: The behaviors of clinical physicians reflecting on the changes of Medical Claims were indeed influenced by the implementation of the Global Budget Scheme. Since our findings were confined to the initial impacts of the Global Budget Scheme, it is suggested that the authority continues to monitor the trend to analyze the extent to which patient's accessibility and medical quality would be influenced in the long run. In addition, before implementing the Global Budget Scheme on hospitals, the authority should establish an automatic unit-price response mechanism. For the health industry, it is suggested that the health administration should re-think the appropriate cooperative model between hospitals and primary clinics.
• 363 - 372
• 10.6288/TJPH2002-21-05-06

• Link 原著 Original Article
• 臺灣全民健康保險的醫療支出重分配效果，1995~2000Redistributional Effects of Health Care Expenditures Under the National Health Insurance Program in Taiwan, 1995-2000
• 蔡貞慧、周穎政
  Jen-Huoy Tsay, Ying-Jenq Chou
• 全民健保 ； 保費 ； 自付醫療費用 ； 所得分配 ； 累進位
  National Health Insurance ; Premium ; Out-of-Pocket ; Income Distribution ; Porgressivity
• 目標：全民健保的實施乃為減少個人就醫的財務障礙，然而，過去幾個橫斷面研究均指出，其保費負擔呈不利窮人的累退分配。由於全民健保自實施以來已歷經多次與保費、部分負擔相關之政策調整，家戶醫療支出重分配效果有必要以時間趨勢的層面作政策評估。方法：本研究究運用1995至2000年主計處家庭收支調查資料，分析不同所得水平間家戶保費負擔及自付醫療費用占可支配所得的比例，並以卡克萬尼指標測量其分配累進程度。結果：(１)與過去研究一致，1995至2000年的家戶保費支出均呈累退分配，惟，其累退性逐年趨緩。(2)1995至2000年的家戶自付醫療費用均比保費負擔呈更明顯的累退分配，惟，其累退性逐年趨。結論：我國的保費分配及自付醫療費用分配的累退程度，與許多OECD國家相仿。不過，保費分配累退性仍有改善空間。此外，全民健保有助於減緩家戶自付醫療費用分配累退性，然而，捨棄對保費結構的調整，而以增加部份負擔揖注健保收入的做法，將不利於家戶醫療支出的分配公平性。
  Objectives: One major objective of Taiwan's National Health Insurance Program (NHI) is to remove financial barriers to health care access. Several cross-sectional studies indicate that the distribution of the NHI premium burdens makes low-income people worse off. As the NHI premium structure and co-payment schemes have undergone many changes since its implementation in March 1995, it is essential to examine the distribution of household health care expenditures under him NHI program longitudinally. Methods: By using 1995-2000 Family Income and Expenditure Survey in the Taiwan Area, this study examines the distribution of household premium burdens as well as out-of-Pocket expenditure across income levels. The progressitity of distribution is measured by the Kakwani index. Results: The distributions of premium burdens were all regressive between 1995 and 2000, whereas the regressivity was decreased annually during this period. The distribution of out-of-pockets was more regressive than that of premium, whereas the regressivity also decreased annually. Conclusion: The distributional regressivity of premium burdens and out of-pockets is similar to many OECD countries. However, the equity of premium distribution could be improved by restructuring the payroll taxing scheme. Although the NHI program improves the distributional equity of household out-of-pocket expenditures on health care, expanding co-payment schemes instead of restructuring the payroll taxing design to increase NHI revenue would harm the distributional equity of household health care expenditures across income levels.
• 373 - 379
• 10.6288/TJPH2002-21-05-07

• Link 原著 Original Article
• 1997年至1999年臺灣地區孩童上呼吸道感染單純疱疹病毒分析Epidemiology of Upper Respiratory Infection Due to Herpes Simplex Virus Type 1 in Children in Taiwan During 1997-1999
• 吳秀玲、王貞仁、 陳宏一、 呂立群、陳豪勇、 涂醒哲
  Shiow-Ling Wu, Jen-Ren Wang, Hong-I Chen, Li-Chun Lu, Hour-Young Chen, Shing-Jer Twu
• 單純疹病毒第一型 ； 十二歲以下病童 ； 上呼吸道感染 ； 流行病學資料
  Herpes simplex virus type 1 ; children under twelve years ; upper respiratory infection ; epidemiological information
• 目標：針對12歲以下病童，分析上呼吸道感染患者的單純?疹病毒第一型檢出率。提供單純?疹病毒第一型流行病學的基本資料，以了解台灣單純?疹第一型病毒檢出率與月份、年齡、性別、及發病日的關係。方法：1997年1月1日至1996年6月30日期間，收集臺北、臺中及臺南三地區各級醫療院所，12歲以下病童，上呼吸道感染患者的咽喉拭子檢體。藉由MDCK及H292細胞進行病毒培養並以免疫螢光染色方法鑑定病毒。結果：檢體總數3473件，4.6%來自醫學中心，6.7%來自區域醫院，5.0%來自地區醫院，83.7%的檢體來自私人診所；844件病毒陽性檢體中116件為單純?疹病毒第一型，平均檢出率為3.3%。不同規模醫療院所的檢出率並沒有顯著的差異，但是北、中及南區的檢出率不同。確定病例中，1至3歲的孩童所佔比例最高(5.0%)。單純?疹病毒第一型全年都可能被分離出來，1998年8月和9月的檢出率分別為22.9%和11.8%較其他月份高。此外，於發病5日內採檢，不同發病日之檢出率並無差異。結論：臺灣地區急性上呼吸道感染病童受到單純?疹病毒第一型感染佔有一定的比例，所以在傳染病防治系統上值得重視。
  Objectives: The purpose of this study was to investigate the relation between isolation rate of herpes simplex virus type 1 (HSY-l) and season, age of the child, gender, and disease day and we intend to provide basic epidemiological information about children with respiratory infection caused . by HSV -1. Methods: From January 1997 to June 1999, throat swab specimens were collected from children under twelve years with suspected upper respiratory tract infection. Samples were I collected from medical centers, area hospitals, local hospitals and private clinics in Taipei, Taichung and Tainan. MDCK and H292 cells line were used for viral isolation; immunofluorescence stain was used to identify HSV-l. Results: A total of 3473 specimens were collected during this period. About 83.7% of the isolates were collected from private clinics, 6.7% from area hospitals, 5.0% from local hospitals and 4.6% from medical centers. There were 844 positive viral isolation including 116 cases of HSV-1. The average isolation rate of HSV -1was 3.3%. Isolation rates of August (22.9%) and September (11.8%) in 1998 were higher than the rest. Isolation rates between the hospitals of different accredited levels were similar. The age distribution of HSV -1 positive cases showed the patients between 1-3 years had the highest incidence rates (5.0%). The isolation rate between first day to fifth day after symptoms begun showed no significant differences. Conclusions: These results imply that HSV-1 plays an important role in causing acute respiratory infection in children. Infectious disease surveillance system should pay more attention to HSV-l.
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• 10.6288/TJPH2002-21-05-08