33卷6期

• Link 公衛論壇 Public Health Forum
• 高雄市石化氣爆災害對登革熱疫情之影響評析高雄市石化氣爆災害對登革熱疫情之影響評析
• 陳秋美、郭宏偉、劉定萍
  陳秋美、郭宏偉、劉定萍
• 無
  none
• 無
  none
• 563 - 567
• 10.6288/TJPH201433103093

• Link 原著 Original Article
• 老人群體居住安排變動與醫療服務使用之多面向長期研究A Longitudinal Study of Multi-Dimensional Interrelationships between Changes in Living-Arrangements and Medical Service Utilization by an Older Population
• 古家萍、王雲東、黃心苑、王鐘貴、林寬佳
  Chia-Ping Ku, Yun-Tung Wang, Nicole Huang, Chung-Kwe Wang, Kuan-Chia Lin
• 老人居住安排動態變化 ； 醫療服務使用 ； 潛在成長曲線模型
  changes in living arrangement ; medical service utilization ; latent growth curve model
• 目標：老人群體走向「僅與配偶同住」與「獨居」之比例持續上升。過去研究鮮少以動態觀點分析老人居住安排與醫療服務使用情形，因此本研究著眼於填補此知識缺口。方法：本研究以「台灣地區中老年身心社會生活狀況長期追蹤調查」1989~2003年共五波資料為研究資料，運用潛在成長曲線模型探討老人居住安排動態變化對於各醫療服務使用面向之長期風險關聯。結果：透過六種居住安排變動經驗之動態分析角度，研究結果指出累積居住安排內容變動次數越多，僅在住院天數的相對風險變化趨勢有關。居住安排內容轉變為獨居者，雖減少西醫門診與急診使用，但對於住院次數與住院日數的相對風險逐年增加；有配偶之居住內容維繫，則顯著減少住院之長期風險。結論：本文透過國家級長期追蹤資料之實證分析基礎，提出二項核心對比：第一為簡單式與複雜式之居住安排比較，第二則為有無配偶之居住安排比較。掌握此二項核心對比將有助於了解老人居住安排動態變化對於醫療服務使用長期風險的不同影響面貌。
  Objectives: It is estimated that the proportion of the elderly population ＂who live only as a couple＂ and ＂who live alone＂ will continue to rise. Studies which focus on the dynamic changes in living arrangements and their temporal association with the use of medical services are few. The aim of this study was to fill this gap in knowledge. Methods: The data were drawn from the ＂Survey of Health and Living Status of the Elderly in Taiwan＂, a population-based, longitudinal study of a nationally representative random sample of adults aged 60 years of age and older. The latent growth curve model was applied to explore the longitudinal development and interrelationships between dynamic changes in living arrangements and medical utilization. Results: The cumulative frequency of changes in living arrangements only increased the risk of additional days of hospitalization. A change in living arrangements to living alone reduced the use of outpatient and emergency services, but increased the relative risk of hospitalization and number of days of hospitalization. Remaining as a couple significantly reduced the risk of long-term hospitalization. Conclusions: This study was distinctive in two ways. First, it compared simple and complex households. Second, it focused on whether people were residing as a couple or not. Future public health strategies must take the impact of dynamic changes in living arrangements on medical service into account.
• 568 - 581
• 10.6288/TJPH201433103063

• Link 原著 Original Article
• 加速失敗時間模式分析新發乳癌病患併發血栓栓塞對其存活的影響Accelerated Failure Time Model Analysis of the Impact of Thromboembolic Events on Survival in Newly Diagnosed Breast Cancer Patients
• 王南天、蘇慧芳、李佩珍、張正雄、林寬佳、謝碧晴
  Nan-Ten Wang, Hui-Fang Su, Pei-Chen Lee, Cheng-Shyong Chang, Kuan-Chia Lin, Pi-Ching Hsieh
• 血栓栓塞 ； 存活 ； 加速失敗時間模型
  thromboembolic events ; survival ; accelerated failure time model
• 目標：血栓栓塞併發症（TEEs）為乳癌併發症主要之一且增加死亡風險，本研究擬探討台灣新發乳癌病患併發血栓栓塞之相關因素及對其兩年存活的影響。方法：本回溯性世代研究使用1997至2010年全民健康保險研究資料庫。以Poisson分佈探討2000到2008年新發乳癌世代觀察兩年其併發TEEs的發生情形。透過propensity socre匹配後再以Accelerated Failure Time Model檢視有無併發症病患對其兩年存活之影響。結果：2000-2008年新發乳癌世代共80,598人，罹癌確診後兩年內併發TEEs之累積發生率1.78%（95% CI = 1.74-1.82），且第一個半年併發症發生密度為1.38發生事件數／每100個人年。併發TEEs危險因子有年齡（≧65歲比＜45歲adjusted incidence rate ratio [adj. IRR] = 3.87，95% CI = 3.80-3.93），共病指數（≧3分比0分adj. IRR = 1.96，95% CI = 1.93-2.00），有高血壓病史（adj. IRR = 1.43，95% CI = 1.41-1.45），有乳房手術者（adj. IRR = 1.47，95% CI = 1.45-1.49），接受放射線治療者（adj. IRR = 1.29，95% CI = 1.28-1.31），接受化學藥物治療者（adj. IRR = 1.40，95% CI = 1.38-1.42），醫院層級（地區醫院比醫學中心adj. IRR = 1.13，95% CI = 1.11-1.15）。AFT model分析顯示在控制其他變項後，有併發TEEs者比無者有較高比例的兩年死亡風險（adjusted Rate Ratio = 2.55, 95% CI = 2.24-2.91），且風險隨時間增加而增加。結論：新發乳癌病患併發TEEs會增加其死亡風險。醫療專業人員者可針對易併發TEE之危險群（如年長、共病指數高、有高血壓、接受乳癌手術、接受化療放療），即早警覺並提供適當的預防措施以利降低併發症的發生及提升癌症照護品質。
  Objectives: Thromboembolic events (TEEs) are major complications affecting breast cancer patients, and are associated with increased mortality. The purpose of this study was to determine the incidence and risk factors for developing a new TEE in a population-based cohort of breast cancer patients, and also to determine the effect of TEEs on 2-year survival. Methods: A retrospective cohort study was conducted between 1997-2010 using the National Health Insurance Research Database in Taiwan. The incidence of TEEs amongst 2000-2008 breast cancer cohorts and the associated risk factors were determined based on the Poisson distribution. Propensity score matching was used to determine the effect of TEEs on 2-year survival through accelerated failure-time (AFT) model analysis. Results: Amongst 80,598 patients with breast cancer between 2000 and 2008, the 2-year cumulative TEE incidence was 1.78%, with a rate of 1.38 events/100 patient-years during the first 6 months. Based on a multivariate model, significant predictors of developing TEEs within 2 years were age (adjusted incidence rate ratio [aIRR] = 3.87 if ≧ 65 years vs. ＜45 years; 95% CI = 3.80-3.93), co-morbidity (aIRR = 1.96 if ≧3 vs. 0, 95% CI = 1.93-2.00), hypertension (aIRR = 1.43 if yes vs. no, 95% CI = 1.41-1.45), history of breast surgery (aIRR = 1.47 if yes vs. no, 95% CI = 1.45-1.49), history of radiotherapy (aIRR = 1.29 if yes vs. no, 95% CI = 1.28-1.31), history of chemotherapy (aIRR = 1.40 if yes vs. no, 95% CI = 1.38-1.42), and type of hospital (aIRR = 1.13 if district medical center vs. patient medical center 95% CI = 1.11-1.15). Based on AFT model analysis, and after controlling for other variables, patients with TEEs had a higher risk of 2-year death than those without TEEs (aRR = 2.55, 95% CI = 2.24-2.91) and had an increased hazard ratio over time. Conclusions: Breast cancer patients with TEEs have a higher risk of death. Early detection of risk factors of TEEs, such as older age, more co-morbidities, hypertension, and histories of surgery, chemotherapy, and radiotherapy) and appropriate preventive care should be provided by health professionals for decreasing the complications and improving the quality of cancer care.
• 582 - 596
• 10.6288/TJPH201433103064

• Link 原著 Original Article
• 醫院非醫務活動收益之分析－以台灣非營利醫院為例Analysis of Non-Patient Revenues in Non-Profit Hospitals-Evidence from Taiwan
• 陳柏瑋、呂昭顯、 譚慧芳
  Po-Wei Chen, Chao-Hsien Lu, Hui-Fang Tan
• 非營利組織 ； 醫院 ； 非醫務活動收益
  nonprofit organizations ; hospitals ; nonpatient revenues
• 目標：探討台灣非營利醫院非醫務活動收益的結構、趨勢與影響因素。方法：以2006－2012年國內醫療財團法人的財務報表資料為樣本，利用描述性統計分析醫院非醫務活動收益的結構及趨勢，並以無母數統計與迴歸模型探討影響醫院非醫務活動收益的關聯因素。結果：樣本期間國內醫療財團法人之非醫務活動收益在醫院整體總收入佔5.72~8.25%之間，其最大來源為「捐贈收入」，佔非醫務活動收益及醫院總收入之比例平均數分別為46.46%與3.23%，而在國際金融危機期間各項非醫務活動收益的來源均明顯衰退。醫院特性中宗教型醫院及醫學中心層級與非醫務活動收益呈正向關聯，而醫務活動損益金額與經濟衝擊對非醫務活動收益有負向影響。結論：非醫務活動收益對非營利醫院財務績效的重要性逐漸提升，除醫院設立屬性與醫院層級是主要影響因素外，面臨醫務活動虧損壓力愈大的醫院較有誘因積極從非醫務活動中得到揖注，以減緩財務壓力，此外，經濟的重大衰退亦會造成非醫務活動收益的波動。
  Objectives: The purpose of this study was to examine the magnitude, trends, and determinants of non-patient revenues in non-profit hospitals in Taiwan. Methods: Data for this study was derived from financial statements of Taiwan foundation hospitals between 2006 and 2012. Descriptive statistics were used to realize the structure and trends of hospital non-patient revenues. Non-parametric statistics and regression analysis were used to evaluate the determinants of non-patient revenues. Results: Between 2006 and 2012, non-patient revenues accounted for 5.72%~8.25% of the total revenues; on average, donations accounted for 46.46% of non-patient revenues and 3.23% of total revenues. All sources of non-patient revenues declined during the years of financial crisis. Non-patient revenues have a significant positive correlation with religionfunded hospitals and academic medical centers, and income from patient services and financial crisis are negative correlated with non-patient revenues. Conclusions: Non-patient revenues are increasingly important for non-profit hospitals. Hospitals founders and the hospital level are factors which influence non-patient revenues. In addition, hospitals which face financial losses would increase non-patient revenues to ease their financial difficulties. Finally, economic downfalls also cause fluctuations in non-patient revenues.
• 597 - 608
• 10.6288/TJPH201433103061

• Link 原著 Original Article
• 台灣營養師工作壓力、工作滿意度、職業倦怠和離職傾向之現況與相關性Work Stress, Job Satisfaction, Burnout, and Turnover Intentions of Dietitians in Taiwan: Description and Relationship
• 賴苡汝、廖梨伶、謝藍琪、李貞慧
  I-Ju Lai, Li-Ling Liao, Lan-Chi Hsieh, Chen-Hui Lee
• 工作壓力 ； 工作滿意度 ； 職業倦怠 ； 離職傾向 ； 營養師
  work stress ; job satisfaction ; burnout ; turnover intention ; dietitian
• 目標：本研究旨在瞭解台灣營養師工作狀態和離職傾向之現況，並分析其工作狀態和離職傾向之關係。方法：採線上問卷調查，全國共有424名執業中營養師志願參與本研究，研究工具包括「職業壓力指標第二版」和「職業倦怠量表」中文版及個人資料問卷，資料分析方法為描述性統計和多元階層迴歸分析法。結果：（1）營養師工作壓力平均總分為166.3分（SD=31.37），工作滿意度平均總分為43.1分（SD=11.44），職業倦怠表現為高度情緒耗盡（Mean=29.21，SD=10.75）、中度去人格化（Mean=9.09，SD=6.83）和中度個人成就（Mean=34.06，SD=7.80），屬於職業倦怠高危險群；且僅18.9 %營養師從未有離職想法。(2)所有變項可解釋營養師離職傾向之總變異量為44.4%，背景變項、工作壓力、工作滿意度、職業倦怠各子構面在逐層控制下，單獨對營養師離職傾向之解釋力達3.6%、15.6%、23.0%及2.3%，所有預測變項中，以工作滿意度具最大預測力。結論：相較其它職業及國外營養師之研究結果，台灣營養師工作狀態表現相對較差，有鑑於其對離職傾向之重要影響，提升營養師工作滿意度，乃營養師人力資源管理之重要課題。
  Objectives: The purpose of this study was to determine the working status and turnover intentions of dietitians in Taiwan, and to analyze the relationship between working status and turnover intentions. Methods: An online questionnaire survey was developed to collect data. Four hundred twenty-four practicing dietitians voluntarily participated in this nationwide study. The instruments which were used included OSI-2, MBI-Chinese, and an individual information questionnaire. Descriptive statistics and multiple hierarchical regression analysis were used. Results: (1) The mean total scores of work stress and job satisfaction were 166.3 (SD = 31.37) and 43.1 (SD = 11.44), respectively. The burnout status of dietitians included a high level of emotional exhaustion (mean = 29.21, SD = 10.75), a moderate level of depersonalization (mean = 9.09, SD = 6.83), and a moderate level of personal accomplishment (mean = 34.06, SD = 7.80); thus, dietitians are at high risk for burnout. Only 18.9% of dietitians never consider leaving their current jobs. (2) Work stress, job satisfaction, and emotional exhaustion were predictors of turnover intention, accounting for 44.4% of total variation (p<.001), while demographic variables, job location, and work setting were not significant predictors of turnover intention. Conclusions: Compared with the results of other studies involving different professionals and dietitians in other countries, the working status of Taiwanese dietitians is poor. In view of the significant impact on turnover intention, there is value in considering how to improve job satisfaction amongst dietitians when planning the responsibilities and staffing of dietitians.
• 609 - 619
• 10.6288/TJPH201433103078

• Link 評論 Commentary
• 評論：台灣營養師工作壓力、工作滿意度、職業倦怠和離職傾向之現況與相關性Commentary: Work Stress, Job Satisfaction, Burnout, and Turnover Intentions of Dietitians in Taiwan: Description and Relationship
• 陳珮蓉
  陳珮蓉
• 無
  none
• 無
  none
• 620 - 620
• 10.6288/TJPH20143310307801

• Link 原著 Original Article
• 乳癌病患使用部落格的疾病經驗交流之初探An Exploratory Study of the Use of Blogs as a Means of Communication for Breast Cancer Patients
• 郭淑珍、楊雪華、陳怡君
  Shu-Chen Kuo, Hsieh-Hua Yang, Yi-Chun Chen
• 網路 ； 疾病經驗 ； 乳癌 ； 部落格
  Internet ; illness experience ; breast cancer ; blog
• 目標：近年來，癌症病患部落格已是網路傳播中不可忽視之現象，然而以癌症病友為主體的部落格研究，在健康相關領域仍是較新的議題。本研究採用深度訪談並輔以參與觀察法，針對乳癌病患使用部落格對於其疾病經驗的影響進行初步探討。方法：本研究從「抗癌同學會部落格」找出15位乳癌部落客進行深度訪談，同時也針對受訪者以部落格為媒介，與其他病友從事面對面活動，進行參與觀察。結果：乳癌病患書寫部落格的動機，是為了面對疾病以及社會連結；使用部落格對於受訪者疾病經驗的影響，包括交流治療經驗與健康知識、感受情感支持、改變生活與反思生命意義等。部落格所提供的健康資訊，是來自病患親身經歷的治療過程，對病友來說是重要訊息來源；因疾病導致的社會隔離狀態，透過部落格的創作找到相同處境的病友，可以得到心靈慰藉。然而部落格的使用，仍受到社會文化規範和意識型態的影響，對於治療的描述聚焦在西醫，死亡相關議題的討論也有限。結論：對醫療專業人員而言，從病患部落格書寫內容，能瞭解其醫療資訊需求和社會心理反應，未來可以根據疾病不同階段，提供適切的照護知識和社會資源介入，相關政府單位也可以規劃醫療資訊政策，建立友善網路平台，提供最新相關醫藥知識，促進病友間交流與互動。
  Objectives: The use of blogs as a means of internet communication is a phenomenon that cannot be ignored. Cancer patient-centered blogs have become an emerging and novel topic for health researchers to study. With in-depth interviews and participant observation, this preliminary study explored the impact of blog usage on the illness experiences of patients with breast cancer. Methods: In-depth interviews were held with 15 breast cancer bloggers from the Cancer Patient Reunion blog, a medium for meeting other breast cancer patients. Results: In order to confront their disease and stay socially connected, breast cancer patients were motivated to create the blog. The blog provided personal experiences of breast cancer treatment and related health information, served as a type of emotional catharsis and social support, and helped the participants reflect on the meaning of life. Personal experiences of the treatment process provided crucial health information for other patients with breast cancer. By writing blogs, breast cancer patients could comfort each other and alleviate the social isolation due to the illness. Nonetheless, it seemed that the illness narratives were still influenced by social/cultural regulation and ideology, and the treatments described were based mainly on Western medicine. In addition, few death-related topics were discussed on the blog. Conclusions: From the blog content, health care professionals should be able to understand the medical information needs and the psychosocial responses of cancer patients, and thus provide proper health care and social interventions based on the different stages of disease. Furthermore, based on analysis of blog content, appropriate government units can develop good medical and health information policies, create user-friendly websites, and provide updated medical information to help breast cancer patients communicate and interact with each other.
• 621 - 636
• 10.6288/TJPH201433103055

• Link 原著 Original Article
• 身體質量指數及日常運動預防台灣中老年人步行能力衰退之組合效應Combined Effect of Body Mass Index and Physical Activity on the Decline in Walking Ability amongst Older Taiwanese
• 丘幸平、蔡仲弘、 王俊毅
  Hsing-Ping Chiu, Alan C. Tsai, Jiun-Yi Wang
• 運動 ； 身體質量指數 ； 步行能力 ； 衰退 ； 組合效應
  physical activity ; Body Mass Index ; walking ability ; decline ; combined effects
• 目標：步行能力衰退是伴隨老化常見的現象。保持身體質量指數（Body Mass Index, BMI）適中和多運動皆有助於維持步行能力，但二者合併的效應則不清楚。本研究目的在探討BMI與運動對預防台灣中老年人步行能力衰退之組合效應。方法：本研究分析「中老年調查」2003及2007年的資料庫。排除非本人作答、嚴重心智功能缺損、中風及日常生活活動失能者，共有3,380位（加權後）50歲以上中老年人納入分析。依據受訪者二年度走完200-300公尺結果，評定其步行能力是否衰退。控制基本人口學、健康狀況及健康行為，以羅吉斯迴歸分析BMI與運動對步行能力衰退的個別和組合效應。結果：以個別變項分析中，肥胖（OR=1.75, p=0.001）及少運動（OR=1.37, p=0.036）與步行能力衰退有顯著關聯。在組合變項分析中，過輕且少運動者（OR=2.38, p=0.001）及肥胖且少運動者（OR=2.23, p=0.001）步行能力衰退的風險，皆明顯高於BMI適中且多運動者。結論：本研究之組合分析可彰顯同時保持BMI適中且多運動，對預防步行能力衰退的好處。研究結果讓民眾更容易及清楚地了解維持正常體重及日常運動對保有良好步行能力的重要，也可供健康促進政策之參考。
  Objectives: A decline in walking ability is a well-known accompaniment of aging. Maintaining a healthy Body Mass Index (BMI) and a higher level of physical activity are helpful to prevent a decline in walking ability; however, the combined effect is not clear. The current study determined the combined effect of BMI and physical activity on the decline in walking ability amongst older Taiwanese. Methods: The 2003 and 2007 ”Taiwan Longitudinal Study on Aging” datasets were analyzed. After exclusion of subjects not self-reported, with severe mental disorders, stroke, and disabilities in one or more activities of daily living, there were 3,380 subjects (weighted) ?50 years of age included in the analysis. Study subjects were defined as having a decline if they exhibited negative changes in the ability to ”walk 200-300 meters” between the two years. By controlling demographic, health status, and health behaviors, logistic regression was used to analyze the independent and combined effects of BMI and physical activity on the decline in walking ability. Results: When analyzed independently, obesity (OR = 1.75, p = 0.001) and less physical activity (OR = 1.37, p = 0.036) were associated with a decline in walking ability. Based on an analysis of the combination of BMI and physical activity, subjects who were underweight and engaged in less physical activity (OR = 2.38, p = 0.001) and subjects who were obese and engaged in less physical activity (OR = 2.23, p = 0.001) were more likely to have a decline in walking ability than subjects who had a BMI in the healthy range and engaged in more physical activity. Conclusions: The combined analysis method demonstrated the advantage of maintaining a healthy BMI and a higher level of physical activity simultaneously to prevent a decline in walking ability. The results of the current study should help people more easily and clearly understand the importance of a healthy BMI and physical activity to maintain good walking ability, and provide the basis for a national policy regarding health promotion.
• 637 - 648
• 10.6288/TJPH201433103071

• Link 原著 Original Article
• 健康行為群聚類別與醫療利用之關係－以台灣成年初顯期族群為例Clustering of Health-Related Behaviors and Healthcare Services Utilization amongst Emerging Adults in Taiwan
• 葉昱佐、施淑芳
  Yu-Tso Yeh, Shu-Fang Shih
• 成年初顯期 ； 健康行為 ； 群聚分析 ； 醫療利用
  emerging adulthood ; health behaviors ; cluster analysis ; healthcare utilization
• 目標：探討18～25歲成年初顯期族群健康行為群聚類別與醫療利用之相關性。方法：本研究使用2009年國民健康訪問調查，以18～25成年初顯期族群為研究對象，運用二階段群聚分析法依健康行為型態進行群聚分析，並使用羅吉斯迴歸及零膨脹負二項迴歸模型分析群聚類別與急診及西醫門診醫療利用與否及醫療利用次數之相關性。結果：成年初顯期族群可分為「菸酒不離族」、「飲食不均族」以及「健康保健族」三個群聚類別。相較於健康保健族，在急診醫療利用與否方面，菸酒不離族較可能使用到急診醫療（OR=1.59; 95% CI=1.14-2.21）；在急診醫療利用次數方面，飲食不均族使用較多次數的急診醫療（IRR=1.49; 95% CI=1.08-2.05）；群聚類別與西醫門診利用與否或其利用次數則無統計顯著相關。結論：成年初顯期健康行為具有群聚之現象且群聚類別與急診醫療利用之機率與急診使用次數有統計顯著相關。未來不管是學校或職場健康促進方案，可針對具有共同健康行為特性之成年初顯期族群，規劃整合及客制化之介入方案。
  Objectives: This study aims to investigate the association between clustering of healthrelated behavirs and heathcare services utilization amongst emerging adults. Methods: This study utilized a sub-sample between 18 and 25 years of age from the 2009 National Health Interview Survey. A two-step cluster analysis was used to identify groups of emerging adults with similar behavior patterns. Logistic regression and a zero-inflated negative binomial regression model were used to determine the association between groups of clustering and utilization of emergency care and outpatient healthcare services. Results: Three clusters were identified, including ”smokingalcohol,” ”unbalanced diet,” and ”healthy lifestyle.” Those who were classified in the ”smokingalcohol” cluster were more likely to use emergency care services (OR=1.59; 95% CI=1.14-2.21), and those who were in the ”unbalanced diet” cluster were more likely to use emergency care service (IRR=1.49; 95% CI=1.08-2.05) when compared to those in the ”healthy lifestyle” cluster. The current study showed no relationship between the clusters and outpatient healthcare services, whether or not use or the number of visits was considered. Conclusions: Health-related behaviors tend to cluster amongst emerging adults. In addition, health behavior clusters were shown to be associated with a higher risk of using emergency care and more visits of emergency care services. These findings suggest that whether school- or workplace-based, health promotion program could adopt an integrated approach and taior-made programs, when taking into account the common determinants across different types of health behaviors.
• 649 - 662
• 10.6288/TJPH201433103082

• Link 實務 Public Health Practice
• 資訊科技應用於改善多重慢性病人門診重複處方之分析Implementing Health Information Technology in an Outpatient Setting to Reduce Duplicate Prescriptions among Patients with Multiple Chronic Diseases
• 蕭淑珍、王郁青、 陳一伶、李浩銓、許茜甯
  Shu-Chen Hsiao, Lily Yu-Chin Wang, I-Ling Chen, Haw-Chyuan Lee, Chien-Ning Hsu
• 藥事照護 ； 醫療資訊科技 ； 慢性病連續處方 ； 重複處方 ； 門診
  pharmaceutical care ; health informatics ; refillable chronic illnesses prescriptions ; medication duplication ; outpatient setting
• 目標：探討醫療資訊科技運用於門診藥事照護對門診多重慢性病人重複處方的影響。方法：南部某一醫學中心門診，於2012年10月至2013年6月期間，凡持1張以上慢性病連續處方箋之成年病人皆納入分析。門診藥事服務—科技化照護模式包括：（1）利用SAS軟體進行門診用藥重複處方篩選；（2）藥師審核重複處方、確立修改必要性、建立並預存電子建議提示；（3）電子提示融入電子醫囑輸入系統，在患者回診接受診療時，醫師將接到重新評估用藥或／與修改提示。病人與重複處方特性以描述性統計進行分析。結果：研究期間藥師共建議572筆處方（483人），重複處方常見於65歲以上（59%）、就診至少3個專科（80%）且用藥品項數大於10筆者（53%）。從完成處方修改的病人與處方分析發現(284人)：(1)高修改率藥品(大於80%)為用於心血管、新陳代謝和抗帕金森症的藥品；（2）相對於處方修改前6個月，修改後6個月的每月平均藥品費用減少47,325元；門、急、住診就診人次也分別相對下降5.7%、18.3%與13.8%。結論：門診藥事科技照護模式值得擴大規模執行以驗證其對減少重複處方發生率與醫療資源浪費的效果。
  Objectives: To determine the effect of implementing health information technology in an outpatient setting on reduction of duplicate prescriptions among patients with multiple chronic diseases. Methods: Adult patients with at least 2 refillable prescriptions for multiple chronic diseases at a medical center in southern Taiwan between 1 October 2012 and 30 June 2013 were enrolled in the current study. The key design principles in the ambulatory pharmaceutical care model included (1) using the SAS Enterprise Guide to systematically screen potential duplicate prescription orders using pre-specified criteria, (2) hospital pharmacists performed medication reviews and provided electronic alerts for duplicate medications to physicians, and (3) medical alerts and recommendations were integrated into the natural workflow of practice to correct duplicate medications. Patient characteristics and patterns of duplicate medications were assessed using descriptive statistical analyses. Results: Of 572 notifications (n=483), the most common duplicate prescriptions occurred in patients > 65 years of age, had > 3 outpatient specialist visits, and were treated with > 10 medications. The correction rate for duplicate prescriptions was high for cardiovascular diseases, endocrinopathies, and Parkinson disease. Among patients who had corrected duplicate medications (n=283), the average monthly medication cost decreased 47,325 TWD during the most recent 6 months when compared to the 6 months preceding the correction. Furthermore, the outpatient clinic, emergency room, and hospitalization person-visits decreased 5.8%, 18.3%, and 13.8%, respectively. Conclusions: Implementation of advancing health information technology in the outpatient setting for a group of patients with multiple chronic diseases revealed a high propensity to successfully reduce duplicate medications in a large population.
• 663 - 673
• 10.6288/TJPH201433103051

• Link 研究紀要 Research Brief
• 台灣新生兒B型肝炎疫苗政策之直接成本分析Direct Cost Comparison of the Hepatitis B Immunization Policy in Taiwan
• 楊舜婷、陳志成、林怡岑、林嘉玲
  Shun-Ting Yang, Solomon Chih-Cheng Chen, Yi-Tsen Lin, Chia-Ling Lin
• B型肝炎 ； 疫苗政策 ； 成本分析 ； 產婦篩檢 ； B肝免疫球蛋白
  hepatitis B ; immunization policy ; cost analysis ; maternal screening ; hepatitis B immunoglobulin (HBIG)
• 目標：台灣B肝疫苗政策實施近30年，但少有成本效益研究，本文擬從成本角度來評估台灣的B肝疫苗政策。方法：整理比較台灣與其他國家的B肝疫苗政策，除了都有全面疫苗接種外，在抗原篩檢和B肝免疫球蛋白（HBIG）的使用上仍有一些差異：1.中國式策略（CH）－不做產婦抗原篩檢，也沒給嬰兒HBIG；2.美國式策略（USA）－產婦只篩檢HBsAg，給所有HBsAg陽性母親所生嬰孩HBIG；3.台灣一階段篩檢策略（TW1）－產婦同時篩檢HBsAg和HBeAg，給兩者都陽性產婦所生嬰孩HBIG；4.台灣兩階段篩檢（TW2）－產婦先篩檢HBsAg，如果HBsAg陽性再繼續篩檢HBeAg，給兩者都陽性產婦所生嬰孩HBIG。我們比較這四種策略的抗原篩檢、疫苗與HBIG等費用。結果：不管B肝帶原率多少，TW2都是最便宜，而TW1都是最昂貴的策略。隨著B肝帶原率下降，HBIG的使用需求會越來越少。從策略TW1改為TW2所節省下篩檢HBeAg的費用，足夠讓所有B肝帶原母親所生嬰孩一劑免費的HBIG。結論：台灣目前B肝防疫實務是TW1，浪費很多錢在HBeAg篩檢上。建議改為TW2，才是最經濟的策略。此外為了提供嬰兒完善的保護，建議給所有HBsAg陽性帶原母親所生嬰孩一劑免費的HBIG。
  Objectives: To study the cost-effectiveness of the hepatitis B virus (HBV) immunization policy in Taiwan after its implementation for nearly 30 years. Methods: Existing HBV immunization policies in different countries were compared. They all have universal HBV vaccination, but differ in maternal antigen screening and the use of hepatitis B immunoglobulin (HBIG). Strategy 1: Chinese strategy (CH)-no maternal screening and no HBIG for neonates; Strategy 2: American strategy (USA)-The parturients are screened for HBsAg, and HBIG is administered to all neonates of HBsAg-positive mothers; Strategy 3: Taiwan 1-step strategy (TW1)-The parturients are simultaneously screened for HBsAg and HBeAg, and HBIG is administered to all neonates of HBeAg-positive mothers; and Strategy 4: Taiwan 2-step strategy (TW2)-The parturients are screened for HBsAg first, then screened for HBeAg if HBsAg is positive, and HBIG is administered to all neonates of HBeAg-positive mothers. Results: Regardless of the HBV carrier rate, the TW2 is always the least expensive HBV vaccination protocol and the TW1 is most expensive. As the HBV carrier rate decreases, the need for HBIG also decreases. The cost-savings realized during the change from TW1 to TW2 is enough for the government to provide one free dose of HBIG for all babies born to HBsAg-positive carrier mothers. Conclusions: The current practice of HBV immunization policy in Taiwan is the TW1, which unnecessarily consumes financial resources for maternal HBeAg testing. We suggest the TW2 replace the TW1. To provide comprehensive protection, we recommend giving free HBIG for all neonates born to HBsAg-positive mothers regardless of the HBeAg status.
• 674 - 680
• 10.6288/TJPH201433103044