24卷1期

• Link 原著 Original Article
• 論病例計酬制度下醫院薪資策略對醫師診療行為之影響：以某區域醫院為例The Impact of Hospital Compensation Strategies on Physician Practice Behavior under the Case Payment System: the Case of a Regional Hospital
• 許玫玲、張維容、黃國哲
  Mei-Ling Sheu, Wei-Jung Chang, Kuo-Cherh Huang
• 論病例計酬 ； 醫師費 ； 醫師行為 ； 財務誘因 ； 醫療資源耗用
  case payment ; physician fee ; physician behavior ; financial incentives ; health resource utilization
• 目標：許多醫院實施以服務量為基礎之醫師費制度，故醫院醫師沒有誘因減少服務密度。本研究分析論病例計酬制度下，當醫院改變醫師費制度，以財務誘因鼓勵醫師節約醫療資源時，醫師如何回應。方法：本研究以一區域醫院為例，分析醫師費制度改變後，八種論病例計酬案件醫療資源利用的變化。資料涵蓋期間為1998到2001年。依變項為住院日數、醫療費用差額（論病例計酬減論量計酬金額）、以及九項醫療費用細項之論量計酬金額。結果：迴歸分析顯示，醫師費制度改變後，四種案件之住院日數減少，包括子宮完全切除術、痔瘡切除術、疝氣手術、前列腺切除術。醫療費用差額方面，除陰道生產與子宮肌瘤切除術外，其餘六種疾病個案之醫療費用差額均增加。醫療費用細項方面，除了闌尾切除之特殊材料費外，每種個案的藥費與特珠材料費都減少，但本研究與法證實醫師是否為了增加其醫師費收入而選擇性地減少醫療服務項目。結論：個案醫院新的醫師費措施的確使醫師減少醫療資源耗用，然而減少程度因不同疾病而有差異。
  Objective: Hospital physicians do not have incentives to decrease the intensity of services because many hospitals have implemented physician fee policies and compensate physicians based on their guantity of services. This study analyzes how hospital doctors respond to a different physician fee policy that gives them incentives to control health care resources under the case payment system. Methods: This study analyzes how health care resource utilization has changed after the implementation of a new physician fee policy for eight case payment procedures at a regional hospital. The data covers the period from 1998 to 2001. Dependent variables include length of stay (LOS), the amount of savings (defined as the difference between the case payment price and fee-for-service (FFS) expenditure), and the FFS expenditures of nine service categories. Results: The regression results show that after the new physician fee policy was implemented, the LOS had decreased for four types of cases: total hysterectomy, hemorrhoidectomy, herniorrhaphy, and prostatectomy; the amounts of savings had increased for all six types of cases with the exception of vaginal delivery and myomectomy. Except for the special materials of appendectomy, the study found that the FFS expenditures for drugs and special materials had decreased across all types of procedures. However, this study could not confirm whether or not physicians decreased services selectively to increase their physician fee income. Conclusion: Physicians have responded to the new physician fee policy by decreasing the utilization of health care resources. However, the extent to which health resources could be reduced varies among different procedures.
• 12-21
• 10.6288/TJPH2005-24-01-01

• Link 原著 Original Article
• 影響醫院資訊系統績效評估之關鍵因素：高階主管觀點之實證研究An Empirical Study of Key Factors Affecting the Performance Evaluation of Hospital Information Systems: Executives' Perspective
• 餘明玲、薛亞聖、黃興進
  Ming-Ling Sher, Ya-Seng Hsueh, Hsin-Ginn Hwang
• 醫院資訊系統 ； 醫療資訊系統 ； 績效評量 ； 績效指標
  Hospital Information Systems ; Healthcare Management Information Systems ; Performance Evaluation ; Performance Indicator
• 目標：透過醫院高階主管的觀點，建構適合評估醫院資訊系統績效的指標及探討影響系統績效評估的各項因素，並透過實證方式瞭解績效指標與評估因素問的關係。方法：本研究對地區教學以上全部一百二十家醫院的高階主管進行問卷調查，回收率為35%。回收問卷的醫院與母群分佈之X^2適合度檢定結果，顯示在醫院等級特性上並無顯著差異，因此研究結果當可代表全體地區教學以上醫院之現況。結果：透過因素分析，歸納出四類績效衡量的指標：使用者滿意度、資訊特性、醫院作業流程，及經營績效等因素。而影響醫院資訊系統績效評估的重要因素，則分別為：環境構面的「政府政策」及「競爭者」等二個因素；資訊科技與廠商構面的「廠商一般特性」、「廠商在醫療業的經驗」、及「硬體設備的功能與成本」等三個因素；以及組織構面的「醫院制度與院長態度」及「醫院對資訊系統的要求與配合」等二個因素。透過迴歸分析，顯示環境與組識構面分別對資訊系統績效的預測具有統計上的意義。以抽取出的的七個因素對資訊系統績效分數的關係整體探討，發現最重要的預測因素是「醫院制度與院長態度」；其次是「政府政策」。結論：影響醫院資訊系統績效的最重要因素是「醫院制度與院長態度」及「政府政策」。
  Objectives: To establish a research framework and to identify the critical factors affecting HIS (Hospital Information Systems) performance evaluation. Methods: Data was collected through a self- administered questionnaire survey. The target population was CEOs of 120 regional hospitals and medical centers in Taiwan. The questionnaires were mailed to the CEOs directly and their response rate was 35%. The results of the surveygoodness of fit test indicate that the accreditation classes of the returned sample hospitals have no significant difference from the target population. Results: Seven factors signficantly affected the results of Information Technology (IT) performance evaluation; they are government policy and competitors of the environmental dimension, vendors' characteristics, previous business experience in hospitals, and costs of the IT and vendors' technical ability, hospitals' structure and top managements' attitude, and expectations of the organization on HIS. The regression model indicates that at a 5% level of significance, only the environment and the organizational dimensions are statistically significant to HIS performance. Conclusions: ”Hospitals' structure and top managements' attitude” is the most important factor affecting the evaluation of results of the HIS performance. The second most important factor is ”government policy”.
• 22 - 32
• 10.6288/TJPH2005-24-01-02

• Link 原著 Original Article
• 全民健保子宮頸抹片檢查受檢情形影響因子分析—個體時間序列資料之實證研究，1997~2000Determinants of the Receipt of Pap Smear Screening under the National Health Insurance, a Panel Study During 1997-2000
• 王本仁、黃心苑、周穎政、 李丞華、張鴻仁
  Pen-Jen Wang, Nicole Huang, Ying-Jenq Chou, Cheng-Hua Lee, Hong-Jen Chang
• 全民健保 ； 子宮頸抹片檢查 ； 個體時問序列資料 ； 廣義估計方程組
  National Health Insurance ; Pap smear screening ; panel study ; Generalized Estimating Equations
• 目標：全民健保提供30歲以上婦女每年一次免費子宮頸抹片檢查，卻有相當高比率之婦女長時間未曾受檢，有別於過去剖面式之問卷調查研究，本文藉由個體時問序列資料(panel data)實證分析，探討需求面（如社經）及供給面（如醫療資源）因數如何影響受檢情形。方法：利用國家衛生研究院承保抽樣歸入檔，擷取1997/0l/01起滿30歲以上婦女且1997-2000年未曾間斷投保者20,608人為固定世代樣本，利用廣義估計方程組(Generalized Estimating Equations, GEE)分析影響因數。結果：(l)未接受年度檢查與四年未曾受檢之影響因數一致(2)未受檢之風險（勝算比）：冉家戶綜合所得稅資料者為高所得者之1.2~1.3倍，於公所投保者則為軍公教人員之1.5~1.6倍，山地離島為大城市之1.5倍；鄉鎮之醫師密度尚無法證明為影響因數。結論：社經因數是影響受檢情形之重要因素，低社經地位者比高社經地位者更有可能長時間從未受檢。醫療資源雖非影響因數，但設籍山地離島之婦女比大城市者更有可能長時間從未受檢。政策上宜先對長時間從未受檢者提高受檢情形。
  Objective: The National Health Insurance (NHI) program in Taiwan has provided free annual Pap smear screening for women aged over 30 since July, 1995. However, the rate of Pap smear screening is still low. In this study, we studied how demand and supply side factors such as SES and medical resource availability influenced Pap smear screening patterns under the NHI in Taiwan between 1997 and 2000. Method: Instead of using cross-sectional survey data, we adopted a fixed cohort sample (N=20608) through employing the NHI claim and administration files. The method of Generalized Estimating Equations was conducted to estimate the screening pattern over time. Factors associated with receiving no Pap smear screening during the 4-year study period were also examined. Results: Women whose income was below the tax return filing requirement were 1.22 times and 1.28 times more likely to have no routine screening and be unscreened for the entire study period than those at upper income levels. It seems that the availability of medical resource had a weaker influence on screening behavior. However, women living in rural towns were less likely to conduct routine screening and more likely to be unscreened for 4 years than those living in urban towns. Conclusions: Our results indicate that 52% of women were not screened over the 4-year period. Attention should be focused on these high- risk women and lower social economic status groups.
• 33 - 42
• 10.6288/TJPH2005-24-01-03

• Link 原著 Original Article
• 台灣地區燒燙傷的趨勢及相關特性分析The Temporal Trend and Distribution of Burns in Taiwan
• 簡戊鑑、 白璐、 邱文達、王先震、高森永
  Wu-Chien Chien, Lu Pai, Wen-Ta Chiu, Hsian-Jenn Wang, Sen-Yeong Kao
• 燒燙傷 ； 死亡率 ； 發生率 ； 住院病患 ； 門診病志
  Burn ; mortality rate ; incidence rate ; inpatient ; outpatient
• 目標：瞭解台灣地區燒燙傷的發生率、盛行率及死亡率之趨勢，以及不同嚴重程度燒燙傷的分佈情況，評估燒燙傷防制及病患照護的整體成效。方法，利用衛生署生命統計及健保資料（醫事機構病床主檔、重大傷病證明明知檔、住院醫療費用清單明細檔、門診處方及治療明細檔）, 分析81~90年燒燙傷的死亡趨勢，以及85~90年燒燙傷的門診、住院及重大傷病情況。結果，十年間，整體燒燙傷的死亡率下降54.23%，且以火焰傷的下降幅度最大。六年間，重大燒燙傷發生率下降28.76%；燒燙傷住院盛行率下降 8.17%，發生率下降6.75%，住院死亡比例下降18.18%;90年燒燙傷門診盛行率及發生率分別是85年的59倍及42倍。燒燙傷呈金字塔型分佈（死亡：重大燒燙傷：住院：門診=1:1.7:21.3:174.7），並由瘦型趨向胖型發展。結論：燒燙傷的死亡率、重大燒燙傷率及住院率逐年下降；而門診率則呈現上升趨勢。整體的燒燙傷防制及病患照護已獲致一定成效。往後必須加以關注的重點在淤為數眾多的輕度燒燙傷的預防。
  Objectives: The aims of this study were to describe the trends of incidence rate and mortality rate of burn injuries over a long period of time, and to understand the characteristics of the distributions for different severity levels of burns. The effect of prevention programs and medical care for burns was also evaluated. Methods: By using 1992-2001 Health and Vital Statistics data and the 1996-2001 National Health Insurance (NHI) Research Database, we counted the numbers of death and causes of burns. We aslo calculated the incidence rate of catastrophic, hospitalized and ambulatory burn injuries. Results: From 1992 to 2001, the overall mortality rate of burn injuries in Taiwan decreased by 54.23%. The mortality rate from flame burns decreased the most. The incidence rate of catastrophic and hospitalized burns decreased by 28.76% and 6.75%, respectively. However, the ambulatory burns increased by 42 times over a 6-year period between 1996-2001. The percentage of hospitalized burn deaths decreased by 18.18%. The proportions of different severity levels of burns (dead: catastrophic: hospitalized: ambulatory=1:1.7:21.3:174.7) consisted of different shaped pyramids. These shapes became wider over time. Conclusions: The overall mortality rate of burn injuries and incidence rate of catastrophic and hospitalized burns showed a decreasing trend, whereas, the incidence rate of ambulatory burns showed an increasing trend. The overall prevention and medical care for burns displayed some effect. In the future, attention should be paid to the prevention of minor burns, which cause a great deal of ambulatory care.
• 43 - 51
• 10.6288/TJPH2005-24-01-04

• Link 原著 Original Article
• 臺灣健康受檢者高脂血相關飲食知識與血脂值之差異研究Discrepancy in Nutrition Knowledge of Hyperlipidemic Risk and Lipid Levels Among Health Check-Up Population in Taiwan
• 簡國龍、陳珮蓉、蘇大成、賴鴻褚、陳明豐、 李源德
  Kuo-Liong Chien, Pey-Rong Chen, Ta-Chen Su, Hong-Shiee Lai, Ming-Fong Chen, Yuan-Teh Lee
• 脂質 ； 營養知識 ； 問卷 ； 高脂血症
  lipids ; nutrition knowledge ; questionnaire ; hyperlipidemia
• 目標：高脂血症營養知識可能與高脂血症危險性有關，本研究之目的係以橫斷式族群探討營養知識及血脂質之間的關係。方法：以自1998年四月到九月共1787位至台大醫院接受健康檢查的民眾，並完成高脂血問卷為研究對象。營養知識問卷共15題，經因素分析定義出四組因數。第一組為高膽因醇或高飽和脂肪食物；第二組為高油脂或低飽和脂肪食物；第三組為高纖維食物；第四組為高能量或高碳水化合物食物。結果：女性教育程度較低，但比男性有較高的營養知識分數。教育程度與營養知識分數呈正相關性，但在高能量營養知識則例外，即教育程度並未能提高對高能量食物之認知。收入狀況與高膽因醇、高脂食物知識呈正相關性。血三酸甘油酯值與高能量食物營養知識分數呈正相關性；身體質量指數亦與高能量食物營養知識分數呈正相關性。經年齡、性別及身體質量指數、社經地位調整之後，所有血脂質與營養知識分數並無相關性。結論：高脂血症相關營養知識分數與血脂質並不一效，此可作為高脂血症飲食阻介計畫之參考。
  Objectives: A cross-sectional study was conducted to investigate the association between nutrition knowledge and hyperlipidemia, Methods: A total of 1787 Taiwanese adults completed hyperlipidemic knowledge questionnaires during their health check-ups in a tertiary hospital from April 1998 to September 1998. Knowledge-based 4 sets were defined and the exploratory factor analysis results were used to confirm the grouping. Set 1 was defined as high cholesterol or high saturated fat foods; Set 2 as high fat or low saturated fat foods; Set 3 as high fiber foods and Set 4 as high energy or high carbohydrate foods. Results: Women had lower educational levels but better knowledge scores than men. Years of education had a positive correlation with nutrition knowledge scores, except for the set of high energy foods. This implied that even people with high educational levels had incomplete knowledge concerning high energy foods. Income was associated positively with high cholesterol and high fat food knowledge. Total cholesterol, HDL cholesterol and LDL cholesterol levels were not significantly associated with knowledge of hyperlipidemia. Furthermore, triglyceride levels were positively associated with scores from high energy foods. Body mass index was significantly positively associated with high energy food knowledge scores. After adjusting for age, gender, body mass index, income and education years, no lipid levels could be predicted by any knowledge scores of hyperlipidemia. Conclusions: The discrepancy between nutritional knowledge of hyperlipidemia and lipid profiles should be taken into consideration when planning for behavior intervention for hyperlipidemia during the health check-ups of the population of Taiwan.
• 52 - 63
• 10.6288/TJPH2005-24-01-05

• Link 原著 Original Article
• 砷暴露地區居民發炎因子基因多形性與頸動脈粥狀硬化之相關性The Association between Carotid Atherosclerosis and Inflammatory Gene Polymorphisms Among Residents in an Arsenic-Endemic Area
• 謝宜蓁、洪啟宗、王淵宏、陳建仁、邱弘毅
  Yi-Chen Hsieh, Chi-Tzong Hong, Yuan-Hung Wang, Chien-Jen Chen, Hung-Yi Chiou
• 砷 ； 頸動脈粥狀硬化 ； 細胞激素 ； 化學激素 ； 黏附因子
  arsenic ; carotid atherosclerosis ; cytokine ; chemokine ; adhesion molecule
• 無
  Objectives: To investigate the association between carotid atherosclerosis and genetic polymorphisms of inflammatory genes among residents in the Lanyan Basin which was a newly confirmed arsenic-endemic area. Methods: Residents aged ?40 years were recruited and examined for carotid atherosclerosis by Duplex ultrasonography. A total of 332 subjects were randomly selected from the study population as carotid atherosclerosis patients based on their health examination reports with IMT?1.0 mm and a plaque score ?1. Controls were 302 subjects with IMT
• 64 - 72
• 10.6288/TJPH2005-24-01-06

• Link 原著 Original Article
• 1991-1994年金門縣30歲以上成人高尿酸血症盛行率與危險因子研究The Prevalence and Risk Factors of Hyperuricemia in a Community-Based Study Among Kinmen Island Adults =30 Years Old in 1991-1994
• 陳水湖、莊紹源、周碧瑟
  Shui-Hu Chen, Shao-Yuan Chuang, Pesus Chou
• 高尿酸血症 ； 盛行率 ； 危險因子 ； 金門研究
  hyperuricemia ; prevalence rate ; risk factor ; Kinmen study
• 目標：探討金門縣社區性高尿酸血症盛行率及其相關危險因子。方法：於1991到1994年間，共11,922之30歲以上居民完成所有研究步驟。由熟練之訪員—陽明十字軍，進行結構式問卷調查，並由公共衛生護士採集禁食血液進行生化檢驗。以邏輯斯複迴歸模式分析高尿酸血症之相關危險因子。結果：篩檢率為59.3%(1l,922/20,112)。高尿酸血症盛行率平均為25.4%，其中男性（尿酸值?7.0mg/dl）為31.0%，女性（尿酸值?6.0mg/dl）為20.9%。男性尿酸平均值為6.3±l.4mg/dl, 女性為5.0±1.4mg/dl，男性高於女性。以性別和年齡分層探討相關危險因數，男女兩性30~39歲者之相關危險因子為高肌酸酐、高血脂、肥胖、高血壓，與女性停經。40歲以上者，除了上述相關危險因子之外，喝酒與使用利尿劑也是其極重要的危險因子。結論：高尿酸血症的相關危險因子會隨著性別與年齡而改變。利尿劑使用的重要性隨著年齡而上升。飲酒、停經與否、分別為男、女性的重要危險因子。
  Objectives: The purpose of present study was to investigate the prevalence and risk factors of hyperuricemia in Kinmen Island. Methods: A total of 11,922 residents aged ?30 years completed all examinations of the survey in Kinmen Island between 1991 and 1994. The response rate was 59.3% (11,922/20,112). The physical examination and structured questionnaire were carried out by the Yang-Ming Crusade, a group of well-trained medical students. Overnight fasting blood was collected by public health nurses. The risk factors of hyperuricemia were determined using multivariate logistic regression. Results: The crude prevalence of hyperuricemia, defined as serum uric acid ?7.0mgIdl for men and ?6.0mg/dl for women, was 25.4% (3 1.0% for men, 20.9% for women). The means and standard deviation of uric acid were 6.3±1.5mg/dl for men and 5.0±1.4mg/dl for women. Men had higher uric acid levels than women (p<0.05). According to the age and sex spectrum, the risk factors of hyperuricemia were hyperlipidemia, high creatinine, obesity, and hypertension among young men and women, aged 30-39 years old and menopausal for women. Middle and old aged group (40-59 yrs and ?60 yrs) had the same risk factors as young aged group except alcohol consumption of man and the use of diuretics in both sexes. Conclusions: The risk factors of hyperuricemia were changed by sex and age. Use of diuretics became more important for middle-aged and elderly subjects. Alcohol consumption for men and menopausal for women were the most important risk factors of hyperuricemia.
• 73 - 83
• 10.6288/TJPH2005-24-01-07

• Link 原著 Original Article
• 上肢快速檢核表評估盒餐業肌肉骨骼傷病之危害因子A Checklist for Evaluating Ergonomic Risk Factors in Taiwan Commissary Foodservice Factors
• 全中妤、宋鴻樟
  Jong-Yu A. Chyuan, Fung-Chang Sung
• 職業性肌肉骨骼傷病 ； 危害因子 ； 快速上臂檢核 ； 盒養業
  work-related musculoskeletal disorders ; risk factors ; Rapid Upper Limb Assessment (RULA) ; commissary foodservices
• 目標：本研究評估中式盒餐業員工之工作姿勢，並應用「快速上臂檢核」測量模式分析肌肉骨骼傷病之危害因子。方法：自台灣南北21家盒餐業取方便樣本（即立意取樣），依據照像及攝影記錄，分析員工工作姿勢、活動角度、頻率及施力箏。受訪者依工作性質分為四組：搬運／清洗食材、切割處理／製作烹飪、清洗碗盤／機器場地和包裝／供應盒養，並以檢核模式估計傷害危險。結果：研究樣本217人中，清洗碗盤與打掃的員工常使用雙手，上手臂屈曲與伸展角度多大90度，下手臂（前臂）提舉的角度多介於。0-60度之間或大於100度，身體有極大的側彎或前屈角度，且雙腳無法平街站立。包裝盒餐員工的活動範圍則限於輸送帶左右狹隘空間，上手臂屈曲與伸展角度約在20度左右，雙腕常保持0至15度間的高頻率包裝盒餐動作。廚師/廚工用力在濕熱的蒸汽炒鍋中製備菜餚或炒麵／炒飯，雙臂的活動角度介於60至100度，手腕的動作極大，向上與向下彎曲之角度均大於15度角。搬運／清洗食材的員工常搬運食材或盒餐／餐桶成品，其搬運重量／距離與僵直的姿勢也是工作中可能有之危害因子。「決速上臂檢核」結果顯示，上述四組人員之工作中以清洗碗盤／打掃地面員工的平均分數最高(5.69)。結論：依「快速上臂檢核」到量模式分析，結果發現盒餐業員工確實有些姿勢與肌肉施力狀態不甚理想。
  Objectives: This study assessed the work postures of commissary foodservice workers and used Rapid Upper Limb Assessment (RULA) to evaluate work-related musculoskeletal disorders (WMSD). Methods: A convenient sample of workers was recruited from 21 commissary foodservice factories in northern and southern Taiwan. Based on camera images and video records, we analyzed each worker's posture, body movement angle, and movement frequency and force. Workers were categorized into four groups, i.e. busser/pre-prep, kitchen/preparation, disher/utility cleaner, and server/packer. RULA was employed to estimate scores representing risks of WMSD at work. Results: Among the 217 workers, disher/utility cleaners frequently used both hands with an upper arm extension with a flexion of >90°, and a lower arm lift angle between 0 and 60° or more than 1000. In addition, their heads were often in extension, their trunks reached the highest degree of flexion, and both legs and feet were improperly balanced. Due to the limited space at the conveying track areas, the range of movement for the servers/packers was approximately 20° in extension and 20° in flexion for the upper arms, and 0-15° in either flexion or extension for movement of the wrist while packing. At the steam kettle, the cooks/chefs moved both upper limbs in a range between 60-100° with wrist flexion or extension of more than 15°. Busser/pre-prep employees have to carry heavy boxes and containers and thus tend to experience greater force/load scores as compared to workers in the other groups. According to the RULA checklist, dishers/utility cleaners had the highest average scores among the four groups of workers. Conclusions: This study revealed that commissary foodservices employees may experience awkward postures and abnormal muscle forces at work. The RULA is a good instrument foe assessing work associated with WMSD.
• 84 - 91
• 10.6288/TJPH2005-24-01-08