35卷4期

• Link 公衛論壇 Public Health Forum
• 關心厝邊的老大人：前進社區的「3+1行動醫療」服務Caring for the elderly in the neighborhood: the "3+1 mobil medical care" service
• 盧鴻毅、林裕珍、李雅莉
  Hung-Yi Lu, Yu-Chen Lin, Ya-Li Li
• 無
  none
• 無
  none
• 343 - 350
• 10.6288/TJPH201635105006

• Link 綜論 Review Article
• 以「雙重詮釋」概念，理解質性研究之多元面貌Understanding the multifaceted perspectives and methods of qualitative research using the concept of "Double Hermeneutics"
• 賴文恩、李秉學
  Wen-An Lai, Ping-Hsueh Lee
• 質性研究 ； 雙重詮釋 ； 測不準定理
  qualitative research ; Double Hermeneutics ; uncertainty principle
• 目前，公共衛生領域，有愈來愈多學者，採質性研究探索實務與理論問題，然而，國內較少討論質性研究科學哲學理論背景的文章。質性研究是引自社會學界之研究方法，自二十世紀初期以來，就以多元面貌出現：其理論基礎，包括後實證主義、扎根理論、建構詮釋學、批判主義、女性主義、後現代主義等；資料收集方式包括深度訪談、觀察法、民族誌法、行動研究、文獻實物分析等；不同學術背景，也有包羅萬象的研究內容。因此，對於何謂質性研究，並沒有一個明確的定義，對於背後的科學哲學理念，也沒有一致的共識，以致於不同背景的初學者，對於不同取向與方法之異同、對錯及應用時機，常常有所混淆，對於如何整合質性研究與量性研究，也不易了解。本文作者以一個寓言故事開始，嘗試以紀登斯「雙重詮釋」的概念，描繪創意、多元、互為主體的社會現象，理解質性研究的內涵、多元的面貌與共通的特徵，並說明在科學哲學的層次上，如何可能整合質性研究與量性研究的理論基礎。
  Nowadays, many researchers adopt qualitative methods to investigate practical or theoretical issues in public health; however, few articles introduced the philosophical and methodological considerations when applying qualitative approaches. Since the beginning of the 20^(th) century, qualitative research originated within the community of sociology and other related academic disciplines with multifaceted perspectives and methods. Different qualitative researchers investigate diverse sociological phenomenon or issues with various study designs in accordance with their academic backgrounds. Their studies are based on different theoretical perspectives such as post-positivism, grounded theory, constructive hermeneutics, critical theory, feminism, or postmodernism. They collect data with different methods including in-depth interviews, participant observation, ethnography, or action research. Because of the diversity of their philosophical backgrounds, there is still no clear definition of qualitative research. Novice researchers frequently lose their way in the terminology jungle of different schools of qualitative research. They also encounter difficulty in understanding how to integrate qualitative and quantitative research methods. In this article, which begins with a fable, the authors try to clarify the philosophical essence of qualitative research using the concept of ”double hermeneutics” and explore the possibility of integrating qualitative and quantitative research methodologies.
• 351 - 358
• 10.6288/TJPH201635105029

• Link 綜論 Review Article
• 以連帶思想檢視台灣長照政策發展之挑戰與啟發Challenges with the long-term care policy in Taiwan: application of solidarity
• 林志遠、陳珮青、李玉春
  Chih-Yuan Lin, Pei-Ching Chen, Yue-Chune Lee
• 長期照護 ； 長照政策 ； 長照保險 ； 連帶思想 ； 社會保險
  long term care ; long term care policy ; long term care insurance ; solidarity ; social insurance
• 長照政策將會是我國衛生福利政策影響深遠的制度。我國長照政策發展脈絡借鑒OECD國家發展經驗，並以典型社會保險路徑國家如德國與日本為藍圖。面對未來資源有限，長照需求龐大的時代，除透過發展成熟的保險治理技術，如何以衛生與福利政策之連帶思想元素，作為長照政策發展之參考，為本文目的。本文回顧中英文資料庫有關連帶思想概念之歷史發展及運用於長照政策中之當代意涵，結果發現：可由人際間連帶、家庭連帶、世代間連帶、制度性連帶及全球連帶等概念來加以討論。最後，本文就政府、服務提供者及服務使用者等利害關係人(stakeholders)角度，依個人實務工作經驗，提出以連帶思想概念檢視我國長照政策發展可能面臨的挑戰及啟發。
  The long-term care policy in Taiwan will have an enormous impact on the health and welfare system. Historical institutionalism and path dependency have served as a blueprint for Taiwan, thus allowing policy makers in Taiwan to learn through the experiences of OECD countries, such as Japan and Germany. Moreover, historical institutionalism and path dependency have shaped the development of the long-term care policy in Taiwan. The purpose of this article was to discuss how to implement a joint concept of solidarity as a health and welfare policy at a time when resources are limited and demand is great. Thus far, the government has been successful in developing insurance management skills, but other means are necessary to implement this new element of solidarity into the current system. This article reviewed the historical development and contemporary implications of solidarity in the English and Chinese databases, and examined how interpersonal, contractual, family, intergenerational, and global factors play a role in the development of solidarity. Finally, we propose the possible challenges and applications of solidarity in the long-term care policy in Taiwan with respect to the views of the government, service providers, and service users.
• 359 - 375
• 10.6288/TJPH201635104100

• Link 綜論 Review Article
• 高風險手術集中化政策之探討A review of how centralization policies affect high-risk surgeries
• 陳靖怡、 鍾國彪、郭年真
  Ching-Yi Chen, Kuo-Piao Chung, Raymond N. Kuo
• 集中化 ； 區域化 ； 醫療品質 ； 服務量與照護結果研究
  centralization ; regionalization ; quality of healthcare ; volume-outcome studies
• 探討醫療照護服務量與照護結果關係的研究(volume-outcome research)發展已相當成熟，也因為有大量的實證證據顯示在某些特定手術處置的服務量與不良照護結果呈現顯著的負向關係，許多國家的學者及政策制定者紛紛提出手術集中化的相關衛生政策，期望將病人導引至高服務量或高專業性的醫療機構就醫，使病人獲得最佳的照護並改善整體照護結果。本文針對手術集中化政策發展歷程、各國實施策略、實施後影響及對於我國的啟示作為探討及文獻回顧的主軸，期望能作為國內制訂改善高風險手術照護品質政策之借鏡。經由文獻探討發現，手術處置集中化政策通常著重在高風險或罕見的手術(如：心臟手術處置、癌症手術或兒童相關手術處置)，政策的介入方式主要分成兩種：「設定最低服務量閾值(Minimum volume standards)」及「指定轉診中心(Designated referral centers)」。文獻指出，多數國家實施手術集中化後對於照護結果確實有正面之影響，但同時也有降低就醫可近性之疑慮。我們建議台灣未來針對提升手術處置照護品質制訂相關政策時，可以將集中化政策納入政策規劃之中，並且進一步評估手術集中化後可能帶來之成效。
  A great deal of evidence from volume-outcome studies has indicated that surgical volume is negatively associated with adverse surgery outcomes; therefore, researchers and policymakers in many countries have advocated for the Centralization of certain surgical procedures. Centralization should improve outcomes and increase the level of care by ensuring that patients are referred to high-quality providers. This article reviews (1) the development of centralization policies and (2) centralization strategies applied in the United States, Canada, and countries in Europe and Asia. We also discuss the impacts that centralization policies have had on surgery outcomes as well as implications for the future of centralization policies in Taiwan. The vast majority of centralization policies focus on rare or high-risk surgeries, such as those performed to treat heart problems or cancer. There are currently two types of intervention: setting minimum volume standards and selecting designated referral centers. A review of relevant literature showed that, for most countries, centralization policies led to better healthcare outcomes; however, some studies noted that centralization can reduce accessibility to care. Nonetheless, we suggest that Taiwan consider adopting centralization as a policy to improve the quality of healthcare. However, future research will be required to estimate the effectiveness of centralization on high-risk surgeries.
• 376 - 390
• 10.6288/TJPH201635105016

• Link 評論 Commentary
• 評論：高風險手術集中化政策之探討Commentary: A review of how centralization policies affect high-risk surgeries
• 周穎政
  Yiing-Jenq Chou
• 無
  none
• 無
  none
• 391 - 392
• 10.6288/TJPH20163510501601

• Link 評論 Commentary
• 作者回覆：高風險手術集中化政策之探討Authors' response to commentary: a review of how centralization policies affect high-risk surgeries
• 陳靖怡、鍾國彪、郭年真
  Ching-Yi Chen, Kuo-Piao Chung, Raymond N. Kuo
• 無
  none
• 無
  none
• 393 - 394
• 10.6288/TJPH20163510501602

• Link 原著 Original Article
• 台灣政府衛生福利開放資料現況及利用率分析An analysis of the current status and utilization of government health and welfare open data in Taiwan
• 韓佩軒、李昇暾、 許明暉、 呂宗學
  Pei-Hsuen Han, Sheng-Tun Li, Min-Huei Hsu, Tsung-Hsueh Lu
• 政府衛生福利開放資料 ； 資料品質 ； 資料加值分析
  government health and welfare open data ; data quality ; value-added analysis
• 目標：檢視台灣政府衛生福利開放資料品質、內容與應用狀況。方法：擷取衛生福利部暨所屬附屬機構釋出在台灣政府資料開放平臺(data.gov.tw)之資料集屬性特徵進行描述性分析。結果：截至2015年12月31日衛生機構釋出890個資料集，中央健康保險署，疾病管制署，國民健康署與食品藥物管理署分別釋出249，193，178與158個資料集。約七成資料集是屬於全球資訊網協會資料格式分類三顆星或以上較佳品質等級。瀏覽次數前十名資料集分別是：死因統計，醫院病床統計，藥局基本資料，登革熱每日確定病例統計，國際醫藥品稽查協約組織有關藥品優良製造指引藥廠名單資料集，災民收容所，不符合食品資訊資料集，各醫院癌症資源中心，可供食品使用原料彙整一覽表，健保用藥品項壓縮總檔。平臺收錄52個活化應用程式，其中有25個有使用到政府衛生福利開放資料。結論：台灣衛生福利機構釋出政府衛生福利開放資料集數目雖然比其他部門機構少，但是被活化應用的比例相對較高。但是，有些衛生機構將同一主題資料集切割成太多小資料集，不符合資料完整原則：資料應該以其來源最完整型式與最精細的尺度收錄，不使用加總或修改後的格式。此外，未來應可加強政府衛生福利開放資料的加值分析質與量，主動回饋釋出機構改善釋出資料品質與內容，朝建立良好資料加值分析生態系統的方向努力。
  Objectives: To examine the current status and utilization of government health and welfare open data in Taiwan. Methods: Characteristic information from datasets released by the Ministry of Health and Welfare and related Institutions available at data.gov.tw were extracted for descriptive analyses. Results: On December 31 2015, 890 health and welfare datasets were available at data.gov.tw. The numbers of datasets released by the National Health Insurance Administration, Center for Disease Control, Health Promotion Administration, and Food and Drug Administration were 249, 193, 178, and 158, respectively. More than seventy percent of the datasets were ranked as third star or above (good quality) according to the W3C (World Wide Web Consortium) classification. The ten most frequently browsed datasets were cause of death statistics, hospital beds statistics, basic information about pharmacies, the daily number of confirmed dengue fever cases, the PIC/S GMP (Pharmaceutical Inspection Convention and Pharmaceutical Inspection Co-operation Scheme Guide to Good Manufacturing Practice for Medicinal Products) pharmaceutical manufactures, the list of shelters for disaster victims, the list of foods which did not meet government standards, the list of cancer treatment centers, the list of food materials for human use, and the list of drugs reimbursed by the National Health Insurance. Fifty-two applications were registered at data.gov.tw and 25 of these used government health and welfare open data. Conclusions: Although the number of datasets released by health institutions was lower than that of other sectors, the number of applications using government health and welfare open data was relatively high. Some of the datasets were divided into too many small datasets by some health institutions however, and this did not follow the primacy principle. We suggest that the quality and quantity of value-added analyses should be improved and that feedback be provided to the institutions releasing the datasets in order to establish a good value-added analyses ecosystem.
• 395 - 405
• 10.6288/TJPH201635105035

• Link 原著 Original Article
• 老年人口自殺與熱島效應之空間關聯分析：以2000年至2008年台北都會區生態調查研究為例Spatial correlation analysis of elderly suicides and Urban Heat Island Effects: an ecological study in Taipei, 2000-2008
• 陳映融、吳治達、潘文驥、陳穆貞、龍世俊、蘇慧貞、張坤城
  Yinq-Rong Chern, Chih-Da Wu, Wen-Chi Pan, Mu-Jean Chen, Candice Shih-Chun Lung, Huey-Jen Su, Kun-Cheng Chang
• 熱島效應 ； 老年人口 ； 自殺 ； 廣義加乘混合模型 ； 空間資訊技術
  Urban Heat Island Effect (UHIE) ; elderly population ; suicide ; Generalized Additive Mixed Model (GAMM) ; spatial informatics
• 目標：本研究旨在應用地理資訊系統與統計模型，以探討台北都會區2000至2008年間熱島效應強度與65歲以上老年人口自殺死亡率之關聯。方法：本研究利用氣象站監測資料以及克利金空間推估以量化熱島效應；其次，針對熱島效應以及老年人口之自殺死亡率進行空間以及時間趨勢分析，並進一步探討自殺死亡率在空間上的群聚情形；最後，於校正大氣溫度、雨量、平均每戶綜合所得、教育程度、65歲以上性別比以及離婚率等因子，並且考慮時間、空間自相關之情況下，利用廣義加乘混合模型，以釐清熱島強度與老年人口自殺死亡率之關聯性。結果：在考慮空間、時間自相關、隨機效應、性別比、人口結構以及各項重要之社會經濟因子等風險因子後，熱島強度對於老年人口自殺死亡率之相對風險達統計上之顯著水準(相對風險：1.0549；p ＜ 0.01)。結論：本研究發現，熱島效應之強度與老年人口自殺死亡具有統計上之顯著關聯，熱島效應強度增加1℃，可能會使得老年人口之自殺死亡率相對上升5.49%。
  Objectives: The aim of this study was to investigate the association between Urban Heat Island Effects (UHIE) and elderly suicides in metropolitan Taipei from 2000 to 2008 using Geographic Information System (GIS) and statistical analysis. Methods: The UHIE intensity in each township was estimated based on onsite air temperature observations using Kriging interpolation. Spatial/temporal trends in UHIE and elderly suicides were examined, and the spatial clustering effect of elderly suicides was assessed. A Generalized Additive Mixed Model (GAMM) was then utilized to assess the association between UHIE and elderly suicides after adjusting for confounders including air temperature, precipitation, income tax, education level, sex ratio of the elderly population, and marital status. Results: Based on the GAMM analysis, UHIE reached the level of statistical significance (Relative Risk: 1.0549; p < 0.01) while accounting for the effects of the other risk factors in the model. Conclusions: The intensity of UHIE was statistically associated with elderly suicides in Taipei.
• 406 - 417
• 10.6288/TJPH201635104089

• Link 原著 Original Article
• 台灣兒童燒燙傷的特性及趨勢Incidence and trend of child burn injury in Taiwan
• 陳楚杰、 楊佳昕、陳靖宜、柯明中、李怡真
  Chu-Chieh Chen, Jia-Sing Yang, Chin-Yi Chen, Ming-Chung Ko, Yi-Chen Lee
• 兒童；燒燙傷；全民健康保險
  children ; burn ; National Health Insurance
• 目標：探討台灣兒童燒燙傷發生率、變化趨勢及住院相關因素。方法：本研究使用台灣全民健康保險研究資料庫2000年、2005年及2010年百萬人歸人檔資料；依人口學特性呈現0-18歲兒童燒燙傷發生率，以卜瓦松迴歸檢定燒燙傷門急診、住院發生率趨勢，以邏輯斯迴歸探討兒童燒燙傷住院的相關因素。結果：2000年、2005年及2010年兒童門急診燒燙傷整體發生率分別是0.70%、0.74%、0.70%。門急診部分三個時段依性別、年齡標準化之總體發生率，每十萬人口分別是699.68、779.63及737.59人，整體發生率有上升趨勢，但未達統計顯著；於4-6歲兒童(806.71, 1025.62, 970.60)則有顯著上升趨勢；住院部分標準化之發生率，每十萬人口，兒童整體分別是38.03、34.07及26.04人，女童整體分別是38.37、35.65及23.41人，1-3歲兒童分別是169.64、129.49及83.83人，均有顯著下降趨勢。13-18歲兒童燒燙傷住院風險較低，南區兒童及急診就醫兒童住院風險較高。結論：兒童燒燙傷門急診發生率整體有上升趨勢，但未達統計顯著，4-6歲兒童則有顯著上升趨勢；兒童整體、女童整體及1-3歲兒童住院發生率均顯著下降，顯示兒童燒燙傷嚴重度下降。
  Objectives: This study investigated the incidence and trends of child burn injuries and factors associated with hospitalization due to burn injuries in 2000, 2005, and 2010. Methods: Data were gathered from the Longitudinal Health Insurance Database 2000, 2005, and 2010 subsets from the Taiwan National Health Insurance Research Database. All patients aged 0-18 years with claim records containing burn injuries were enrolled to analyze the incidence of these injuries according to patient characteristics. Poisson regression was applied to test the linear trend of incidence. Logistic regression was adopted to identify factors associated with hospitalization for burn injuries. Results: The overall incidences of child burn injuries in 2000, 2005, and 2010 were 0.70%, 0.74%, and 0.70%, respectively. The corresponding overall standardized incidences of child burn injuries were 699.68, 779.63, and 737.59 per 100,000 population. The trend of increase was a statistically non-significant. The corresponding figures for those aged 4-6 years were 806.71, 1025.62, and 970.60 per 100,000 population, with a significant trend of increase. The overall standardized incidence of hospitalization for child burn injuries for 2000, 2005, and 2010 were 38.03, 34.07, and 26.04 per 100,000 population, respectively. There was a statistically significant trend of decrease. The corresponding figures for girls were 38.37, 35.65, 23.41 per 100,000 population, and those for patients aged 1-3 years were169.64, 129.49, 83.83 per 100,000 population, with statistically significant decreasing trends in both groups. Patients who were living in southern Taiwan, who visited the emergency department, and who were aged 13-18 years had lower risks of hospitalization compared with other groups. Conclusions: The trend of increase in the overall incidence of child burn injuries was non-significant, whereas that for children aged 4-6 years was significant. The trends of decrease in the incidence of burn injury hospitalization for all children, girls, and patients aged 1-3 years were significant, which may imply that the severity of burn injury decreased.
• 418 - 429
• 10.6288/TJPH201635105001

• Link 原著 Original Article
• 應用全民健康保險研究資料庫比較不同合併症指標對中風病患的醫療費用之預測表現Comparison of different comorbidity measures in predicting the medical expenditures of stroke patients by utilizing the National Health Insurance Research Database
• 林縈縈、翁瑄甫、楊哲銘、楊長興、黃國哲
  Ying-Ying Lin, Shuen-Fu Weng, Che-Ming Yang, Chiang-Hsing Yang, Kuo-Cherh Huang
• 合併症指標 ； 中風病患 ； 醫療費用 ； 全民健康保險研究資料庫
  comorbidity indices ; stroke patients ; medical expenditures ; National Health Insurance Research Database
• 目標：比較不同合併症指標對中風病患的醫療費用之預測表現。方法：全民健康保險研究資料庫2005年承保抽樣歸人檔(LHID2005)為主要資料來源，以首次中風住院患者為研究對象，比較四種合併症指標[Deyo-Charlson comorbidity index(CCI)、Romano-CCI、D`Hoore-CCI及Elixhauser方法]對患者出院後一年產生高醫療費用情形之預測力。本研究的基本模式包含病患年齡、性別、首次中風住院有無手術及首次中風住院天數變項，並且擷取2005年及2008年兩個不同年度之樣本資料進行比較分析。最後使用邏輯斯蒂迴歸分析(logistic regression analysis)的c值(c-statistics)，以檢定增加不同合併症指標後對模式預測力的表現差異。結果：四種合併症指標對於基本模式的預測力均有增進效果，其中又以Romano-CCI表現最佳的預測力(c值：0.710-0.746)。結論：本研究的研究結果顯示，合併症指標為中風住院病患出院後的醫療費用之重要預測因素，而Romano-CCI的預測力表現則最佳。建議衛生主管機關在擬定有關中風病患的醫療費用等相關給付制度時，應考量病患因合併症所造成之醫療照護負擔，而採取不同程度的調整。
  Objectives: This study compared the performance of different co-morbidity measures in predicting medical expenditures of stroke patients. Methods: Data were sourced from the Longitudinal Health Insurance Database 2005 (LHID205), and the study population comprised all patients who were hospitalized due to stroke for the first time. Four co-morbidity measures were compared regarding the performance of predicting medical expenditures of subjects within 1 year after discharge: the Deyo-Charlson comorbidity index (CCI); Romano-CCI; D`Hoore-CCI; and Elixhauser method. The baseline model included patient age and gender, whether or not surgery was undertaken when hospitalized, and the length of stay. Two target years (2005 and 2008) of data were compared. The discriminatory power of the co-morbidity measures was assessed using the c-statistics derived from multiple logistic regression models. Results: All four co-morbidity measures significantly improved the predictive capacity of the baseline model. Furthermore, the Romano-CCI performed best in predicting medical expenditures of subjects within 1 year after discharge (c: 0.710-0.746). Conclusions: This study suggested that co-morbidity measures are significant predictors of medical expenditures of stroke patients, and the Romano-CCI performed best among the four co-morbidity measures in the research. When designing the payment schemes for stroke patients, the Taiwanese health authority ought to make adjustments in accordance with the burden of health care caused by co-morbidities.
• 430 - 445
• 10.6288/TJPH201635104112

• Link 實務 Public Health Practice
• 探討醫院歷經策略聯盟與併購之經營績效差異—以南部某地區醫院為例Exploring the difference in operation performance between strategic alliance and acquisition: a case study of a local hospital in southern Taiwan
• 方素秋、翁瑞宏、郭彥宏、劉巡宇、黃靖媛
  Su-Chiu Fang, Rhay-Hung Weng, Yen-Hung Kuo, Hsun-Yu Liu, Ching-Yuan Huang
• 策略聯盟 ； 併購 ； 經營績效 ； 醫院 ； 合作策略
  strategic alliances ; acquisitions ; business performance ; hospital ; cooperation strategy
• 目標：近來我國中小型醫院為求永續經營，乃積極透過各種外部合作策略，來強化醫院本身之競爭力，本研究欲探討某地區醫院歷經策略聯盟與併購之經營績效差異。方法：本研究以台灣南部某地區教學醫院為研究對象，採用個案研究法，針對該醫院進行個案分析，該醫院乃國內少見同時歷經策略聯盟與購併之醫院，績效觀察期間乃分成策略聯盟與併購兩階段：以2009年9月至2011年8月為期；以2011年9月至2013年8月為期。結果：個案醫院合作類型，於策略聯盟期間為契約式書面合約關係，個案醫院的所有權與經營權並無變動；而被併購後法律形式屬新設醫院，併購後個案醫院的所有權與經營權變動。績效分析結果顯示權益基礎併購期間的投入績效、財務績效、非財務績效優於非權益基礎策略聯盟合作期間。結論：個案醫院跨組織的合作涉入程度、關係緊密及鬆散程度、以及所有權與控制權變動皆會影響醫院經營，而在策略聯盟與併購期間經營績效亦有顯著差異。
  Objectives: In order to achieve long-term survival, interorganizational cooperation is the most effective way for many small- and medium-sized hospitals to go. The aim of this study was to explore the differences in business performance between periods of strategic alliance and acquisition in one local hospital. Methods: We selected a local teaching hospital in southern Taiwan as the study subject and used the case study method to carry out our analysis. We also collected secondary data about the hospital for performance analysis. There were two periods in which performance was observed: strategic alliance from September 2009 to August 2011 as the first and acquisition from September 2011 to August 2013 as the second. Results: The strategic alliance period was a contract-based relationship. There were no changes in ownership or the management team during this period. After being acquired by a Medical Center, the case hospital became one part of a Medical Foundation system. It became a new hospital. The ownership and management team changed. The results of performance analysis showed that the case hospital had superior input performance, financial performance, and non-financial performance during the period of acquisition than that during the period of non-equity strategic alliance. Conclusions: The involvement and strengthened relationship of interorganizational cooperation and the change in ownership and control affected hospital management. There were also significant differences in business performance between the periods of strategic alliance and acquisition.
• 446 - 458
• 10.6288/TJPH201635104081