23卷6期

• Link 公衛論壇 Public Health Forum
• 新興傳染病對公共衛生的衝擊挑戰—從衛生政策談因應策略新興傳染病對公共衛生的衝擊挑戰—從衛生政策談因應策略
• 石曜堂、施淑芳
  Yaw-Tang Shih, Shu-Fang Shih
• 無
  none
• 無
  none
• 429 - 430
• 10.6288/TJPH2004-23-06-01

• Link 原著 Original Article
• 我國現有職業病案例不同通報系統之概況分析Analysis of Occupational Disease Cases from Different Systems in Taiwan
• 林洺秀、陳秋蓉
  Ming-Hsiu Lin, Chiou-Jong Chen
• 職業病案例 ； 通報 ； 檢查策略
  occupational disease cases ; surveillance ; inspection policy
• 了解常職業病發生之行業及不同職業病資料來源所呈現之差異性。方法：收集及分析1999至2001年間，國內勞保現金給付、勞工健康檢查資料、事業單位職業災害統計及衛生署疑似職業病通報資料，其案件數與行、職業之分佈。結果：(l)特殊健康檢查及分級健康管理，因噪音作業引起之聽力損失310件佔極度大部分(88.1%)。行業別其中以棉紡紗葉及水泥製造業最多，醫院次之。(2)衛生署疑似職業病通報系統，總個業務數似職業性異常氣壓疾病(l448件，佔46.0%)最多；行業別以近海漁業最多，稻作栽培業次之。較為確定之個案數中，以疑似塵肺症85件(佔36.3%)最多；行業別以醫院最多，稻作栽培業次之。(3)事業單位職業災害統針侗業主要集中在製造業，營造業次之。(4)勞保現金給付資料，總個案數以塵肺症(22,225件，佔93.2 %)最多。結論：國內現有與職業病相關之四通報系統，皆有其侷限處，但其分佈概況仍可供勞工主管機關擬定預防職業病檢查策略之參考。
  This study is aimed to comprehend the differences between different reporting sources on common occupational diseases occurring according to profession distribution. Methods: Occupational disease case numbers, professions and occupational distribution between 1999 and 2001 from the records of labor-insurance compensation database, the physical examination of workers, the surveillance system of the Department of Health and the occupational injuries statistics of business units were collected and analyzed. Results: 1. According to special physical examination and classification health management, hearing loss caused by working in a noisy environment is the most reported occupational disease with 310 cases (88.1%). The cotton spin- fling industries and cement industries have the highest numbers of reported occupational disease cases followed by hospitals 2. According to the surveillance system of the Department of Health, occupational abnormal air pressure disease caused by working in an abnormal air pressure environment is the most commonly reported occupational disease with 1,448 cases (46.0%). The inshore fishery had the highest numbers of reported occupational disease cases followed by rice planting. Among the confirmed cases, pneumoconiosis was the most reported occupational disease with 85 cases (36.3%). Hospitals had the highest numbers of confirmed reported occupational disease cases followed by rice planting. 3. According to the occupational injuries statistics of business units, reported occupational injury cases are concentrated in manufacturing followed by construction industries. 4. According to the records of the labor-insurance compensation database, pneumoconiosis was the most commonly reported occupational disease. Totally, there were 22,225 cases (93.2%). Conclusion: All four reporting sources have their limitations, however, the study results of the distribution of occupational diseases may offer references and recommendations to labor inspection agencies in drafting the occupational diseases prevention inspection strategy.
• 431 - 439
• 10.6288/TJPH2004-23-06-02

• Link 原著 Original Article
• 加護病房院內感染指標—影響呼吸器相關肺炎感染因素之探討Study on Factors for Ventilator-Associated Pneumonia in Intensive Care Unit
• 吳肖琪、陳啟禎
  Shiao-Chi Wu, Chi-Chen Chen
• 呼吸器豐關肺炎感染 ； 加謢病房 ； 院內感染
  ventilator-associated pneumonia ; intensive care unit ; nosocomial infection
• 利用全國健保申報住診次級資料，探討加護病房呼吸器相關肺炎(Ventilator-Associated Pneumonia, VAP)感染情形及相關因素。方法：以民國88年健保申報曾住加謢病房且使用呼吸器病患屬研究對象，以選輯斯迴歸分析其VAP感染情形與病患特質(性別、年齡、加謢病房住院天數及是否患有慢性肺部疾病)及醫院特質(權屬別、評鑑層級、總床數及加謢病房床數)間關聯性。結果：在加護病房裝置呼吸器共計申報有76,979人次，其中2,952人次?VAP感染，感染機率?3.53%。在病患特質中，男性(AOR,1.27;95% CI,1.17-1.38)、年齡愈大(25-44歲[AOR,1.56;95% CI,1.20-2.02], 45-64歲[AOR,1.56;95% CI,1.54-2.25],65歲以上[AOR, 2.72;95% CI,2.28-3.26 ]之VAP感染機率顯著較高；加護病房住院天數愈長(3-5天[AOR,1.91;95% CI,1.63-2.241,6-1天[AoR,4.14;95% CI,3.61-4.76], 14天以上[AOR,7.25;95% CI,6.37-8.29])與VAP感染機率有關；在髻院特質中，私立(AOR,1.67;95% CI,1.51-1.54)、評鑑層級愈低(區域醫院[AOR,2.26;95% CI,2.03-2.51], 地區教學醫院[AOR,3.15;95% CI,2.51-3.61]，地區醫院[AOR,5.54;95% CI,5.16-6.60)之醫院VAP感染機率顯著較高。結論：衛生主管機關可利用健保申報次級資料，監控加護病房VAP感染情形，並針對加護病房VAP感染相關因素，作進一步預防措施。
  Using claimed data from National Health Insurance (NHI) to identify factors associated with the development of ventilator-associated pneumonia (VAP). Method: Insured patients, who received mechanical ventilation in the Intensive Care Unit (ICU) in 1999, were analyzed in this study. The relationship among VAP, patients' characteristics (such as sex, age, history of chronic obstructive pulmonary disease (COPD), and length of stay of ICU) and the characteristics of hospitals (such as ownership, accredited, number of general and ICU beds) were analyzed by logistic regression. Results: There was 2952 of 76979 (3.83%) patients who developed VAP during hospitalization in ICU. The infectious rate of VAP was significantly higher in male (adjusted odds rate (AOR) 1.27, 95% CI 1.17-1.38) and elder patients (AOR of 25-44 years old was 1.56, 95% confidence interval (95% CI) was 1.20-2.02; AOR of 45-64 years old was 1.86, 95% CI was 1.54-2.25; AOR of above 65 years old was 2.72, 95% CI was 2.28-3.26). The rate of VAP was related to the longer length of stay in ICU (AOR of 3-5 days in ICU was 1.91, 95% CI was 1.63-2.24; AOR of 6-13 days in ICU was 4.14, 95% CI was 3.61-4.76; AOR of over l4days in ICU was 7.25, 95%CI was 6.37-8.29). The rate of VAP was higher in private hospitals (AOR 1.67, 95% CI 1.51-1.84). Compared with teaching hospitals, the lower hospital accreditation level was assoicated with a higher rate of VAP (AOR of regional hospitals was 2.26, 95% CI 2.03-2.51; AOR of district teaching hospitals was 3.18, 95% CI 2.81-3.61; AOR of district hospitals was 5.84, 95% CI 5.16-6.60). Conclusion: The claimed data from NHI can be used for monitoring the condition of VAP in ICU patients by the governmental institute in order to construct policy to prevent further VAP.
• 440 - 446
• 10.6288/TJPH2004-23-06-03

• Link 原著 Original Article
• 衛生署與內政部死亡資料連結比對分析Comparison of the Number of Deaths Released by the Registration Data of Department of Health and Ministry of Interior: a Linkage Study
• 朱慧凡、吳肖琪
  Hui-Fan Chu, Shiao-Chi Wu
• 內政部 ； 衛生署 ； 死亡登記 ； 資料庫
  Ministry of Interior ; Department of Health ; death registration ; dataset
• 以內政部與衛生署死亡資料速結進行比對，探討兩單位死亡資料之差異，以為研究者使用該資料庫與相關單位改善資料庫品質之參考。方法：以內政部統計與衛生署統計公布之歷年(民國71-91年)死亡人數統計比較人教差異之趨勢，並速結民國88年內政部死亡檔與衛生署死因檔比較實際差異之情形。結果：若以歷年內政部戶政司與衛生署統計室公布死亡人數統計做比較，可發現各年度檔案人數之符合率皆高達98%以上。但若以實際資料逐筆連結比對，則88年死因檔符合率由內政部與衛生署統計死亡人數的98.7%降為95.09%，內政部與衛生署檔案中未連結上之人數分別為6,203人與4,747人。進一步分析發現不同年齡別與地區別之連結率有顯著差異。結論：本研究發現內政部與衛生署公佈之死亡人數總數差異約為2%，逐筆連結比對後差異約為4%，此差異會隨死亡年齡增加而減少且有地區性差異。建議未來使用者應小心年齡與地區差異。關於造成此比對差異的原因與政策意涵，有待未來研究進一步釐清。
  To explore the difference between the datasets of the death registration of the Department of Health (DOH) and Ministry of Interior (MOI) for the reference of the researchers in the future. Methods: We used the annual number of deaths published by the MOI and DOH during 1982-2002 to analysis the difference; and linking the datasets of the death registration of MOT and DOH, published in 1999, by ID number to verify the actual difference in the number of cases. Results: The concordant rate of number of deaths published by DOH and MOI was 98.7%. When the datasets were linked by ID number, the concordant rate was dropped to from 98.7% to 95.9%. There were 6,203 cases from the MOI dataset and 4,747 cases from the DOH dataset not matched by ID number. The rate of mismatch varied by age and area. Conclusions: The difference in the number of death published by DOH and MOI was about 2%. When the datasets were linked by each ID number, the difference in the number of death was increased to 4%. The concordant rate between the datasets of DOH and MOI varied by age and area. When using the dataset of death registration from the DOH or MOI for study, researchers should be aware of the variance. The causes of the difference and policy implication of this should be investigated in further study.
• 447 - 452
• 10.6288/TJPH2004-23-06-04

• Link 原著 Original Article
• 影響住院病患跨區利用之因素Cross-Region Hospitalization Behavior and Its Related Factors in Taiwan
• 林維娟、張鴻仁、王本仁、周穎政、李丞華
  Wei-Chuan Lin, Hong-Jen Chang, Pen-Jen Wang, Ying-Jeng Chou, Cheng-Hua Lee
• 跨區利用 ； 住院服務 ； 全民健保
  Cross-region utilization ; inpatient services ; national health insurance
• 本研究的目的有兩項，第一為描述台灣地區住院病患跨越醫療區之利用情形；第二為探討個人特質、疾病特性與醫療資源等三項因素對跨區住院利用之影響。方法：本研究利用國家衛生研究院提供之2000年保險對象個人歸戶資料檔，並透過中央健康保險局數據中心協助，進行住診明細檔、醫事機構檔、重大傷病檔及戶籍資料檔等檔案串聯，共完成89,814名具全國代表性樣本為分析對象。本研究以病患戶籍地與其住院醫院所在地是否為相同醫療區，判斷是否跨區住院，並進一步對病患個人特質、疾病特性與地區醫療資源與跨區住院之間關係進行對數迴歸分析。結果：西元2000年內台灣民眾住院人次有21%為跨越醫療區住院，跨區住院比例以雲林醫療區57%?最高，南投醫療區49%居次，而台北醫療區8%及高雄醫療區9%為最低。對數複迴歸分析顯示四歲以下幼童、高薪資所得者、手術病患、癌症及精神病等重大傷病患者，以及居住在醫師及醫院病床數較少之醫療區的民眾，均有顯著較高比例之跨區住院利用。結論：影響住院病患跨區醫療利用的因素，除了地區醫療資源外，病患個人特質及病情因素均是重要因素，未來醫療資源地區規則須進一步重視民眾人特質及疾病特性。
  The objectives of this study were to describe the utilization pattern of patients seeking hospitalization services outside their medical regions and to explore factors influencing cross-regional hospitalization behavior. Method: This study adopted the National Health Insurance enrollment and claims data of the year 2000 provided by the National Health Research Institute. A representative sample of 89,814 beneficiaries was analyzed. This study identified cross-regional hospitalization by comparing patients' residential locations and the locations of the hospitals they were admitted to. Multivaraite logistic regressions were used. Results: For the year 2000, about 21% of hospitalized patients were from medical regions outside the regions of the hospital that they were admitted to. The highest cross-regional hospitalization rates were observed in Yunlin County (57%) and Nantou (49%). The lowest rates were observed in Taipei (8%) and Kaohsiung (9%). Multivariate results showed that children under the age of four, high-incomer individuals, surgical patients, cancer patients, the mentally ill, other catastrophic illness patients, and citizens residing in areas with poorer medical resources had higher cross-region hospitalization rates. Conclusion: It was not only the sufficiency of medical resources that had a significant influence on cross-region hospitalization, but also the patient's personal characteristics and the attributes of disease. The planning and allocation of future medical resource should take patient characteristics and the attributes of their diseases into consideration.
• 453 - 461
• 10.6288/TJPH2004-23-06-05

• Link 原著 Original Article
• 醫師服務量對極低出生體重新生兒醫療費用的影響分析Impact of Physician Volume on Medical Expenditures: Empirical Study of Very Low Birth Weight InfantsImpact of Physician Volume on Medical Expenditures: Empirical Study of Very Low Birth Weight Infants
• 黃昱瞳、翁新惠、楊長興、許玉君
  Yu-Tung Huang, Shin-Huey Wung, Chiang-Hsing Yang, Yu-Jung Hsu
• 醫師服務量 ； 極低出生體重新生兒 ； 醫療費用
  physician volume ; very low birth weight infants ; medical expenditures
• 本研究旨在探討在照護極低出生體重新生兒時，其出生後首次住院所花費之醫療費用是否因醫師服務量的多寡而有差異。方法：以國家衛生研究院全民健保資料庫2000年出生體重介於500~1499 公克的極低出生體重新生兒為研究對象，串連照護醫師及機構特性資料，進行迴歸分析。結果：符合研究定義之樣本共1191個新生兒，在控制新生兒特性、醫院特性及疾病嚴重度後，醫師服務量與其所照護新生兒的醫療花費呈負相關。結論：由較有經驗的醫師照護極低出生體重新生兒時，其花費的醫療費用相對較低，但是影響微小。
  To empirically evaluate the impact of physician volume on medical expenditures with very low birth weight infants who were initally haspitalized. Method: NHI claim record data from 1191 cases of very low birth weight (500g-1499g) infants were obtained from the NHI research database. The regression model was employed to evaluate the relationship between physician volume and medical expenditures. Results: After adjusting for hospital characteristics, patient characteristics and outcome, we found a negative correlation between physician volume and medical expenditures. Conclusion: Medical expenditures may be lower for very low birth weight infant when cared for by a high volume physician, but the effect was limited.
• 462 - 468
• 10.6288/TJPH2004-23-06-06

• Link 原著 Original Article
• 醫藥分業西醫診所門診處方釋出率及影響因素之分析Impact of the Separation of Drug Prescribing and Dispensing Policy on the Release Rate of Prescriptions from Clinics
• 黃光華、李玉春、黃昱瞳
  Kuang-Hua Huang, Yue-Chune Lee, Yu-Tung Huang
• 醫藥分業 ； 處方釋出率 ； 影響因素
  separation of drug prescribing and dispensing ; release rate of prescriptions ; influence factors
• 本研究目的在瞭解台灣醫藥分業政策實施前後處方箋釋出比例之趨勢，及影響診所釋出門診處方箋之因素。方法：本研究採次級資料分析，研究對象?全民健保西醫分所，資料來源為國家衛生研究院1996~2000年全民健康保險學術研究資料庫中之全民健保西醫基層門診申報資料。結果：醫藥分業政策顯著影響處方釋出率，隨著實施地區人口比率增加，整體的處方釋出率雖仍相當低，但有顯著成長；都市化程度較高或較低地區、診所執業醫師數較少、每日服務量較低、專案案件相對於慢性病，一般珍所相對於專科分所，處方釋出可能性顯著較高；相對於耳鼻喉科，眼科、皮膚科、外科及婦?科釋出處方率顯著較低，而家醫或不分科、內科及兒科則顯著較高；病患年齡愈輕，疾病嚴重度愈低(A類疾病)處方釋出可能性顯著較高。結論：雖然本研究發現除醫藥分業外，環境因素、機構特性及病患特性皆顯著影響處方釋出率，但財務誘因可能才是最重要之因素。為落實醫藥分業政策，建議提高健保釋出處方誘因並降低藥品利潤，俾利整體處方釋出率之提升。
  This study aimed to investigate the trend and related factors of the release rate of prescriptions (RRP) to the pharmacies of primary care clinics with reference to the implementation of separation of drug prescribing (SDP) policy in Taiwan. Methods: Secondary data analysis was applied to the claim data of primary care clinics under the National Health Insurance scheme from 1996 to 2000. The database was obtained from the National Health Research Institutes. Results: The implementation of SDP was found to be related to the RRP. The greater the population covered by SDP, the higher the RRP, despite the low rate of RRP nationally. Clinics in the most and least urbanized areas, with fewer physician numbers and a lower patient volume, registered as specialist unit, and claiming the visits as special services rather than chronic diseases had higher RRP. Compared with E.N.T., those practicing family medicine, general practice, internal medicine, and pediatrics had higher RRP than those practicing gynecology, surgery, dermatology and ophthalmic. Regarding patients' characteristics, the younger, and the less severe (type A diseases) the patients were, the higher the RRP. Conclusion: Although this study found that environmental, institutional and patient factors, as well as SDP, all had significant impact on RRP, the financial incentives, still played the most important role. For the purpose of reinforcing the SDP policy and promoting the total RRP, it is recommended that NHI should increase financial incentives and reduce the profit gained from drugs.
• 469 - 478
• 10.6288/TJPH2004-23-06-07

• Link 原著 Original Article
• 與公衛護士互動關係感受、疾病知識、疾病態度與糖尿病自我照顧行為的關係The Rrelationships among the Perception of Interactions with Public Health Nurses, Knowledge of Disease, Attitude Toward Disease, and Self-Care Behaviors of Diabetes Mellitus
• 林冠品
  Kuan-Pin Lin
• 非胰島素依賴型尿病 ； 自我照顧行為 ； 互動關係感受 ； 知識 ； 態度
  non-insulin-dependent diabetes mellitus (NIDDM) ; self-care behaviors ; perception of interaction ; knowledge ; attitude
• 本研究目的為控討社區非胰島素依賴型糖尿病個案對與公衛護士互動關係感受、疾病知識和態度輿自我照顧行為的相關性。方法：本研究為橫斷式研究設計，以高雄市八區衛生所列管之非胰島素依賴型糖尿病個案為對象，共計收取有效樣本143人，並利用結構式問卷收集資料，包括自我照顧行為量表、對與公衛護士互動關係感受量表、糖尿病知識量表、糖尿病態度量表。結果：個案自我照顧行為標準化得分為62.37，其中以飲食自我照顧行為得分最高，而足部護理自我照顧行為得分最低；對輿公衛護士互動關係感受、疾病知識、疾病態度均與自我照顧行為呈現正相關；對輿公衛護士互動關係感受、疾病知識是自我照顧行為的重要預測因子，總解釋變異有29.00%。結論：由研究結果建議公衛護士應典管理的糖尿病個案建立良好互動關係，尤其應該鼓勵個案參輿疾病的決定控制，並賦權給個案做決定，同時增強個案相關的疾病知識，以促進個案自我照顧計劃的執行和改善自我照顧行為。
  The purpose of this study was to understand the relationships among perceptions of interactions with public health nurses (PHNs), knowledge of disease, attitude toward disease, and self-care behaviors among patients with non-insulin-dependent diabetes mellitus (NIDDM). Methods: A cross-sectional study was conducted among 143 community-based NIDDM cases that were cared for by PHNs from eight public health centers in Kaohsiung City, Taiwan. The structured questionnaire included a diabetes self-care scale, perception of interactions with PHNs scale, knowledge of DM scale, and attitude toward DM scale. Results: The results showed that the standardized score for overall self-care behaviors was 62.37. According to each subscale, the diet self-care scale had the highest standardized score, while the foot self-care scale had the lowest standardized score. The perception of interaction with PHNs, knowledge of disease, and attitude toward disease were all significantly positively correlated with self-care behaviors. The perception of interaction with PHNs and knowledge of disease were important predictors of self-care behaviors, and explained 29% of the total variance. Conclusions: According to the findings, PHNs should maintain good interactions with diabetes cases, especially encouraging clients to participate in control over their decisions. PHNs should empower clients to increase decision-making and reinforce the related disease knowledge of clients, so that the clients will comply with self-care plans and improve their overall self-care behaviors.
• 479 - 486
• 10.6288/TJPH2004-23-06-08

• Link 原著 Original Article
• 影響學齡前兒童過重相關因素之探討A Study of Overweight in Preschool Children in Taiwan
• 張慈桂、藍忠孚、李燕嗚、王本榮
  Tzu-Kuei Chang, Chung-Fu Lan, Yin-Ming Li, Pen-Jung Wang
• 學前兒童 ； 過重 ； 身體質量指數 ； 父母
  preschool children ; overweight ; body mass index ; parents
• 兒童期的過重及肥胖，容易在成年罹患慢性疾病而影響健康，是目前重要的公共衛生問題。本研究以社區樣本探討學齡前兒童過重情形及其影響因素。方法：本研究資料來自於“家庭社經地位與其學前兒童健康狀況及醫療保健需求之比較分析”計畫，該研究以橫斷性之調查訪視進行，先依台閩地區人口統計中都會區定羲，於91年7月15日至9月底期間，在各不同都會區中收集1191位元3~5歲學齡前兒童為樣本，以面對面訪視其主要照護者為對象，以結構式問卷收集兒童父母背景資料、兒童特性及其身高、體重，依衛生署公告之“兒童及青少年肥胖定義”區分界定其身體質量指數是否過重，並探討影響其過重與否的相關因素。結果：依衛生署公告標準，發現3~5李前兒童樣本遇重的比率高達23.9%。進一步邏輯迴歸分析結果發現，在控制了相關因素後，孩童的居住地區扁“?”層級(OR=2.30,95% CI:1.33-3.97)、母親過重(OR=1.90,95% CI:1.34-2.70)、及就讀幼稚園(OR=0.68,95% CI:0.49-0.96)是主要影響學前兒童過重與否的因素。結論：依據研究結果，學前兒童過重的問題，在社區的嚴重性高於已進入幼教機構者，母親過重以及居住於“?”層級也是重要的指標。提供作為未來規劃學前教育、進行兒童研究及健康介入計畫的參考。
  Children overweight or obesity affects their adult health and is becoming an increasing public problem. The aims of this study were to explore the main factors which caused preschool children aged at 3 to 5 in Taiwan to be overweight. Method: This data came from the part of a study entitled “A comparative study on the health conditions and health care demands of preschool children of different family socioeconomic status”. The study was a cross-sectional study and was conducted by face-to-face interview with the children's caregiver. It contained 1191 samples from different urbanization levels during the 15th, July to the end of September 2002. The urbanization levels were based on the classification in the Taiwan-Fukein Demographic Fact Book from the Ministry of Interior. The subjects were asked to complete a set of questionnaire that included the height, weight, child's characteristics and parents' background. Children's overweight was defined according to the age/sex specified body mass index criteria given by the Department of Health in 2002. Results: The prevalence rate of overweight in preschool children samples was 23.9%. After controlling for the variables of the child's characteristics and parents' background, we found that living at “Chens” level (OR=2.30, 95%CI:l.33-3.97), mother being overweight (OR=l.90, 95%CI:1.34-2.70) and attending kindergarten(OR=0.68, 95%CI:0.49-0.96) significantly affected the preschool children's overweight. Conclusion: According to the result, overweight in preschool children was more common in the group that didn't attend the kindergarten and were also significantly correlated with mother being overweight and living at the “Chens” level. The findings here should be helpful in designing an effective formal preschool education and weight control intervention program.
• 487 - 496
• 10.6288/TJPH2004-23-06-09