21卷6期

• Link 原著 Original Article
• 甲狀腺切除論病例計酬之甲狀腺癌與良性甲狀腺疾患醫療資源耗用分析The Analysis of He Resource Utilization for Patients With Thyroid Cancer and Benign Thyroid Diseases With Thyroidectomy Case Payment
• 吳仁佑、葉玲玲、閻愷正、黃達夫
  Jen-You Wu, Ling-Ling Yeh, K. Lawrence Yen, Andrew T. Huang
• 診斷關聯群 ； 甲狀腺癌 ； 論病例計酬 ； 甲狀腺切除術 ； 良性甲狀腺疾患
  DRGs ; Thyroid Cancer ; Case Payment ; Thyroidectomy ; Benign Thyroid Diseases.
• 目標：本研究以HCFA DRGs為架構，分析同屬DRG290之甲狀腺疾患兩類病人實施甲狀腺切除術住院人次醫療費用與住院天數，並探討不同支付方式與不同醫院層級之甲狀腺癌與良性甲狀腺疾患醫療資源耗用的差異性，作為日後全面實施DRGs的參考。方法：本研究資料來源為1999年3月至12月全民健保住院申報資料。研究對象為符合HCFA DRG 290定義ICD-9主手術碼之所有實施甲狀腺切除術住院人次，分析不同支付方式與不同醫院層級論病曆與非論病例計酬甲狀腺癌與良性甲狀腺疾患病人之醫療費用、住院日數等醫療資源耗用，以及不同醫院實施甲狀腺切除術病人中甲狀腺病人所佔比率之分布情形。結果：整體而言，實施甲狀腺切除術之甲狀腺癌病人平均住院醫療費用及住院天數均高於良性甲狀腺疾患，而且國內實施甲狀腺切除術的病人92%不是甲狀腺癌病人。無論是論病例計酬個案或非論病例計酬個案，甲狀腺癌病人平均費用與住院天數均高於良性甲狀腺疾患。核實申報個案除醫學中心外，區域醫院及地區醫院甲狀腺癌病人平均費用均高於良性甲狀腺疾患。而定額申報個案不同醫院層級之甲狀腺癌病人平均費用也均高於良性甲狀腺疾患。非論病例計酬個案之甲狀腺癌病人平均費用也均遠高於良性甲狀腺病患，其中以醫學中心差異最大，達28,998元。結論：健保局未來將以HCFA DRGs為主要架構全面實施DRGs。HCFA DRG 290範圍包括本研究論病例計酬與非論並病例計酬甲狀腺切除術病人，亦即同時包含甲狀腺癌與良性甲狀腺疾患病人。根據本研究分析結果，甲狀腺癌病人醫療資源耗用明顯高於良性甲狀腺疾患，而且在臨床上亦屬兩種不同的治療方式，因此未來如果將甲狀腺切除術之甲狀腺癌與良性甲狀腺疾患歸為同一組DRG，將對更需手術前謹慎評估且處置困難度高的甲狀腺癌疾患產生給付過低的現象。國內實施甲狀腺切除術之良性甲狀腺病患病人比例過度頻繁，恐有濫用醫療資源與不當醫療之虞。DRGs如果以全國甲狀腺切除病例之平均醫療費用為定價基準，則將過度鼓勵醫院進行不必要之手術，亦間接懲罰嚴格遵循各類甲狀腺手術治療準則之醫療機構。上述皆值得全民健保局重視並加以改進。
  Objective: Based on the framework of HCFA DRGs, we conducted an analysis of the relationship between medical expenditures and the number of hospital days in patients who undergo thyroid surgery in. Taiwan. It compares the differences in surgery for thyroid cancer and benign thyroid diseases, in relation to the two types of payment system and three levels of hospitals, in which these operations were performed. It is our hope that these findings will contribute to the design of the DRGs payment system in the immediate future. Method: Our data set utilizes claims data recorded by the Bureau of National Health Insurance (BNHI) for in-patients from March to December 1999. Subjects of interest were those who were admitted for thyroid surgery and were identified using the HCFA DRG 290 ICD-9 thyroid gland surgical codes. These subjects were then categorized into case payment and non-case payment groups, and further classified into cancer and non-cancer groups. Total health expenditures paid by the BNHI and the hospital days for each subgroup were evaluated. The differences were then determined according to the three levels of hospitals in which the procedure was performed. Results: A general trend prevailed in that thyroid cancer patients incurred greater hospital costs as well as longer days of hospitalization than benign diseases patients, whether the payment system was case payment or not. For the non-case payment subjects, the discrepancy in cost was evident in all hospitals, with the largest variation seen in the medical centers, reaching an average of NT$28,998. The predominant form (92%) of thyroid surgery performed in this country IS for benign thyroid diseases. Conclusion: Based on our analysis, the consequence of HCFA DRGs design encourages biased patient selection by hospitals to operate on benign diseases, which leads to unnecessary surgery by promising better financial returns. The risk is thus shifted to hospitals which follow a more stringent surgical indication and treats a greater proportion of cancer patients. Such a payment system runs counter to promoting good surgical practice.
• 387 - 396
• 10.6288/TJPH2002-21-06-01

• Link 原著 Original Article
• 低體重早產兒的住院醫療資源耗用分析Analysis of Hospitalized Care Resource Utilization of Low Birth Eight Premature Infants
• 翁新惠、楊長興
  Shine-Huey Wung, Chiang-Hsing Yang
• 早產兒 ； 低體重兒 ； 醫療資源耗用
  premature infant ; low birth weight ; resource utilization
• 目標：本研究旨在分析低體重早產兒的首次住院醫療資源耗用狀況，並探討影響醫療資源耗用的相關因素。方法：以北部某醫學中心於民國87年89年之間338名低體重早產兒的住院及費用資料，進行回溯性研究。採用百分比以及複迴歸模式進行分析。結果：(1)出生體重小於750公克組的低體重早產兒之平均住院費用及平均住院天數，約是出生體重750-999公克組的兩倍，隨著出生體重的增加，住院醫療費用呈等比級數的下降。(2)出生體重、合併症數量及住院疾病嚴重度為影響低體重早產兒首次住院醫療資源之重要因素。影響住院日數及住院醫療費用之模式解釋量(R2)分別為0.70、0.69。結論：(1)出生體重750公克之早產兒為照護資源耗用的閾值點。(2)存活狀況不同對於資源耗用會有很大差異。(3)醫療給付應參考出生體重、疾病嚴重度、合併症之病例組合，並制定出院條件規範。
  Objective: This study was to determine the resources that were used by initial hospitalized care for infants with low birth weight, and to explore the factors that contributed to the resource utilization. Methods: A retrospective study was designed to collect data from a medical center in northern Taiwan. From 1998 to 2000, all infants in the study were under 37 weeks gestation and weighed less than 2,500g at birth. Variables were examined using multiple regression for their independent effects on hospitalization resources. Results: (1) The average hospitalization resource utilization per surviving infant was twice as high for infants weighing under 750g as for the group of infants weighing between 750-999g. The cost dropped by gradient with birth weight in surviving infants. (2)Birth weight, number of complications and severity of illness were related to initial length of stay (R2: 0.70) in the hospital and hospital expenses (R2: 0.69). Conclusion: (1) Birth weight less than 750g was a critical point for resource utilization. (2) Initial hospital care resource utilization among surviving infants and non-survivors was significantly different. (3) Reimbursement for in patient care of low birth weight infants should be based on factors such as birth weight, number of complications, and severity of illness.
• 397 - 402
• 10.6288/TJPH2002-21-06-02

• Link 原著 Original Article
• 全民健保實施牙醫總額預算制度對醫療資源分布的影響評估Impacts of Dental Global Budgeting Under National Health Insurance on the Distribution of Health Resources
• 黃昱瞳、楊長興、薛亞聖
  Yu-Tung Huang, Chiang-Hsing Yang, Ya-Seng Hsueh
• 總額預算 ； 資源分配 ； 勞倫斯曲線 ； 吉尼係數 ； 介入分析模式
  global budgeting ; health resources distribution ; Lorenz curve ; Gini coefficient ; intervention analysis model
• 目標：許多研究均證實總額預算支付制度能有效控制醫療花費的成長，但是否能促進資源的平均分配則未有定論。本研究以牙醫師人力、民眾就醫診次及醫療費用等三項牙醫醫療資源指標分部的變動，評估全民健保實施牙醫總額預算制度是否促進牙醫醫療資源的均勻分布。方法：以衛生統計、台閩地區人口統計及健保資料庫申報總檔等資料，運用Lorenz曲線及其Gini係數作為衡量醫療資源資源分布不均勻程度的指標，採用時間數列之介入分析模式，評估開辦總額預算制度前後Gini指標的變動，並與中醫進行對照比較。結果：牙醫總額預算實施後，三項醫療資源分布不均指標顯著下降，依據研究分析結果，本研究認為總額預算制度可能具有促進醫療資源均勻分布之效果。結論：總額預算制度除了可控制醫療費用總量的上漲外，因支付制度之影響使得內部結構進行調整，似乎亦具促進醫療資源均勻分布效果，若在醫療品質得以確保的情況下，應可逐步推展。
  Objectives: Many studies have indicated that global budgeting can control medical expenses to some extent; nevertheless, whether global budgeting can improve health resources distribution is still unclear. This study attempts to evaluate whether NHI’s implementation of dental global budgeting has improved the equality of health resources distribution. Method: The Lorenz curve and Gini coefficient were used to analyze the degree of inequality of health resources distribution. The intervention analysis, based on time series data was employed to identify the potential impact resulted from the policy of global budgeting. Results: After the implementation of dental global budgeting, the inequality of three health resources distribution measured by Gini coefficients has dropped dramatically. The result reveals that global budgeting could have improved the equality and accessibility of health resources distribution. Conclusions: Previous studies have pointed out that the implementation of global budgeting could control the increase in medical expenses. This study examined the new payment system from another angle, and found that it could cause the structural change of dental industry and led to some adjustments of dental practice, which have potentials to enhance equalizing the health resources distribution. As a result, when the quality of dental care is assured, the global budgeting reimbursement system could be adopted to enhance the equalization of health care resources distribution.
• 403 - 410
• 10.6288/TJPH2002-21-06-03

• Link 原著 Original Article
• 社區老人實際服務利用與自覺需要－1994～1998世代追蹤研究The Use and Perceived Need for Services of Community Elderly Persons – a Cohort Study of 1994-1998
• 謝穎慧、邱亨嘉、毛莉雯
  Ying-Hui Hsieh, Herng-Chia Chiu, Lih-Wen Mau
• 服務利用 ； 自覺需要 ； 未滿足需要 ； 世代研究 ； 多元功能評估
  service utilization ; perceived need ; unmet need ; cohort study ; multidimensional functional assessments
• 目標：本研究旨在探討社區老人各項服務之實際服務利用和自覺需要之長期變化。方法：藉由為期四年之世代追蹤研究，以兩階段比例分層抽樣法選取居住在高雄市三民區65歲以上社區老人，於1994年進行第一次面訪，1998年再次面訪，初訪總計完訪1,260位社區老人，四年後成功追訪874位；其餘有218位老人死亡，168位失訪。本研究工具為「中文版老人多元功能評估問卷」。統計分析包括描述性統計分析、獨立樣本之T檢定為McNemar's test。結果：1998年完成追訪之874位老人，與1260位原始樣本相比，其各項人口學特質並無顯著差異。在1994～1998年間，社區老人對於家事服務、餐飲準備、持續性照顧、個人照護及護理照護等各項服務，無論是實際使用及自覺需要的比例皆呈現上升趨勢；在身體健康評估服務一項，由1994年實際使用之42.4%，上升至1998年之56.8%；然社會暨娛樂活動服務一項則有將近60%之受訪老人未曾使用或自覺需要該項服務。有關各項服務之未滿足需要，除個人照護項目外，其餘各項服務之未滿足需要者比例在時間上皆呈現下降趨勢，其中以家事服務、身體健康評估及社會暨娛樂活動三項服務達統計顯著差異(p＜.05)。就服務提供者而言，家人朋友鄰居仍是家事服務、餐飲準備、持續照護、個人照護及護理照護等各項服務的主要提供者，但隨年紀漸增，使用機構或受雇者所提供服務的老人比例顯著上升。結論：本研究之主要目的在於瞭解高雄市社區老人長期服務利用及自覺需要是否因老化而有所變化。透過為期四年長期觀察結果，可瞭解不同服務項目之使用變化及自覺需要趨勢，以克服橫斷性研究所無法呈現的動態改變過程，做為老人衛生和社會福利之服務提供或政策制訂者之參考。
  Objectives: This study examined the longitudinal use of and perceived need for services of the community elderly people. Methods: The study design was a cohort study over a four-year period. Two-stage proportional to size sampling was used. A baseline sample of 1, 260 elderly subject, dwelling in San-Ming District in Kaohsiung city, were successfully interviewed in 1994. Among them, 874 subjects were followed; 218 subjects deceased; and 168 subjects failed to be tall awed. The measurement instrument was the Chinese-version at the Multidimensional Functional Assessment Questionnaire (CMFAQ). Descriptive analysis, independent T test, and McNemar’s test were used. Result: No demographic significance was found between the baseline sample and the follow-up sample. The included 8 items of services were homemaker-household services, meal preparation, personal care services, nursing care, continuous supervision, health-related information supplement and relocation, physical examination services, and social recreation services. During the period of 1994-1998, the use of and perceived need for homemaker-household services, meal preparation, personal care services, nursing care, continuous supervision services significantly increased. As with the example of physical examination services, the percentage of use was 42.4% in 1994, which increased to 56.8% in 1998. However, close to 60% of the-followed sample had never used of or perceived need for social recreation services. As regards the unmet need of services, the percentage of unmet need for each item of service decreased over a four-year-period; except for the persona care unmeet need for each item of service decreased over a four-year-period, except for the persona care service. Especially, the unmet need of homemaker-household services, meal preparation, physical examination services, and social recreation services were fulfilled overtime. The major provider for each Item of service remained family, friends, and neighbors. As the sample increased with age, the use of a formal care system was correspondingly increased. Conclusions: In short, the present study intended to understand whether the use of and perceived need for services had been changed over a tour-year-period in the community of elderly people. According to longitudinal observations, the limitations of a cross-sectional study can be eliminated and the changing patterns of actual service use and perceived need have been uncovered. The findings here should be helpful for health care and social service providers as well as decision markers for program development and. Policy planning on long-term care services.
• 411 - 419
• 10.6288/TJPH2002-21-06-04

• Link 原著 Original Article
• 「負荷－控制－支持」與「付出－回饋失衡」工作壓力模型中文版量表之信效度檢驗：以電子產業員工為研究對象Reliability and Validity of the Chinese Demand-Control-Support Model and Effort-Reward Imbalance Model Questionnaires: a Study Among Employees of the Microelectronic Industry
• 曾慧萍、鄭雅文
  Hui-Ping Tseng, Yaewn Cheng
• 工作壓力 ； 負荷-控制-支持模型 ； 付出-回饋失衡模型 ； 信度 ； 效度
  Job stress ; Demand-Control-Support model ; Effort-Reward Imbalance model ; validity ; reliability
• 目標：探討兩個工作壓力模型，即「負荷－控制－支持模型」(Demand-Control-Support Model)與「付出－回饋失衡模型」(Effort-Reward Imbalance Model)之理論基礎，並檢驗中文版量表之信效度。方法：以高科技電子業男女性員工各401及667名為研究對象，以問卷評估其社會心理面向工作特質、工作滿意度與自評健康狀態。工作特質包含工作控制、心理負荷、社會支持、外在付出、回饋、及工作過度投入。信度以Cronbach's alpha coefficients量測量表題目的內部一致性。效度則包括內容效度及建構效度。結論：除心理負荷之內部一致性較差外，其他分量表的Cronbach's alpha coefficients皆高於0.65。因素分析顯示實證資料所抽取的因素結構與理論架構吻合。結論：依兩理論模型所研發的工作壓力量表能有效的測量職場中重要的工作特質，如「工作控制」、「心理負荷」、「回饋」與「過度投入」等，有助於我們對工作壓力問題的瞭解。
  Objective: In this study we explored the theoretical background of two alternative job stress models – the Demand-Control-Support model and the Effort-Reward Imbalance model, and examined the reliability and validity of their Chinese questionnaires. Methods: In this study, we recruited 40 I men and 667 women who were employed in high-tech microelectronic companies in Taiwan. A self-administered questionnaire was used to assess their psychosocial job characteristics, including job control, psychological demands, work-related social support, extrinsic effort, rewards, and over-commitment. Cronbach’s alpha coefficient was calculated for each scale to assess the internal consistency. For validity analyses, we examined content validity and construct validity. Results: Cronbach’s alpha coefficients for most sub-scales were all above 0.65, except for the psychological demands subscale. Exploratory factor analyses extracted 4 factors that corresponded closely to the theoretical constructs of the two models. Conclusion: Our results showed that the questionnaires developed from the two models are useful tools for the assessment of some important psychosocial work characteristics, and can help shed light on our understanding of job stress problems.
• 420 - 432
• 10.6288/TJPH2002-21-06-05

• Link 原著 Original Article
• 嫘縈絲勞工的健康狀況自知程度Awareness of Health Status Among Viscose Rayon Workers
• 張淑如、石東生、陳秋蓉、陳尹柔、宋鴻樟
  Shu-Ju Chang, Tung-Sheng Shih, Chiou-Jong Chen, Yin-Jou Chen, Fung-Chang Sung
• 健康狀況 ； 聽力損失 ； 嫘縈絲
  health status ; hearing loss ; viscose rayon.
• 目標：本研究針對嫘縈絲製造廠暴露到二硫化碳的勞工，以勞工自我認知的健康狀況與實際醫事檢查結果比較，探討其差距。方法：本研究於2000年間為嫘縈絲廠員工做健康檢查，並做問卷訪談自我認知健康狀況，再和勞工1998年度及2000年健康檢查結果比較。結果：這次健康檢查的員工中有103人(66.5%)有高血壓，但只有26人(25.2%)自知，心電圖檢查結果異常的34人(21.9%)中，但只有2人在訪視時表示知道，受訪者大多數不認為自己有高膽固醇及高三酸甘油酯的比率亦偏高。不過有86.3%的聽力損失者知道自己的聽力障礙。結論：勞工疾病預防，應該加強勞資雙方的職業安全衛生教育，強化檢查結果的追蹤機制。
  Objective: This study examined the gap between health examination results and the selfreported health status among workers who were exposed to carbon disulfide in viscose rayon industry. Methods: Health status in the insurance records of 1998 and the year 2000 annual examinations were extracted and compared with the self-reported health status in questionnaires. Results: The year 2000 health examination results showed that among 103 workers (66.5%) with hypertension, only 26 persons (25.2%) were aware of their hypertensive status. Two workers (4. 8%) reported having had ECG abnormalities among 34 workers with ECG abnormalities found in the examination. Low proportions of workers were also aware that they had elevated cholesterol and/or triglyceride. However, 86.3% of those who had hearing loss were aware of their difficulties in hearing. Conclusion: This study suggests that a mechanism should be established to inform employees of their health examination results. Both employers and employees in industries need health education on worker’s occupational safety and disease prevention.
• 433 - 438
• 10.6288/TJPH2002-21-06-06

• Link 實務 Public Health Practice
• 醫院應用網站現況與相關因素研究A study on building hospitals' websites and related factors
• 郭年真、鍾國彪、楊銘欽
  Nien-Chen Kuo, Kuo-Piao Chung, Ming-Chin Yang
• 網際網路 ； 醫院網站 ； 影響因素
  internet ; hospital website ; related factor
• 目標：本研究在調查國內醫院應用網站的現況，及探討影響醫院應用網站的因素。方法：以473家地區級以上醫院為母群體，郵寄問卷進行應用現況與影響因素的普查。同時收集醫院特性資料、並以內容分析法分析醫院網站，以及嘗試以「神秘顧客法」測量醫院處理民眾電子郵件的情形。結果：共回收174份有效問卷(回收率36.7%)，其中109醫院(62.6%)有架設網站。應用網際網路的好處認同比例最高的是增加服務品質與增加工作效率，超過7成的醫院同意未來網路會對醫療服務的提供產生很大改變。有9成以上的醫院網站有提供門診表，但進一步提供網路掛號功能的不到1/2，醫院網站應用互動式服務功能的比例不高。醫院處理民眾的電子郵件平均約需1至2的工作天，有回應民眾詢問的基本需要。結論：醫院網站的普及仍有很大空間，網站互動服務是未來可加強的重點。在影響應用網際網路科技的因素中，網路安全與院方高層的態度是關鍵，而競爭醫院的應用狀況與健保相關制度的要求，對於決策者具有相當的重要性。
  Objectives: The purpose of this study was to investigate the current situation in building hospitals’ websites, and find out related factors. Methods: Four hundreds and seventy four accredited hospitals in Taiwan were treated as the census population. Data collection was applied by a mailing questionnaire. We also collected data about hospitals’ characteristics, and use “Content Analysis” to evaluate hospitals’ websites contents. Furthermore, “Mystery Shopper” method was applied to measure how hospitals replied to customers’ E-mail. Results: 109 sample hospitals of total 174 replies (62.6 percent) have their own websites. Most of sample hospitals agreed that applying Internet technology can improve service quality and work efficiency. More than 70 services. More than ninety percent of hospitals provided a schedule of ambulatory service on their websites. Hospitals took one to two working days before replying to our “Mystery Shopper” email. Conclusion: Hospitals’ administrators should provide interaction between the hospital and customer through website. Internet security and attitude of hospitals’ administrators are key factors of hospitals in the application of websites. But how competitors apply websites and the regulations of the National Health Insurance still have a strong influence of website application strategies.
• 439 - 448
• 10.6288/TJPH2002-21-06-07

• Link 研究紀要 Research Brief
• 地理資訊系統應用於傳染流行病的疫情偵測、數據分析與速效控制Application of Geographic Information Systems to Epidemiological Surveillance, Data Analysis, and Effective Control in Infectious Disease
• 溫在弘、金傳春、蕭朱杏、嚴漢偉、范毅軍、蘇明道
  Tzai-Hung Wen, Chwan-Chuen King, Chuh-sing Kate Hsiao, Eric Yen, I-Chun Fan, Ming-Daw Su
• 地理資訊 ； 傳染病 ； 流行病特徵 ； 偵測系統,疾病地理擴散
  geographic information, infectious disease ; epidemiologic characteristics ; surveillance system ; disease geographic diffusion.
• 目標：傳染病的突然爆發式流行，最需「及早」防疫，以減少「零星病例」而有足以燎原的趨勢，尤其對新滋生傳染病(如第71型腸病毒)，或流行多起始於「境外移入病例」(如登革熱與登革出血熱)。方法：應用「地理資訊系統」(geographic information system，簡寫為GIS)的觀念於公共衛生的領域，包括深入探討地理資料型態、模式分析與統計檢定，偏重研討地理空間資訊(geo-spatial information)在協助傳染流行病疫情控制之重要性，如尋找病媒蚊滋生之防疫死角(空地、空屋或工地等)以及病例的感染來源。結果：本研究群已展開跨領域的合作研究，並呼籲趁早推動國內中央與基層衛生單位逐漸開始建立地理空間資訊的觀念。結論：地理資訊系統應用在疫病控制上仍有許多潛在問題，但是隨著地理資訊軟體的功能日益擴充、價格漸廉以及空間資訊之推廣教育，期能未來以地理資訊系統配合該地更健全的傳染病偵測系統、新興研發之生物統計方法與電腦軟體，確實協助公共衛生單位擬定更迅速有效的疫病防制策略。
  Objective: Sudden epidemic of an infectious disease urgently needs ear1y prevention and control measures for minimizing the cases leading to an epidemic, particularly on emerging infectious disease (enterovirus 7l) or an epidemic strongly associated with imported cases (dengue fever/dengue hemorrhagic fever). Methods: Application of geographic information science (GIS) plus geo-spatial information to public health, including data types, data models, data analysis and statistic tests, will be very useful in immediate control of infectious diseases, such as searching for dead corners of vector-breeding sites (empty ground, or empty houses) and sources of infection among those cases. Results: We initiated multi-disciplinary research collaboration on important infectious diseases in Taiwan and advocated its usage and advantages to local health bureaus and central government health agencies. Conclusion: Although potential problems of the application of GIS and its integration with different information systems exist, the lower cost of developing software and extension of educational purposes plus newly developed biostatistic analysis methods in future years will be very helpful in monitoring the dynamic transmission of pathogenic microbes. They will provide the most effective approaches in prevention and control strategies of infectious diseases.
• 449 - 456
• 10.6288/TJPH2002-21-06-08