30卷5期

• Link 綜論 Review Article
• 可避免住院研究回顧對台灣基層醫療照護的意涵A Literature Review of Preventable Hospitalizations: Implications for Primary Care in Taiwan
• 梁亞文、陳文意、林育秀、李卓倫、張曉鳳
  Yia-Wun Liang, Wen-Yi Chen, Yu-Hsiu Lin, Jwo-Leun Lee, Hsiao-Feng Chang
• 可避免住院 ； 門診敏感照護狀況 ； 基層醫療
  Preventable hospitalization ; ambulatory care sensitive conditions ; primary care
• 健保局採取多項措施減緩醫療支出增加，但成效有限。若能減少可避免住院醫療費用，將可舒緩健保財務惡化。本文回顧國內外研究對可避免住院的訂定原則、疾病與影響因子，期開啟國內對此議題的重現並提出建議。本文發現研究依疾病碼定義明確、住院率高、具文獻依據且可經由基層醫療提供照護等原則，訂定出11-24種可避免住院。國內外研究均發現，性別、年齡、社經地位、健康狀況、地理區域、照護連續性是顯著影響因子；國外研究另發現種族、婚姻狀況、有無保險、保險類別、基層醫師人力為顯著影響因子。未實施全民健保的國家，有無保險及保險類別是顯著因子，但實施全民健保的國家，個人社經狀況及醫療資源的影響可能凌駕保險。可避免住院可用以衡量基層醫療照護可近性，亦可監控門診照護結果品質，在台灣全民健康保險即將邁入以公平、品質、效率為核心精神的二代健保之際，建議將可避免住院列為例行收集之正式衛生統計指標，並發展台灣版的可避免住院表列。
  The Bureau of National Health Insurance adopted several policies to control rising healthcare expenditures; however, the results were limited. The financial burden on National Health Insurance can be reduced by avoiding expenditures for preventable hospitalizations. This article provides a brief review of criteria for preventable hospitalizations, describes diseases associated with preventable hospitalizations, and summarizes factors associated with preventable hospitalizations in a review of the national/international literature. It concludes with our recommendations for further work and a look at what the future might hold. Criteria developed for considering the appropriateness of hospitalization include clarity in the definition and coding of diagnoses, a hospitalization rate of at least 1/10,000, the existence of prior studies, and if the hospitalization could potentially have been avoided through utilization of primary health care. We selected 11-24 ICD codes as a list of ambulatory care sensitive conditions (ACSCs). Gender, age, socioeconomic status (SES), health status, geography, and provider continuity were found to be associated with preventable hospitalizations both internationally and in Taiwan; however, race, marital status, insurance status, insurance type, and primary care provider were also found to be significant in other countries. For countries without universal insurance, insurance status and insurance type were significant predictors; however, for countries with universal insurance, SES and medical resources were significant predictors. The measurement of preventable hospitalization can be adopted to indicate both the accessibility and effectiveness of primary care. Since Second Generation National Health Insurance that focuses on equity, quality, and efficiency is now being contemplated, this study suggests that the rate of preventable hospitalizations should be considered as one of the health indicators in conjunction with Taiwan's ACSCs list.
• 409 - 421
• 10.6288/TJPH2011-30-05-01

• Link 原著 Original Article
• 社區復健中心服務對精神分裂症病患後續醫療利用之影響The Effects of Community Rehabilitation Services for Patients with Schizophrenia on the Utilization of Health Services
• 吳希文、楊銘欽
  His-Wen Wu, Ming-Chin Yang
• 精神病患 ； 社區復健 ； 傾向分數 ； 醫療利用 ； 醫療費用
  Psychiatric patient ; Community rehabilitation ; Propensity score ; Health Services Utilization ; Medical cost
• 目標：本研究探討精神分裂症病患有無接受社區復健中心服務及治療時間長短，對其結束治療後1年內／2年內醫療利用的影響。方法：以2006年自精神科住院出院後一年內，連續接受30日以上社區復健中心治療的個案203人，及僅接受精神科門診追蹤之1631人為研究對象。以描述性統計、卡方檢定、t檢定、複迴歸進行資料分析，另以傾向分數分析法校正選樣誤差。結果：接受社區復健中心治療時間為10-12個月者比僅接受1-3個月者，追蹤其結束社區復健中心治療後2年內精神科急慢性住院日數、醫療費用、精神醫療治療費皆較低。相較於僅接受精神科門診治療者，接受社區復健中心治療者，其結束治療後1年內及2年內精神科急性住院日數、醫療費用、精神醫療治療費較低；但精神科慢性住院日數、醫療費用較高，結束社區復健中心治療後2年內，精神科慢性住院精神醫療治療費亦較高。結論：本研究呈現精神分裂症病患接受社區復健中心服務後之醫療利用情形，藉此反映精神分裂症患者就醫之重要資訊，並進而推論病患社區復健之成效。
  The aim of this research was to investigate the effects on health service utilization among patients with schizophrenia after 1 or 2 years of treatment in community rehabilitation centers. Methods: We included 203 patients discharged from psychiatric hospitals within 1 year and continuously in treatment for more than 30 days in community rehabilitation centers. We also included 1631 patients readmitted to psychiatric hospitals within 1 year after receiving only psychiatric outpatient follow-up. Data were analyzed by descriptive methods, ?^2 tests, t-tests, and multiple regression analysis. In order to reduce selection bias, the researchers used the propensity score method to balance the covariates. Results: Patients with 10-12 months of treatment in community rehabilitation centers had a shorter length-of-stay and lower medical expenditures and psychiatric medical expenditures in acute and chronic psychiatric hospitals over a 2-year follow-up period than did those with 1-3 months of treatment. Compared with patients who received only psychiatric outpatient treatment, patients who received treatment from community rehabilitation centers had a shorter length-of-stay and lower medical expenditures and psychiatric medical expenditures in acute psychiatric facilities over 1 or 2-years of follow-up, but had a longer length-of-stay and higher medical expenditures in chronic psychiatric facilities over 1 and 2-years of follow-up, and higher psychiatric medical expenditures in chronic psychiatric facilities at 2-year follow-up. Conclusions: The results characterized the utilization of health services by patients with schizophrenia after treatment in community rehabilitation centers. They provide important information about medical utilization by these patients and show the effects of their community rehabilitation.
• 422 - 435
• 10.6288/TJPH2011-30-05-02

• Link 原著 Original Article
• 職場經期健康與生理假實施初探A Preliminary Study on Menstrual Health and Menstrual Leave in the Workplace in Taiwan
• 張珏、陳芬苓、張菊惠、徐儆暉
  Chuen Chang, Fen-Ling Chen, Chu-Hui Chang, Ching-Hui Hsu
• 生理假 ； 性別工作平等法 ； 經期健康
  menstrual leave ; Gender Equal Employment Act ; menstrual health
• 我國《性別工作平等法》於2002年通過，生理假是其中對婦女健康的一項福利措施，在實施多年後有必要瞭解國內女性勞工因工作性質及環境影響其生理假需求情形，生理假實際執行的狀況，探索生理假制度是否會因女性勞工工作而有執行上差異，以俾提出相關政策或方案。方法：本研究運用檔案研究法與日本生理假政策做比較，並以焦點團體方法訪談不同行業女性因工作而經期不適的差異經驗，以及對生理假看法與經驗。結果：目前明確實施生理假的國家有日本、印尼、韓國與台灣。在焦點團體分析上，發現被訪問大多數女性都有經歷經期不適的情況，也瞭解不同的公司及生理假的實施和使用規定。但是在使用情況，會因為「規定太過僵化」、「其他人都沒有請」、「有其他假可以休」、「沒有人代班」或「必須要有醫生證明」等因素導致生理假使用率低。女性勞動者也反映希望主管和男性員工能增加對生理假的認知，職場中友善工作環境的建立才能使生理假制度順利推行。結論：文後針對生理假的爭議，包括生理假制定的必要性、舉證及濫用問題、考績評核問題、職場經期健康促進與生理假的關係等議題進行討論，並提出政策未來建議，包括：l.鼓勵職場建立經期支持環境；2.工作場所管理模式改變；3.生理假彈性化；4.經期健康教育融入每年例行職業安全衛生講習中；5.對廠護提供經期健康訓練課程；6.加強經期與工作關聯性資料蒐集等。
  The Gender Equal Employment Act was enacted in 2002 and the right to apply for menstrual leave was one of its provisions. It is important to evaluate the need for this policy, the impact of menstrual leave and the relationship between women menstrual health and work. Methods: In order to understand the practice of menstrual leave under the Gender Equity Work Act, two research methods were adopted by this study: documentary research and 8 focus groups. Results: According to the focus group, most of our interviewees had experienced menstrual discomfort. Their reasons included congenital physical problems, pressure, nervousness, an bad life style, and drinking cold liquids. They did not understand the regulations about menstrual leave such as how to apply for it or how to use it. They seldom used menstrual leave for the following reasons: the regulation had no flexibility, no one they knew had ever applied for it, there are many other leaves that might apply, nobody could take over their jobs, and the organization needed medical receipts if the workers wanted to apply for menstrual leave. We also asked interviewees for their opinions about governmental policies regarding menstrual leave. Conclusions: Further actions should be: 1. to build a supportive environment for menstrual care in the workplace, 2. to adjust management style in the workplace, 3. to make menstrual leave flexible, 4. to provide lectures to help female workers take care of themselves during their menstrual periods and to include these lectures in routine occupational health and safety courses, 5. to train nurses in the factories to care for menstrual discomfort, 6. to collecting data related to the relationship between menstrual health and employment.
• 436 - 450
• 10.6288/TJPH2011-30-05-03

• Link 評論 Commentary
• 評論：職場經期健康與生理假實施初探Commentary: A Preliminary Study on Menstrual Health and Menstrual Leave in the Workplace in Taiwan
• 蔡慈儀
  Tzu-I Tsai
• 無
  none
• 無
  none
• 451 - 451
• 10.6288/TJPH2011-30-05-04

• Link 評論 Commentary
• 作者回覆：職場經期健康與生理假實施初探Response: A Preliminary Study on Menstrual Health and Menstrual Leave in the Workplace in Taiwan
• 張珏、陳芬苓、張菊惠、徐儆暉
  Chuen Chang, Fen-Ling Chen, Chu-Hui Chang, Ching-Hui Hsu
• 無
  none
• 無
  none
• 452 - 452
• 10.6288/TJPH2011-30-05-05

• Link 原著 Original Article
• 社經地位與健康路徑關係之性別差異Gender Differences in a pathway Linking Socioeconomic Status and Health
• 李妙純、張華庭
  Miaw-Chwen Lee, Hua-Ting Chang
• 性別不平等 ； 自覺健康 ； 健康不均 ； 路徑分析
  gender inequality ; self-reported health ; health inequality ; path analysis
• 為瞭解性別之健康差異，本文以路徑分析探討性別如何經由社經地位影響性別之健康差異。方法：本研究以「2005年國民健康訪問調查」12-64歲個人問春為資料，以台灣版SF-36自覺健康狀態為健康指標。結果：當調整年齡、社經地位、健康行為、環境風險因子及飲食多樣性後，男性健康皆比女性佳。性別透過社經地位或再由社經地位影響健康行為、環境風險因子及飲食多樣性等間接影響健康；若未考慮間接效果，將低估性別之健康差異。對大部分的健康指標而言，社經地位對女性健康的直接效果比男性小；社經地位透過環境風險因子對女性健康的間接效果較大，男性則為飲食多樣性；社經地位透過健康行為對女性健康的效果相當小，男性則不然。結論：性別為影響健康之重要因素，但也與社經地位相關，並透過其他因素，特別是健康行為、環境風險因子及飲食多樣性而影響兩性健康差異。在社會資源有限及性別主流化趨勢下，應該針對兩性之特異性提出有效政策，以提升整體健康並改善性別之健康差異。
  This study examined the influence of socioeconomic status on gender disparities in health by using a path analysis. Methods: Data came from the 2005 National Health Interview Survey in Taiwan, which contains data about 18099 non-institutionalized residents aged 12-64. Health was measured with the Short-form 36 health status, Taiwan version. Results: When other factors were controlled, women's health was worse than men's. The direct effect of gender on health contributed the most to the gender disparity. The indirect effect of gender on health (through its effect on socioeconomic status) was positive and significant. For men, higher socioeconomic status and more health-damaging behavior had negative effects on health. If we neglect the indirect effect, the gender disparities in health were under-estimated. For separate samples of women and men, the direct effect of socioeconomic status on health was smaller for women than for men. Most of the indirect effect of socioeconomic status on health was through environmental risk factors for women, but through food varieties for men. These indirect effects of health-related behavior were smaller for women than for men. Conclusions: Our results confirmed that gender differences in health are potentially moderated by socio-economic status through variables such as health-related behavior, environmental risks and food varieties. Understanding the gender differences in health is helpful for policy-makers in order to devise gender-equality in social policy for the improvement of health of both men and women and to address the gender disparity in health.
• 453 - 467
• 10.6288/TJPH2011-30-05-06

• Link 原著 Original Article
• 鄰里層次社會資本與個人層次特質對嚼檳榔行為之多層次分析A Multilevel Analysis of neighborhood-level Social Capital and individual-level Characteristics in Relation to Betel Quid Chewing Behavior in Taiwan
• 張芳華
  Fang-Hua Jhang
• 台灣社會變遷調查 ； 社會資本 ； 嚼食檳榔 ； 多層次分析
  Taiwan Social Change Survey TSCS ; social capital ; betel quid chewing ; multilevel analysis
• 本研究目的在了解2000年至2005年檳榔嚼食率變化，並分析探討兩年度鄰里層次社會資本與個人層次特徵對嚼檳榔行為的影響。方法：運用「台灣社會變遷調查」20歲以上資料，有效樣本分別為1,774與1,995人，村里數分別為87與88個，以雙變項分析、比例Z檢定與多層次邏輯迴歸來分析資料。結果：檳榔嚼食率在5年間未顯著下降，整體嚼食率仍在9%上下，男性檳榔嚼食率更達15%以上。以多層次邏輯迴歸分析發現鄰里層次社會資本持續發揮影響力，在兩個年度社會互動與嚼食檳榔風險皆顯著相關(OR=1.60, 95%CI: 1.01-2.54; OR=2.50, 95%CI: 1.16-5.39)。性別、年齡、教育程度、吸菸與喝酒行為等個人層次變項對嚼檳榔行為亦為影響因素。結論：嚼食檳榔不僅與個人特質有關，也與社會資本有關。在社會互動脈絡下，檳榔成為與他人建立某種關係的媒介物，而非被視為致癌物。建議除應在鄰里間加強檳榔危害宣導外，培養國人健康社交活動的認知也是有效對策，以弱化檳榔在文化與社會互動上的角色。
  The aims of this study were to compare the rates of betel quid chewing between 2000 and 2005, and to explore the effects of neighborhood-level social capital and individual-level characteristics on betel quid chewing behavior over that time period. Methods: Nationally representative data from the Taiwan Social Change Survey were obtained from 1774 respondents in 87 neighborhoods in 2000 and 1995 respondents in 88 neighborhoods in 2005. Bivariate analysis, two-sample tests for proportions, and multilevel logistic regression were used to analyze the data. Results: The rates of betel quid chewing were not significantly reduced in 5 years. Between 2000 and 2005, the rate of overall chewing was about 9%, and, for men, it was over 15%. In multilevel logistic regression, neighborhood-level social capital's influence on the risk of betel quid chewing was durable. This study demonstrated that the risk of betel quid chewing was significantly related to social interaction in 2000 and in 2005 (OR=1.60, 95%CI: 1.01-2.54; OR=2.50, 95%CI: 1.16-5.39). Individual-level characteristics associated with betel quid chewing were gender, age, education, and smoking and drinking behavior. Conclusions: Betel quid chewing was associated not only with individual characteristics but also with social capital. In the context of social interactions, betel quid was treated as a medium for establishing relationships with others instead of as a carcinogen. The results suggest that educating the public about the dangers of betel quid in neighborhoods and developing healthy cognitions about social interactions are effective strategies to weaken the role of betel quid.
• 468 - 480
• 10.6288/TJPH2011-30-05-07

• Link 原著 Original Article
• 以類神經網路及分類迴歸樹輔助肝癌病患預測存活情形Prediction of Survival in Patients with Liver Cancer Using Artificial Neural Networks and Classification and Regression Trees
• 陳正美、徐建業、邱泓文、白其卉、吳柏動
  Cheng-Mei Chen, Chien-Yeh Hsu, Hung-Wen Chiu, Chyi-Huey Bai, Po-Husn Wu
• 肝癌 ； 類神經網路 ； 分類迴歸樹 ； 預測模型
  Liver Cancer ; Artificial Neural Networks ; Classification and Regression Trees ; Prediction Model
• 無
  This study created a survival prediction model for liver cancer using data mining algorithms. Methods: The data were collected from the cancer registry of a medical center in Northern Taiwan between 2004 and 2008. A total of 227 patients were newly diagnosed with liver cancer during this time. Following a literature review, expert consultation, and collection of patients' data, nine variables pertaining to liver cancer survival rates were analyzed using t-tests and chi-square tests. Six variables were significant. An artificial neural network (ANN) and a classification and regression tree (CART) algorithm were adopted as prediction models. The models were tested in three conditions: one variable (clinical stage alone), six significant variables, and all nine variables (significant and non-significant). Five-year survival was the output prediction. Results: The ANN model with nine input variables was a superior predictor of survival (p<0.001). The area under the receiver operating characteristic (ROC) was 0.843, and 0.78, 0.76, and 0.80 for accuracy, sensitivity, and specificity respectively. Conclusions: An artificial neural network was more accurate than a CART system in predicting liver cancer survival. In the future, we suggest developing a computer system using the nine input variables in the ANN prediction model to predict liver cancer survival. The system would use an ANN algorithm to automatically calculate the prediction result and assist patients in understanding their potential treatment outcomes and survival.
• 481 - 493
• 10.6288/TJPH2011-30-05-08

• Link 原著 Original Article
• 台灣司法從業人員工作壓力與健康功能之性別差異Gender Differences in Occupational Stress and Health among Legal Professionals in Taiwan
• 蔡奉真、詹長權
  Feng-Jen Tsai, Chang-Chuan Chan
• 付出回饋失衡 ； 性別 ； 負荷控制支持 ； 司法從業人員 ； 工作壓力
  ERI ; gender ; JCQ ; legal professional ; occupational stress
• 目標：了解工作壓力及健康功能之性別差異，及「負荷－控制－支持」與「付出－回饋失衡」兩種不同工作壓力模型，對於男性及女性司法從業人員造成之不良健康功能影響。方法：本橫斷性研究之樣本係來自6個地方法院，1個高等法院，3個地方檢察署及26個法律事務所之193位男性及170位女性司法從業人員。以中文版之「負荷控制支持量表」及「付出回饋失衡量表」測量工作壓力，以簡式「生活品質量表」測量健康功能，並以復迴歸統計方式在控制年齡、婚姻狀況、工作內容、年資、每日工作時數後，分析女性對於男性在不良健康功能之勝算比，及個別性別之工作壓力模型與不良健康功能間之關連性。結果：男性司法從業人員回報顯著較女性司法從業人員為高之工作控制(70.54 vs. 66.46)與工作滿意度(59.99 vs. 57.45)。女性回報顯著低於男性之身體功能(90.23 vs. 93.80)、身體疼動(72.73 vs. 77.68)、社會功能(66.25 vs. 72.85)及心理健康(58.02 vs. 62.41)。工作壓力與不良健康關係間之關連性有顯著之性別差異。我們發現男性的不良健康功能與工作負荷較顯著相關，而付出回饋失衡與男女性之不良健康功能影響則較為平等。結論：性別差異存在於司法從業人員之工作壓力、健康功能及不同工作壓力模型與不良健康狀態之關聯性強度上。
  This study sought to determine gender differences in occupational stress and health and to compare the strength of association between two occupational stress models, demand-control-support (DCS) and effort-reward imbalance (ERI), on poor health among male and female legal professionals. Methods: This cross-sectional study included 193 male and 170 female legal professionals from 6 district courts, 1 appeals court, 3 District Procurators Offices and 26 law firms. The Chinese versions of Karasek job content questionnaire (C-JCQ) and Siegrist effort-reward imbalance questionnaire (C-ERI) were used to evaluate occupational stress, and the International Quality of Life Assessment Short Form-36 (IQOLA SF-36) questionnaire to evaluate health. Multivariate logistic regression analysis was used to calculate the odds ratio of poor health among female legal professionals versus male legal professionals, and the gender-specific association between DCS and ERI models and poor health adjusted for age, marital status, job content, years of work experience, and working hours per day. Results: Male legal professionals scored significantly higher on job control (70.54 vs. 66.46) and job satisfaction (59.99 vs. 57.45) than did female legal professionals. Females scored significantly lower on physical function (90.23 vs. 93.80), bodily pain (72.73 vs. 77.68), social function (66.25 vs. 72.85) and mental health (58.02 vs. 62.41) than did males. There was a significant gender difference in the association between occupational stress and poor health. We found that men’s poor health was more significantly related to job strain while effort-reward imbalance was associated equally with poor health in both males and females. Conclusions: Gender differences exist in occupational stress, health and the strength of association between occupational stress models and poor health among legal professionals in Taiwan.
• 494 - 504
• 10.6288/TJPH2011-30-05-09

• Link 原著 Original Article
• 非緊急急診病人特性及其相關因素探討Non-urgent Emergency Department Use by Patients in a Regional Hospital
• 梁亞文、蔡哲宏、陳文意
  Yia-Wun Liang, Jeffrey Che-Hung Tsai, Wen-Yi Chen
• 急診 ； 非緊急急診 ； 病人特性 ； 加拿大檢傷分類系統
  emergency department ; non-urgent emergency department visits ; patient characteristics ; Canadian Triage and Acuity Scale
• 目標：本研究以加拿大檢傷分類系統(CTAS)探討非緊急急診比率並探討其影響因子。方法：本研究以中台灣某區域教學醫院急診病人為研究對象，共完成840位急診病人的訪視及病歷相關資料的檢視，最後完整收集758位急診病人資料，作為統計分析之用。本研究將CTAS第四級第五級病人定義為本研究之非緊急急診病人，再以邏輯斯複迴歸計算非緊急急診發生因子的危險對比值與95%信賴區間。結果：非緊急急診比率達51.97%，就診日、急診病人認為病情是否需要急診、檢傷人員判定病人疼痛程度及病人期望多快接受看診是非緊急急診發生的顯著因子。結論：衛生主管機關應持續加強民眾對急診的認識，積極宣導急診的正確使用時機，減少急診醫療資源的浪費；推動各項醫療服務改革政策時，必須跳脫單一醫療服務的思維，鼓勵不同層級醫療照護體系的合作，保障民眾的就醫可近性與醫療服務的適當性與品質。
  This study determined the percentage of non-urgent emergency department (ED) patients and the factors influencing their visits by using the Canadian Triage and Acuity Scale (CTAS). Methods: During the study period, 840 patients presenting at a central Taiwan regional hospital ED were seen by the triage nurses and classified according to the CTAS. Data from 758 patients were analyzed. Non-urgent patients were defined as those who were classified CTAS IV and V. Multivariate logistic regression analysis was performed to identify factors associated with non-urgent ED visits. Results: Of these 758 visits, an estimated 51.97% were non-urgent. Significant factors associated with non-urgent ED patients were: visit days, patients perceptions about the emergency nature of the visit, pain level assigned by the triage nurses, and patient expected waiting time to be seen by a physician. Conclusions: Health administrators should persist in trying to educate people as to how to use ED services properly. In addition, policy makers need to understand that there is an inter-categorical relationship between ED use and other medical services; therefore, development of an integrated delivery system is encouraged along with implementation of policies to improve access to comprehensive, high quality health care services.
• 505 - 516
• 10.6288/TJPH2011-30-05-10