25卷5期

• Link 原著 Original Article
• 台灣婚姻移民的人口學特性與公共衛生需求初探Exploration of the Demographic Characteristics of Marital Immigrants in Taiwan and Its Public Health Needs
• 黎雅如、沈佩瑩、廖玫涵、林宜平
  Ya-Ru Li, Pei-Ying Shen, Mei-Han Liao, Yi-Ping Lin
• 婚姻移民 ； 人口學特性 ； 地理分佈 ； 婦幼衛生
  marital immigrants ; demographic characteristics ; geographic distribution ; maternal and child health
• 目標：本研究旨在描述台灣婚姻移民的人口學特性及地理分佈，並探討這些分佈對公共衛生政策可能的影響。方法：本研究彙整政府相關單位有關外籍婚姻配偶的次級資料進行分析。結果：台灣的婚姻移民以女性為主，佔所有婚姻移民的九成左右。從2000年起，每年都有約四萬名的女性婚姻移民進入台灣，這樣的異國聯姻約佔台灣每年結婚對數的四分之一。本國、中國、束南亞及其他國籍的新娘，年齡及教育程度有顯著差異，相較於本國籍新娘，中國與束南亞籍新娘較年輕，而且學歷較低。女性婚姻移民在台灣的地理分佈並不平均，外籍配偶人數最多的是台北縣（2萬人）及桃園縣（1.3萬人），而佔各縣市有偶女性人口的比例最高的則是新竹縣及澎湖縣（均為4.1%）。自2001年起台灣每年都有超過兩萬名的新生兒其生母非本國籍，約佔總新生兒人數的七分之一。結論：公共衛生政策應考量婚姻移民的人口學特性及其地理分佈，並持續追蹤相關政策對婚姻移民生理、心理及社會健康的影響。
  Objectives: We investigate the current demographic and geographic distributions of marital immigrants in Taiwan, and discuss its impacts on public health. Methods: We retrieved and integrated secondary data from different government institutions for our analysis. Results: About 90% of marital immigrants in Taiwan are females. Since 2000, there were approximately forty thousand female marital immigrants migrated to Taiwan annually. Inter-racial marriages accounted for one-fourth of total marriages in Taiwan. Our study reveals that immigrant brides from China and Southeast Asian countries were significantly younger, and had significantly lower education as compared to Taiwanese brides. The geographic distribution of marital immigrants varied in Taiwan. The majority of marital immigrants from Southeast Asian countries resided in Taipei county (20 thousand) and Taoyuan (13 thousand). However, counties with the highest proportion of marital immigrant from Southeast Asian countries were Xinzhu and Penghu (both 4.1%). Since 2001, there were more than twenty thousand babies born of a ”foreign mother” annually, which accounted for about one-seventh of the total newborns in Taiwan. Conclusions: Public health policies should take marital immigrants' demographic characteristics and its geographic distribution into consideration. Further, we should follow the physical, psychological, and social health impacts of public policies on marital immigrants.
• 482 - 493
• 10.6288/TJPH2006-25-06-08

• Link 綜論 Review Article
• 美國老人醫療保險急性後期照護的發展The Development of Medicare post-acute Care in USA
• 戴桂英、吳淑瓊、江東亮
  Guey-Ing Day, Shwu-Chong Wu, Tung-Liang Chiang
• 美國老人醫療保險 ； 急性後期照護 ； 前瞻式支付制度
  Medicare ; post-acute care PAC ; prospective payment system PPS
• 美國實施急性醫院前瞻式支付制度後，急性後期照護蓬勃發展。台灣自1995年實施全民健保，為控制醫療利用也提出醫院前瞻式論病例支付之擬議。本研究目的在探討美國Medicare的急性後期照護供給成長趨勢、利用狀況、影響急性後期照護消長的政策，以及提出對台灣的啟示。我們發現美國Medicare急性後期照護(1) 1997年起受預算中平法案影響供給成長趨緩；(2) Medicare約有12%的花費用於居家健康照護、技術性護理機構、復健醫院和長期照護醫院；(3)機構式服務要自負額、每日定額等部分負擔；(4)以四種前瞻式支付制度擬限制其過度成長。我們建議台灣於推動醫院前瞻式論病例支付制度時，宜(1)同時研議急性後期照護的範圍、支付方式和部分負擔設計，且避免費用過度轉成民眾自付；以及(2)思考如何將急性醫療與急性後期照護配套，以求服務連續完整，並設計客觀的成果評估方式。
  Following the implementation of Medicare's acute care hospital prospective payment system in the USA in 1984, Medicare spending for post-acute care (PAC) began to grow rapidly. Taiwan's National Health Insurance (NHI), which was implemented in 1995, is planning a hospital case payment system to avoid such unnecessary utilization. The purpose of the current study was to review the trend of post-acute care providers and spending for Medicare from the early 1990s to 2004, prospective payments for post-acute care providers in the USA, and the impact of the changes in Medicare payment policies. The main findings of the study are as follows: (1) the number of PAC providers increased rapidly across all settings after implementation of DRGs payment, but increased slowly, or decreased in facilities such as home health agencies, after implementation of PPS for PAC providers, following mandates in the Balanced Budget Act of 1997, (2) PAC made up about 12% of Medicare's total spending, (3) beneficiaries should pay deductible or co-payments while using institutional PAC, and (4) in order to control spending, Medicare's system of PAC payments should be converted to prospective payments. When the prospective case payment system is implemented in Taiwan, we: (1) recommend that the coverage, the payment system, and the co-payments of post-acute care should be redesigned at the same time and (2) suggest that the hospital case payment system should be planned carefully to make post-acute care integrated with acute care.
• 323 - 329
• 10.6288/TJPH2006-25-05-01

• Link 綜論 Review Article
• 門診醫師以抗生素治療上呼吸道感染症與急性支氣管炎的影響因素與介入策略Factors Influencing Antibiotic Prescriptions for Patients with Airborne Infections and Intervention Strategies to Change Antibiotic Prescribing Behavior by Ambulatory Care Physicians
• 劉嘉年、楊志良
  Chia-Nine Liu, Chih-Liang Yaung
• 抗生素處方 ； 門診 ； 上呼吸道感染症 ； 急性支氣管炎 ； 介入策略
  Antibiotic prescribing ; Ambulatory care ; Upper respiratory tract infections ; Acute bronchitis ; Intervention strategies
• 不當使用抗生素治療上呼吸道感染症，是導致病菌抗藥性的主因之一。瞭解醫師處方行為的影響因素與有效的介入策略，可以提供政策建議減少不當抗生素的使用。透過文獻探討，分析討門診醫師使用抗生素治療上呼吸道感染症與急性支氣管炎的影響因素與介入策略。結果發現醫師處方行為受到醫療與臨床因素、醫病互動、醫療組織因素、醫療保險與政策等因素影響。單一提供書面?教或審核回饋的介入策略，對醫師的抗生素處方行為的影響有限，而針對醫師、病患與社區民眾的多面向介入較能有效改變醫師行為，延緩處方的介入策略則是有效又低成本的介入方式。未來宜針對高抗生素處方之醫師進行影響因素的分析，採用多面向的介入模式，進行醫師在職教育與病患衛教，審核醫師檔案並加以回饋，並選派藥劑師至高抗生素處方醫師的診所提供專業建議。
  The excessive use of antibiotics in ambulatory patients with airborne infections in Taiwan is associated with increased rates of antibiotic-resistant bacteria. To understand the factors which influence the prescribing of antibiotics and develop intervention strategies to reduce the inappropriate use of antibiotics would be helpful in providing suggestions for policy making. We reviewed the literature and identified important factors underlying antibiotic prescribing behaviors by ambulatory care physicians for patients with URIs and acute bronchitis and the intervention strategies successfully employed to limit the over-prescription of antibiotics. The results revealed that imprudent prescribing of antibiotics in ambulatory care was influenced by clinical factors, physician-patient interactions, health care organization factors, type of health insurance coverage, and policy factors. A simple, single-intervention, in the form of printed educational materials, medication audits, or performance feedback, generally resulted in small changes in prescribing behaviors. Multi-faceted interventions involving physicians, patients, and community education programs consistently produced moderate changes in prescribing behaviors. Delayed prescribing was an effective intervention with a low associated cost to reduce antibiotic use for viral respiratory tract infections. Efforts to reduce the inappropriate prescribing of antibiotics should target the high-prescribing physicians and apply multi-faceted interventions involving a combination of healthcare providers with consumer education, medication audits, and performance feedback, supplemented by educational outreach from pharmaceutical representatives.
• 330 - 339
• 10.6288/TJPH2006-25-05-02

• Link 綜論 Review Article
• 台灣健康照護制度改革的理論面探討：代理人與效率A Theoretical Discourse on Healthcare Reform in Taiwan: Agency Theory and Efficiency
• 李卓倫
  Jwo-Leun Lee
• 健康照護體系改革 ； 效率 ； 代理人關係
  Health Care Reform ; Efficiency ; Agency Relationship
• 本文的主旨在探討臺灣健康照護體系改革如何達成效率的理論基礎和制度設計，以論述及文獻回顧把制度設計建立在理論的合理性之上，並強調社會制度與人類行為動機假設兩者的緊密聯結。本文首先討論健康照護的本質，包括其基本特質、從屬特質及其政策意涵。第二節討論醫療體系設計的人類行為動機假設，第三節與第四節討論效率的人性面定義與制度面設計，其中人性面定義是為質量與價格的權衡，接著再討論何種制度設計可以引發這種有效率的行為。第五節為本文推論對台灣總額預算制度所提出的建議與結論。本文的討論指出以消費者或病患為出發點來設計醫療體系的思考邏輯，有必要轉變為以代理人關係作為制度設計的基礎。有效率的選擇來自於花費與品質數量之間的權衡，好的代理人制度應該可以確保由醫師來代理病患作這樣的權衡，亦即有效率的選擇來自醫師在既想節省費用又想提高品質數量兩者的衝突下所做的權衡。
  Herein we have described the theoretical background regarding efficiency and healthcare reform. Literature review and discourse are used, with a specific focus on the connection between healthcare system design and assumptions pertaining to human traits and behavior motivation. Five sections are presented: 1) the intrinsic characteristics of healthcare, 2) the consumers' utility, 3) the definition of efficiency from a psychosocial perspective, 4) the agency relationship, and 5) suggestions for Taiwan's healthcare reform. Three intrinsic characteristics are described, the fundamental triad from which all other listed characteristics can be derived, either as variants or as resulting social responses. Healthcare, as that set of goods and services which patients use solely or primarily because of the anticipated impact on their health status, is then defined. In so doing, the concept of efficiency as a trade-off between quality/quantity and expenditures, which would be the most relevant perspective for designing and reforming a healthcare system, is delineated. Finally, the agency theory is discussed and suggested for healthcare reform in Taiwan. The national cap system and the primary healthcare fund holder, paid by a capitation base, are also discussed in the final section.
• 340 - 350
• 10.6288/TJPH2006-25-05-03

• Link 原著 Original Article
• 台灣地區高齡人口存活之相關因素探討Factors Associated with Survival Status of Order Taiwanese Adults
• 林正祥、林惠生
  Cheng-Hsiang Lin, Hui-Sheng Lin
• 老人健康調查 ； 存活狀況 ； Cox比例風險模式
  survey of health and living status of the elderly ; survival status ; Cox proportional hazard model
• 目標：探討台灣地區高齡人口存活之因素。方法：本研究利用1989年「台灣地區老人保健與生活問題調查」，歷時十年之資料以Cox比例風險模式分析與老人存活之相關因素。根據以往文獻我們共選擇了與老人存活有密切關聯的15個重要變項並以此建構6組模式，包括背景特徵、身心狀況、家庭環境、社會參與及衛生行為之組合並分別就各模式間差異探討之。結果：研究結果顯示身心狀況(ADL、體能狀況和健康自評)對老人的存活影響至鉅，換句話說，除了一些人口變項外，健康的身體及獨立活動的能力，遠甚於教育程度、經濟狀況及抑鬱程度對老人存活的影響。此外，配偶存在亦有降低死亡風險的作用。我們亦探討了在這些變項同時存在時各變項之死亡風險，並針對在控制其他變項平均值時各重要變項之老人調整存活機率做了一些說明。另外，也討論了在人口變項組合（年齡＋性別＋族群）之風險。結論：經統計模式選擇，選出了年齡、體能狀況、健康自評、ADL狀況、性別、有無配偶、族群、社團活動、抽煙年數、嚼檳榔年數等十個變項之模式，其可視為影響老人存活的重要指標且足以預測老人存活狀況。另外，本研究中6組模式藉由不同變項組合來解釋影響老人存活狀況，可因探討目的不同而相互比較分析。
  Objective: To investigate the factors associated with survival status of the elderly in Taiwan. Methods: The impact of factors on the survival status of older Taiwanese during the 10 year interval from April 1989 to April 1999 was examined. Data was derived from the Taiwan Survey of Health & Living Status of the Elderly, as published in 1989, 1992, 1996, and 1999. The Cox proportional model was used for data analysis. Results: With the exception of some demographic variables, ADL function, physical function, and self-rated health, had a much stronger relationship to the survival status of the elderly in Taiwan than did education, economic status, and depression. In addition, we (i) discussed the risk ratio of the impact factors on survival status, (ii) investigated the adjusted survival curve of some important factors, and (iii) explored the risk ratio of combined demographic variables (i.e., age + gender + marital status) of the Taiwanese elderly. Conclusion: Based on model selection, ten factors were strongly related to the survival status of the elderly: age, gender, ethnicity, marital status, social participation, self-rated health, Ssmoking, consumption of areca nuts, ADL function, and physical function. These variables had a good prediction index for survival status of the elderly in Taiwan. However, the six models utilized in this study can be compared with each other for specific research purposes.
• 351 - 362
• 10.6288/TJPH2006-25-05-04

• Link 原著 Original Article
• 利用地理資訊系統評估台南安順污染廠址周圍之土壤污染Identification of Soil Contamination in AnShen Using a Geographic Information System
• 江博煌、謝顯堂、陳筱蕙、詹大千、劉德明、溫啟邦、陳筱蕾、毛義方
  Po-Huang Chiang, Dennis H Hsieh, Hsiao-Hui Chen, Ta-Chien Chan, De-Ming Liou, Chi-Pang Wen, Hsiao-Lei Chen, I-Fang Mao
• 地理資訊系統；空間分析；土壤污染；克利金法
  ?Geographic Information System?;?Spatial Analysis?;?Soil Contamination?;?Kriging
• 目標：台南安順地區土壤被嚴重污染，主要的污染源包括戴奧辛、汞及五氯酚(PCP)。本研究利用地理資訊系統的空間插值法分析該地區之土壤及魚塭底泥採樣資料，並預測在安順廠區附近戴奧辛及汞的污染範圍及嚴重程度。方法：本研究是利用檢測不同克利金法(Kriging)以選擇最佳的模式，最佳模式之選取是以最小標準預測誤差(SPE, Standardized Prediction Error)及最小均方根標準誤差(RMSS, Root Mean Square Standardized Error)做為檢驗之標準。結果：基於上述之方法，所選取出來的最佳預測模型分別為：戴奧辛－通用克利金球面模型(Dioxin-Universal Kriging spherical model)、汞－一般克利金指數模型(Mercury - Ordinary Kriging exponential model)。結論：研究結果與環境保護署之檢測資料相符，但由此研究提供更多的訊息以利政府迅速清理污染地區之參考。更多的資料及更好的GIS方法會得到更佳的預測結果。
  In a ”superfund site” in Tainan City, Taiwan, soils are heavily polluted. Major pollutants include pentachlorophenol, dioxin, and mercury. The current study used a geographic information system (GIS) spatial interpolation method to analyze soil and sediment samples in this area and estimate the range and severity of pollution in areas in the An-Shun ”superfund site” with respect to dioxin and mercury. Methods: Different Kriging methods were used to select the best model, based on the smallest standardized prediction (SPE) and root mean square standardized (RMSS) errors. Results: The Universal Kriging with Spherical and the Ordinary Kriging with Exponential models were shown to be the best models for estimating dioxin and mercury levels, respectively. Discussion: Our results confirmed the monitoring data generated by the Taiwan EPA and provide additional information to aid in targeting areas in need of immediate clean-up action. Better simulation results are expected as more data and better GIS methodologies become available.
• 363 - 371
• 10.6288/TJPH2006-25-05-05

• Link 原著 Original Article
• 市場與組織因素對醫院技術創新多元性之影響Exploring the Impact of Market and Organizational Factors on the Diversity of Technological Innovation of Hospitals in Taiwan
• 翁瑞宏、邱柏松、黃金安
  Rhay-Hung Weng, Pe-Song Chiu, Jin-An Huang
• 組織創新 ； 技術創新 ； 醫院 ； 醫療產業
  Organizational Innovation ; Technological Innovation ; Hospitals ; Healthcare Industry
• 目標：本研究主要目的為探討市場與組織因素對台灣醫院技術創新多元性的影響。方法：在資料收集方面，乃自92年度台灣醫院年鑑、內政部統計年報以及全民健康保險學術研究資料庫等三個資料庫中擷取研究變項，並獲得有效樣本共277家醫院，之後採用階層迴歸分析來進行實證分析。結果：研究結果發現，市場因素並未能對醫院技術創新多元性產生直接性的效果，僅醫院規模、醫院權屬、教學狀態與醫療專科數等組織因素能產生直接性的影響，且醫院規模對技術創新多元性乃呈現正向的指數型影響，此外，創院年數則須透過市場競爭度的調節，才能產生正向的影響。結論：本研究結果支持Damanpour (1996)在組織創新權變模式中的論點：組織因素為創新的決定性因素，而市場因素為組織在提升技術創新多元性時的重要權變因素。
  Objectives: The emphasis of the current study was to analyze market and organizational factors which affect the diversity of technological innovations at hospitals. Methods: Research data were obtained from three sources: 1) the Taiwan Hospital Annual, 2) the Statistical Yearbook of the Interior, and 3) the National Health Insurance Research Database of 2003. Organizational and market factors were analyzed by using a sample of 277 hospitals which were obtained from the data so urces. Hierarchical multiple regression was used to test our hypotheses. Results: Only some organizational factors, including hospital size, ownership, teaching status, and the number of medical specialties, had a direct effect on the diversity of technological innovation. Unexpectedly, however, the relationship between size and technological innovation was not linear, but exponential. Moreover, market size and market competition had no main effect. Only market competition positively moderated the relationship between hospital age and the diversity of technological innovation. Conclusions: Based on our results, market factors, especially market competition, do not play a direct role, rather a contingency role, on affecting the diversity of technological innovation at hospitals. Indeed, our study supports the argument of the contingency model of organizational innovation, as proposed by Damanpour (1996).
• 372 - 383
• 10.6288/TJPH2006-25-05-06

• Link 原著 Original Article
• 急診醫療服務與其它醫療服務之類別間關係Relationship of Utilization of Emergency Medical Services and Other Medical Services
• 黃金安、賴其勛、胡哲生
  Jin-An Huang, Chi-Shiun Lai, Jer-San Hu
• 急診醫療服務 ； 類別間關係 ； 醫療利用
  Emergency medical services ; intercategory relationship ; medical care utilization
• 無
  Objectives: Following implementation of the global budget payment system, understanding the relationships between service use between specialties has become essential for hospital management and health policy makers. The purpose of this study was to explore the intercategorical relationships of emergency and other medical services. Methods: This study used nationwide claims data for the year 2001 from the National Health Insurance Research Database in Taiwan. Data from 6,996 insured individuals who had used emergency medical services were included. Multiple regression and logistic regression analyses were used to determine relationships among various medical services. Results: Elderly patients, patients who frequently used outpatient (OPD) services, and patients with frequent admissions tended to be frequent ED users (p<0.001). High utilization of outpatient and primary care services and frequent hospital admissions were significantly correlated with emergency service use after controlling for age and gender (p<0.001). Odds Ratios were 10.29 (95% CI: 7.65-13.84), 5.43 (4.15-7.11), and 1.46 (1.11-1.93), respectively, for outpatient use, hospital admissions, and primary care use. Conclusion: Hospital OPD use, hospital admission and primary care use all have an impact on ED use. Frequent ED users are more likely to use other medical services. In other words, there is an intercategorical relationship between ED use and use of other medical services.
• 384 - 393
• 10.6288/TJPH2006-25-05-07

• Link 公衛論壇 Public Health Forum
• 倡導本土化的媒體報導自殺新聞準則倡導本土化的媒體報導自殺新聞準則
• 呂淑妤
  呂淑妤
• 無
  none
• 無
  none
• 253 - 255
• 10.6288/TJPH2006-25-04-01