35卷3期

• Link 公衛論壇 Public Health Forum
• 以論人計酬制度提供矯正機關收容人之健康照護芻議A capitation system for providing health care service to inmates in the correctional institution in Taiwan - a proposal
• 李妙純、吳元培、陳孝平
  Miaw-Chwen Lee, Yuan-Pei Wu, Michael S. Chen
• 無
  none
• 無
  none
• 235 - 238
• 10.6288/TJPH201635105043

• Link 公衛論壇 Public Health Forum
• 論我國生物醫學研究者利益衝突管制－以研究者利益衝突之揭露制度為中心Regulation of biomedical researchers' conflict of interest in Taiwan with a focus on the disclosure of conflict of interest by the researchers
• 李銘杰、劉宏恩
  Ming-Chieh Li, Hung-En Liu
• 無
  none
• 無
  none
• 239 - 244
• 10.6288/TJPH201635105033

• Link 公衛論壇 Public Health Forum
• 從美國爽身粉訴訟判決，看台灣化妝品滑石與石綿暴露的健康風險From the baby power litigation in the United States to the potential health risks of talc-based cosmetic products and asbestos exposures in Taiwan
• 林恭儀、鄭雅文
  Justin Kung-Yi Lin, Ya-Wen Cheng
• 無
  none
• 無
  none
• 245 - 247
• 10.6288/TJPH201635105028

• Link 綜論 Review Article
• 以整合照護指引與文獻回顧為基礎的老年人慢性便秘非藥物照護建議Non-pharmacologic care for chronic constipation in the elderly based on intergraded guidelines and literature review
• 陳雅莉、林文絹
  Ya-Li Chen, Wen-Chuan Lin
• 便秘 ； 老年人 ； 膳食纖維 ； 益生菌
  constipation ; the elderly ; dietary fiber ; probiotics
• 老年人因老化、生理功能改變、咀嚼能力減弱、罹患各種慢性疾病及用藥等多重因素影響下，使便秘成了老年人常見的健康問題，便秘的盛行率隨著年紀增長而增加。長期便秘引起腹部脹痛、食慾不振、噁心、嘔吐等不適；此外，若因便秘致使排便用力，也易誘發心肌梗塞、中風猝死等危險，影響老年人的生理及心理健康，降低生活品質，因此便秘的預防和處置是照護者均需面對的重要課題。本文整合現今國內外老年人慢性便秘非藥物照護指引與文獻，提出慢性便秘照護上的實證建議，內容包括護理人員及主要照顧者在評估老年人便秘時應留意的重點，於便秘的預防及處置上，如何適當的攝取膳食纖維、益生菌及水分等，並配合腹部按摩與活動來改善便秘問題，可適用於無特殊疾病(如慢性腎衰竭、神經性便秘)之居家、社區、機構及醫療院所有慢性便秘困擾的老年人，提供照護人員之參考，以提升老年人之生活品質。
  Constipation is a common medical disorder in the elderly, and results from aging, physiologic changes, co-existing chronic diseases, and the administration of multiple drugs. The prevalence of constipation increases with advancing age. Chronic constipation may lead to significant gastrointestinal discomfort. In addition, defecating with force induces myocardial infarction and death from stroke, which affect physiologic and psychological health, thus impairing the quality of life. It is therefore of paramount importance for caregivers to prevent and manage constipation. Herein we provide evidence-based suggestions for chronic constipation care on the basis of guidelines and a literature review pertaining to the non-pharmacologic care of chronic constipation. The themes derived from the guidelines and a literature review are intended to aid nurses and primary health caregivers focus on the prevention and the treatment of constipation, and consists of an adequate intake of dietary fiber, probiotics, and fluids, together with interventions, such as abdominal massage and physical activity, to improve constipation while taking care of these elderly patients. Evidence-based suggestions provided herein are useful for the management of chronic constipation in the elderly free of other specific diseases (e.g. chronic renal failure and neurotic constipation) dwelling at home or institutions.
• 248 - 259
• 10.6288/TJPH201635104088

• Link 原著 Original Article
• 台灣縣市兒童貧窮與死率之關係：1980-2009年Region-specific child poverty and child mortality in Taiwan: 1980-2009
• 江宛霖、江東亮
  Wan-Lin Chiang, Tung-Liang Chiang
• 兒童貧窮率 ； 五歲以下兒童死亡率 ； 地理差異
  child poverty rates ; under five mortality rates ; geographical disparity
• 目標：本研究旨在描述過去30年來台灣縣市別兒童貧窮率的趨勢與差距，及縣市別的兒童貧窮率與五歲以下兒童死亡率之關係。方法：首先，我們採用「家庭收支調查」資料，計算1980-1989年，1990-1999年及2000-2009年三個時期的縣市別兒童貧窮率，並使用「中華民國台閩地區人口統計」計算縣市別五歲以下兒童死亡率。接著，我們以皮爾森相關分析，檢定三個時期的縣市兒童貧窮率與五歲以下兒童死亡率之關係，以及縣市兒童貧窮率改變率及兒童死亡率改變率的相關性。結果：1980年以來，台灣兒童貧窮率雖然呈現微幅下降，但縣市之間的兒童貧窮率差距卻從1980-1989年的18.2%增加為2000-2009年的21.6%。其次，縣市兒童貧窮率與五歲以下兒童死亡率呈顯著正相關，三個時期的相關係數依序為0.79(p＜0.001)，0.64(p＜0.01)及0.83(p＜0.001)，而兒童貧窮率改善幅度越大的縣市，五歲以下兒童死亡率下降幅度也越大(r=0.51, p=0.018)。結論：台灣各縣市之間的兒童貧窮率差距越來越大，且與縣市別兒童健康不平等息息相關.
  Objectives: This study aimed to describe the trends and the differences in region-specific child poverty rates, and the relationship between region-specific child poverty rates and underfive mortality rates in Taiwan during the past 3 decades. Methods: City or county was defined as a region in this study. We measured region-specific child poverty rates during 3 time periods (1980-1989, 1990-1999, and 2000-2009) using data from the Family Income and Expenditure Survey. Data on under-five mortality rates were obtained from the Taiwan-Fukien Demographic Fact Book. Pearson’s correlation was used to determine the associations between child poverty and child mortality for each of three time periods. Results: The overall child poverty rate in Taiwan decreased slightly from 1980, but the difference in child poverty rates between the highest and lowest regions increased from 18.2% in 1980-1989 to 21.6% in 2000-2009. The association between child poverty and the under-five mortality rates was markedly positive; the correlation coefficient for the 3 time periods was 0.79 (p<0.001), 0.64 (p<0.01), and 0.83 (p<0.001), respectively. Also, a greater decline in the child poverty rate was significantly related to a more rapid improvement in the under-five mortality rates (r=0.51, p=0.018). Conclusions: The regional difference in child poverty rates has been widening in Taiwan, and has contributed to inequality in child health.
• 260 - 267
• 10.6288/TJPH201635104091

• Link 原著 Original Article
• 實施全民健康保險住院診斷關聯群支付制度對醫療機構之影響Impact of DRG-based payments on health care providers
• 陳珮青、郭年真、 黃昱瞳、黃光華、楊銘欽、李玉春
  Pei-Ching Chen, Raymond N. Kuo, Yu-Tung Huang, Kuang-Hua Huang, Ming-Chin Yang, Yue-Chune Lee
• 全民健康保險住院診斷關聯群 ； 醫療費用 ； 轉院治療 ； 結果成效
  Taiwan Diagnosis Related Groups (Tw-DRGs) ; medical expenses ; inpatient transfer rate ; outcome quality
• 目標：探討全民健康保險住院診斷關聯群(Taiwan Diagnosis Related Groups，簡稱Tw- DRGs)支付制度實施後，對於醫療機構申報健保醫療費用、病患轉院治療及出院成效之影響。方法：選取2008-2011年期間健保住院申報案件數，每一住院人次為一個案，排除Tw-DRGs不適用之案件後，將研究對象分成DRG組與非DRG組，以傾向分數(propensity score)進行一比一配對，配對條件為「同醫師ID」、「MDC別」、「年齡」、「性別」及「Tw-DRGs權重」等變項，配對後將兩組住院人次經由加權後歸戶至醫療機構，分為「DRG組」與「非DRG組」，以年代與組別的交互作用呈現制度實施後實驗組之影響，並以廣義估計方程式(generalized estimating equation; GEE)進行統計分析。結果：Tw-DRGs支付制度實施後，在醫療費用部分，2010年DRG組平均單次住院申報點數顯著低於非DRG組。在轉院治療部分，2010年DRG組住院轉院治療率顯著低於非DRG組。在結果成效部分，2010年DRG組180天內死亡率顯著低於非DRG組。然而，Tw-DRGs支付制度實施後，在結果成效部分，2010年DRG組180天內再住院率顯著高於非DRG組。結論：實施Tw-DRGs支付制度後，醫療院所受到影響為單次住院申報點數減少、病患轉院減少，但對於結果成效影響不同。建議仍需監控醫療機構住院病人其出院後之醫療利用與結果，以確保病患就醫之醫療品質及療效，此外，並建議重新定義結果成效指標，應採納計算同科或同診斷案件計算較具公平。
  Objectives: The aim of this study was to determine the impact of the Taiwan Diagnosis Related Groups (Tw-DRGs) payment system on medical institutions with respect to medical expenses and quality of care. Methods: Inpatient-related data were obtained from the National Health Insurance research database (NHIRD) during the study period (2008-2011). Propensity score matching (PSM) was used to divide the subjects into DRG and non-DRG groups and differentiate the subjects according to the medical institutions at which they were treated. The difference-in-difference approach and the generalized estimating equation (GEE) model were used to compare the DRG and non-DRG groups with respect to changes in health care efficiency before and after the introduction of Tw-DRGs and to evaluate the impact of Tw-DRGs on medical institutions. Results: After Tw-DRGs were implemented, the DRG group had lower medical expenses, a lower inpatient transfer rate, and a lower mortality rate within 180 days after discharge compared to the non-DRG group. In contrast, after Tw-DRGs were implemented, the DRG group had a higher readmission rate within 180 days after discharge compared to the non-DRG group. Conclusions: After implementing the Tw-DRGs payment system, the medical expenses, mortality rate within 180 days after discharge, and inpatient transfer rate had decreased, but the readmission rate within 180 days after discharge had increased. We suggest that the NHI should continue monitoring medical institutions to ensure high-quality medical care, and the measurement of indicators, such as the readmission rate, should be more strictly and precisely defined.
• 268 - 280
• 10.6288/TJPH201635104043

• Link 原著 Original Article
• 運用決策樹技術探討基層診所門診量之影響因素Analysis of outpatient visits to primary care clinics and its influencing factors using a decision tree model
• 許文錦、李佳桓、余致廷
  Wen-Chin Hsu, Jia-Huan Li, Chih-Ting Yu
• 選址分析 ； 基層診所 ； 資料探勘 ； 地理資訊系統
  location analysis ; primary care clinic ; data mining ; geographical information system
• 目標：開業地點對醫療院所經營具有重要影響力，便利性高的地點可提高病患就診意願，更可讓醫療院所取得競爭優勢。隨著開放資料時代來臨，如何運用開放資料協助選址成為醫療機構經營重要課題。本研究旨在運用資料探勘技術分析開放資料，探勘影響基層診所門診量的關鍵分類規則，藉以協助選址決策。方法：本研究以台北市306間高門診量基層診所為對象，蒐集相關之開放資料，包括社經資料、診所門診量、地價金額、地理空間資料等19項資料，運用CART決策樹分析影響高門診量診所之成功關鍵因素。結果：研究結果顯示決策樹分析之資訊增益順序為(可支配家庭收入＞所屬行政區診所密度＞女性人口數)。迴歸分析發現65歲以上人口數(β=0.836)與離最近捷運站距離(β=-0.297)顯著影響基層診所門診量(p＜0.001)。結論：本研究所發現之選址分類規則可協助診所、藥局、醫療器材與政府衛生部門找出符合高門診量診所地理條件且尚未設立診所的位址，提供開業者選址參考。
  Objectives: The process of locating health facilities has been studied extensively using mathematical optimization (e.g., covering model); however, few researchers have applied the techniques of data mining to this problem. This study proposes a novel prediction model, based on the Geographic Information System and data mining to assist in the selection of optimum locations for medical clinics. Methods: This study examined 306 medical clinics in Taipei, focusing on those with a high number of outpatients, using 19 variables associated with location decisions. A CART decision tree was used in the development of the model based on the collected variables. Results: The decision tree model indicated that household disposable income has the strongest impact on the number of outpatients, followed by clinic density, and gender. Regression analysis identified age, and distance to the nearest Mass Rapid Transit station as the two factors with a significant effect on the number of outpatients at a given clinic (p<0.001). Conclusions: This study constructed a novel prediction model to aide in identifying the optimal location for a clinic and evaluating options with regard to clinic relocation.
• 281 - 293
• 10.6288/TJPH201635104052

• Link 原著 Original Article
• 部立醫院行政法人化之芻議The transition to non-departmental public bodies -- a preliminary study of hospitals affiliated with Taiwan's Ministry of Health and Welfare (MOHW)
• 李天申
  Tien-Shen Li
• 部立醫院 ； 署立醫院 ； 行政法人
  MOHW-affiliated hospitals ; DOH-affiliated hospitals ; non-departmental public bodies (NDPBs)
• 目標：本研究探討署立醫院改制行政法人未成功的原因，以及針對部立醫院(原署立醫院)未來行政法人化提出建議。方法：本研究採用深度訪談，對象包括5位署立醫院高階主管，5位行政院與衛生署官員，1位立法委員。結果：當年行政法人化未成功的主因為：第一，政治氛圍不利於行政法人化；第二，員工抗拒行政法人化；第三，部分醫院擔憂行政法人化後財務更困難。結論：衛生福利部應從行政、法律、政治等面向，個別評估各家部立醫院改制為行政法人的可行性。針對適合行政法人化者，衛生福利部應積極向立法院遊說推動組織法案，以及向醫院員工充份宣導行政法人化的工作權益事項。
  Objectives: This study determined the reasons for failed transformation of DOH- affiliated hospitals into non-departmental public bodies (NDPBs). Suggestions are proposed for the future transformation of MOHW-affiliated hospitals into NDPBs. Methods: Five senior officers in DOH-affiliated hospitals, five political appointees and senior officers in the Executive Yuan and the Department of Health, and one member of the Legislative Yuan were interviewed. Results: There are three main reasons for failed transformation of DOH- affiliated hospitals into NDPBs. First, the political atmosphere was unfavorable for the transformation. Second, the hospital staff declined the transformation. Third, some hospitals feared that the transformation might result in a worsening financial condition. Conclusions: We suggest that transforming MOHW-affiliated hospitals into NDPBs can be evaluated individually based on the administrative, legal, and political feasibility by the MOHW. For hospitals which are well-suited for transformation into a NDPB, the MOHW should actively lobby the Organizational Act Reform, and communicate the working benefits of the transformation to the hospital staff.
• 294 - 303
• 10.6288/TJPH201635104102

• Link 原著 Original Article
• 外籍看護與家庭照顧者對接受居家照顧老人住院與死亡風險之差異Differences between foreign care workers and family caregivers in risk of hospitalization and mortality among home care elders in Taiwan
• 黃郁超、吳建賢、張淑惠、陳雅美
  Yu-Chao Huang, Chien-Hsien Wu, Shu-Hui Chang, Ya-Mei Chen
• 長期照顧 ； 外籍看護 ； 家庭照顧者 ； 居家照顧品質
  long term care ; foreign care worker ; family caregiver ; quality of home care
• 目標：為解決老人照顧人力之需求，我國從1992年開始引進外籍看護，目前已經成為長期照顧人力的主要來源。有鑑於我國開放引進外籍看護二十多年，對於其照顧品質的相關研究仍然相當缺少。因此本研究希望探討由外籍看護照顧，相較於家庭照顧者，對於居家照顧老人預後風險之影響，並分析造成老人預後差異可能的因素。方法：研究資料取自273位新北市某區域醫院附設居家護理所之居家老人護理紀錄，所涵蓋之資料日期從2003年7月至2015年5月。以收案期間死亡與住院事件進行存活分析，比較外籍看護與不同性別、不同親屬關係之家庭照顧者照顧，對居家老人死亡與住院風險之影響。結果：由女性(HR= 0.715)、女兒或媳婦(HR= 0.653)所照顧之老人，其住院風險明顯低於由外籍看護照顧。短期由子女照顧住院風險同樣低於於外籍看護(HR= 0.552)，但子女照顧時間超過1.1年之後兩者則無顯著差異。結論：本研究顯示家庭照顧者照顧之老人預後優於外籍看護照顧。政府應重新考量目前外籍看護的開放政策，並對於願意投入照顧工作的家庭照顧者提供更多的長照資源與協助。
  Objectives: The purpose of this study was to evaluate the quality of home care provided to older adults in Taiwan whose caregivers were either family members or foreign care workers. Methods: Data from July 2003 to May 2015 was retrieved from the records of a home care agency in new Taipei city. A total of 273 older adults were included for analysis. Cox proportional hazards and recurrent event models were applied to compare the risk of mortality and hospitalization for disabled older adults with caregivers who were foreign workers or family members; in addition, the effects of gender and family roles were determined. Results: Older adults who were taken care of by female family members (HR = 0.715), such as a daughter or daughter-in-law (HR = 0.653), had a significantly lower risk of hospitalization than older adults who were taken care of by foreign care workers. Older adults who were taken care of by their children during early episodes of disability also had lower rates of hospitalization compared to older adults who were taken care of by foreign care workers (HR = 0.552). The differences between these two caregiver roles (children vs. foreign care workers) were not significant when the duration of care lasted > 1.1 years. Conclusions: The study findings showed that family caregivers provided better care to older adults than foreign care workers. The government should re-evaluate the open-door policy for foreign care workers and provide more long-term care resources and support for family caregivers who are willing to take care of disabled older relatives.
• 304 - 315
• 10.6288/TJPH201635104108

• Link 原著 Original Article
• 父母的社經地位對兒童的自覺健康、身高與BMI指數的影響Effects of parental socioeconomic status on child self-reported health, height, and BMI
• 尤素娟、陳碩亨、蔡偉德
  Su-Chuan Yu, Shuo-Heng Chen, Wei-Der Tsai
• 兒童自評健康狀態 ； 身高 ； BMI值 ； 父母社經地位
  child self-reported health status ; height ; BMI values ; parental socioeconomic status
• 目標：觀察台灣地區父母社經地位對子女健康之影響。方法：本研究利用2001年台灣國民健康訪問調查建立親子配對資料，分別以序列邏吉斯機率迴歸模型、線性迴歸模型與多元邏吉斯迴歸模型，分析父母社經地位(教育程度與家戶所得)對0~12歲子女健康(自評健康狀況、身高及身體質量指數)的影響。結果：在子女自評健康狀態方面，家庭所得愈高，子女自評健康狀況愈好。在子女身高與身體質量指數方面，母親的教育程度若為高中及大學以上學歷，其子女身高明顯較高，也有較低肥胖的機率；家庭所得較高的子女，體重過重的機率較高，但不致於增加肥胖的機率。另外，母親有全職工作者，其子女健康良好的機率較低，肥胖的機率較高。結論：本研究結果顯示子女健康因父母社經地位不同而有明顯地差異。鑑於父母社經地位對子女未來成年時的健康有直接或間接的影響，為防止健康階層世代移轉，政府應採取一些公共政策改善經濟弱勢兒童的健康，或保護兒童免於受家庭貧困的拖累。
  Objectives: The relationship between parental socioeconomic status (SES) and child health was determined. Methods: The relationship between parental SES and child health was empirically investigated using the 2001 National Health Interview Survey in Taiwan. ”Selfreported health,” ”height,” and ”body mass index (BMI)” were used as health indicators for children 0-12 years of age and linked to the parental SES, as indicated by household income and parent’s education via the ordered and multinomial logit models, respectively. Results: Household income was positively associated with the child’s self-reported health and the likelihood of being overweight. Maternal education had a positive effect on a child’s height and was associated with a lower probability of a child being obese. Conclusions: Our empirical results provide some evidence that a child’s health varies as a function of parental SES. Due to the existence of health gradients in children, the government should adopt policies to promote child health and hamper the transmission of low SES across generations.
• 316 - 329
• 10.6288/TJPH201635104093

• Link 評論 Commentary
• 評論：父母的社經地位與兒童健康指標間之非階層性效果Commentary: non-gradient effect between parental socioeconomic status and children's health indicators
• 吳文琪
  Wen-Chi Wu
• 無
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• 330 - 330
• 10.6288/TJPH20163510409301

• Link 評論 Commentary
• 作者回覆：父母的社經地位與兒童健康指標間之非階層性效果Authors' response to commentary: non-gradient effect between parental socioeconomic status and children's health indicators
• 尤素娟、陳碩亨、蔡偉德
  Su-Chuan Yu, Shuo-Heng Chen, Wei-Der Tsai
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• 331 - 331
• 10.6288/TJPH20163510409302

• Link 原著 Original Article
• 以21世紀風險矩陣評估國人DDT花茶之潛在健康風險A RISK21 matrix for assessing the potential health risk of DDT from flower tea in Taiwan
• 林怡君、游舒涵、周韋均、翁甄憶、張琇惠、 詹菀菁、林偉瑄、江宏哲、林嬪嬪
  Yi-Jun Lin, Shu-Han You, Wei-Chun Chou, Chen-Yi Weng, Hsiu-Hui Chang, Wan-Ching Chan, Wei-Hsuan Lin, Hung-Che Chiang, Pin-Pin Lin
• 21世紀風險評估 ； 滴滴涕 ； 花茶 ； 健康風險評估
  RISK21 ; DDT ; flower tea ; health risk assessment
• 目標：21世紀風險矩陣(RISK21 matrix)是一個簡單、高效能、透明化且視覺化之健康風險評估方法。本研究目的為引用RISK21結合傳統風險評估方法，評估國人不同年齡族群飲用含DDT花茶或直接食用含DDT花瓣之潛在健康風險。方法：以風險評估為基礎，整合特定年齡層DDT每日總攝取量、非致癌與致癌毒性資料，以RISK21 matrix評估國人DDT暴露之肝病變與發育毒性健康關注程度，亦以傳統風險評估方法增量終生癌症風險(incremental lifetime cancer risk, ILCR)量化肝腫瘤風險。結果：不同年齡族群之RISK21 matrix評估結果顯示飲用DDT花茶所造成之肝病變與發育毒性為低度安全疑慮，然而若直接食用花瓣則有高度關注之必要性。飲用花茶及直接食用花瓣之ILCR分別為1.14×10^(-19) - 3.40×10^(-12)及2.12×10^(-10) - 3.29×10^(-3)，顯示食用花瓣有高度潛在肝腫瘤風險。結論：儘管飲用含DDT之花茶似乎不太可能造成公共衛生安全疑慮，但從直接食入花瓣之保守觀點來看，DDT暴露之健康風險仍應提出警訊。RISK21 matrix是一個易於使用之工具，不僅增進風險評估之理解，亦促進科學家、業界、政府及社會大眾之間的風險溝通。
  Objectives: RISK21 matrix is a straightforward, efficient, transparent, and visual approach for health risk assessment. The purpose of this study was to adopt RISK21 approach combining traditional risk assessment method to assess the potential health risks of DDT (dichlorodiphe nyltrichloroethane) when flower tea is drunk or when petals are directly consumed by various age groups. Methods: Based on the principles of risk assessment, we integrated age-specific total daily intakes of DDT with non-carcinogenic toxicity data to assess the level of health concern regarding liver lesion and developmental toxicity by RISK21 matrix. We also applied the carcinogenic toxicity data to quantify the incremental lifetime cancer risk (ILCR) for liver tumor. Results: RISK21 matrix for all age groups showed that DDT in flower tea drinks posed a low health concerns of liver lesion and developmental toxicity. However, there were very significant health concerns when the DDT exposure through a direct intake of petals. The ILCRs of DDT ranged 1.14×10^(-19)-3.40×10^(-12) and 2.12×10^(-10) - 3.29×10^(-3) for drinking flower tea and directly consuming petals, respectively, indicating a high potential risk of liver tumor from consuming petals. Conclusions: Although drinking DDT-contaminated flower tea is unlikely to be a significant safety concern, the human health risks related to DDT exposure are alarming from a conservative point of view when there is direct intake of flower tea petals. RISK21 matrix is an easy-to-use tool that not only promotes an understanding of risk assessment but also helps the risk communication among scientists, industries, governments, and the public.
• 332 - 341
• 10.6288/TJPH201635104116