36卷2期

• Link 綜論 Review Article
• 全球化下生殖旅遊現況與評析Current status and analysis of reproductive tourism in the context of globalization
• 孫佳婷
  Chia-Ting Sun
• 配子 ； 全球化 ； 醫療旅遊 ； 生殖旅遊 ； 人工協助生殖技術
  gamete ; globalization ; medical tourism ; reproductive tourism ; assisted reproductive technologies
• 在當代高度全球化的經濟脈絡中，以醫療為主、旅遊為輔的跨國醫療旅遊已成為市場裡快速崛起與擴張的產業，而生殖旅遊作為其新興的一支，提供了難以順利在母國懷孕，或者不符母國人工協助生殖手術對象的非婚人士另一醫療選擇。不過其跨國特質亦提高了懷孕過程中將面臨的可能風險，且引來如重營利而失醫療本質與優生學等面向的爭議。因此本文欲以人工協助生殖技術為徑，一探全球化下配子轉移與生殖旅遊之產業現況。經文獻探討後發現，使用者多以能提供高品質照護、費用低廉、生殖律法寬鬆且可快速取得精卵來源及手術服務的國家為目的地，生殖旅遊顯示了生殖政治的複雜性，其所需的經濟資本使其充滿階級差異，且配子的轉移與價格在不同國家亦有巨大的落差，使部分國家之捐贈/販售者易淪為被剝削的對象。因此，生殖旅遊之現象，實需政府積極研擬相關法規，以保障人民權利。
  In a highly globalized economic context, transnational medicine (which focuses on medical tourism) has become a rapidly expanding industry. Specifically, reproductive tourism provides more medical choices to people who are unable to become pregnant or unmarried people whose access to reproductive technologies in their home countries is prevented by law. However, this practice has been a source of controversy: its transnational character increases the risk of pregnant and has drawn accusations of eugenic practices and focusing on profit at the expense of medicine. Therefore, this article investigates the use of assisted reproductive technologies to analyze the role of gamete transfer and reproductive tourism in globalization. After conducting a literature review, we found that most patients choose countries that provide high-quality care, have low medical costs, allow patients to quickly undergo surgery and obtain gametes, and have relatively less rigorous laws. The economic capital required for reproductive tourism and the class differences it delineates demonstrate the complexity of reproductive politics. Moreover, the price of gametes differs greatly between countries, which in some cases leads to the exploitation of donors or sellers. Consequently, it is necessary to actively formulate relevant laws and regulations to protect people’s rights in reproductive tourism.
• 95 - 106
• 10.6288/TJPH201736105096

• Link 原著 Original Article
• 評估結核病接觸者在不同接觸情境的潛在感染風險Assessing the infection risk of Tuberculosis (TB) contacts in different case-contact contexts
• 陳慈忻、溫在弘、方啟泰、詹珮君
  Tzu-Hsin Chen, Tzai-Hung Wen, Chi-Tai Fang, Pei-Chun Chan
• 結核病接觸者 ； 接觸情境 ； 感染風險 ； 接觸效率
  Tuberculosis (TB) contacts ; social contact ; infection risk ; contact efficiency
• 目標：本研究旨在探討台灣結核病發病者與接觸者之間不同的接觸情境與社會經濟條件，對於結核病感染風險的影響。方法：研究材料是疾管署在2010-2012年的台灣結核病接觸者調查資料，本研究建立接觸者與指標個案之接觸網絡，以迴歸模式分析接觸者感染風險因子，以及結核病潛伏感染接觸效率較高的社會情境。結果：在3,297名接觸者中，控制痰塗片陽性與接觸者年齡因素下，指標個案為原住民族群、居住於低度都市化地區、指標個案學歷大學以下、低網絡連結數是接觸者感染風險的獨立預測因子。在831名感染的接觸者中，導致結核病感染的接觸效率較高的社會關係，主要是孩童與青少年的親戚關係、在低度都市化的社區近鄰關係，以及醫療照護的接觸關係。結論：本研究發現在缺乏接觸者個人社經資料的情況下，指標個案的社會經濟條件即可做為接觸者感染風險的預測因子；另一方面，利用接觸效率的概念，可證實致病風險在不同社會關係、城鄉與不同年齡層的社會情境下有別，區辨這些特性有助於防疫調查找出具有高度感染風險的接觸者。
  Objectives: The risk of tuberculosis (TB) infection within different case-contact contexts is unknown. This study aimed to assess the role of different social contacts in the risk of latent TB infection (LTBI). Methods: We analyzed the records of the TB contact investigation conducted by the Taiwan Centers for Disease Control (CDC) between 2010 and 2012, including 3297 contacts. Among the 3297 contacts, 831 were infected. We propose two TB risk indices: the probability of getting infected; and contact efficiency for investigating the risk factors in terms of different social contacts and demographics using multivariate regression analysis. Results: After adjusting the smear-positivity and age of contacts, we identified statistically significant social-demographic characteristics of an index case who had a higher probability of spreading TB to contacts. These social-demographic characteristics included aboriginal race, residence in non-urban areas, lowlevel education, and low degree of contact. Among 831 infected contacts, we also identified the types of social contacts with high-contact efficiency for TB infection, including the relationships of relatives among young people 0-14 years of age, the relationship with neighbors > 55 years of age in the non-urban areas, and interactions with home care providers. Conclusions: By analyzing case-contact contexts, we conclude that social-demographic characteristics of an index case can be used to assess the probability of TB spread. Furthermore, contact efficiency differs from case-contact contexts and implies that profiling significant types of social contacts could be beneficial to identify high-risk contacts in a TB contact investigation
• 107 - 121
• 10.6288/TJPH201736105125

• Link 評論 Commentary
• 評論：評估結核病接觸者在不同接觸情境的潛在感染風險Commentary: Assessing the infection risk of Tuberculosis (TB) contacts in different case-contact contexts
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• 122 - 122
• 10.6288/TJPH20173610512501

• Link 原著 Original Article
• 性別差異在宗教信仰與健康生活品質關聯性之研究Gender differences in the relationship between religion and Health-Related Quality of Life
• 林晏如、 梁景洋、陳俊志
  Yen-Ju Lin, Ching-Yang Liang, Chun-Chih Chen
• 性別差異 ； 宗教 ； 宗教活動 ； 健康生活品質
  gender difference ; religion ; religious activity ; Health-Related Quality of Life
• 目標：探討宗教與健康關聯性在性別間之差異，利用健康生活品質量表將健康生活品質分成生理、心理及一般健康等三方面，以比較不同健康層面在性別間之影響是否有所不同。方法：利用國家衛生研究院與國民健康署於2009年國民健康訪問調查（National Health Interview Survey, NHIS）之全國性抽樣資料，研究對象數計有15,978人，男、女性分別為7,553人、8,425人。控制個人年齡、教育程度、婚姻狀況、所得、慢性疾病、籍貫及居住地區等變數，以釐清信仰與健康關聯性在性別間是否存在差異。結果：不論是有無宗教信仰或宗教活動參與度和健康生活品質之關聯性，在性別間有顯著不同之迴歸結果。有宗教信仰及宗教活動參與度愈高男性，其一般健康較佳。有信仰女性的生理、心理及一般健康狀況均較無宗教信仰者差；隨宗教活動參與度的增加，其生理及心理層面的健康狀況易顯著較差。結論：男性之迴歸結果和既有文獻大致相符，女性則顯然不同，推測女性通常在遭遇困境時才尋求宗教協助，抑或女性宗教者的心理、生理及一般健康原本就比較差，藉由宗教以尋求慰藉及解脫，因此原本健康較差女性反而更積極投入參與宗教信仰活動。
  Objectives: The aim of this investigation was to explore whether the relationship between religion and health-related quality of life was different according to gender. Methods: This study utilized the 2009 National Health Interview Survey (NHIS) obtained from the National Health Research Institutes and Bureau of Health Promotion. A total of 15,978 individuals (7,553 males and 8,425 females) were selected from the 2009 NHIS database. We divided health-related quality of life into three dimensions, including physical, psychological and general health, to analyze their associations with religion. After controlling for age, education, marital status, income, chronic diseases, race and geographic location, we examined the effects of religion on these three dimensions by gender. Results: Males with religious beliefs and more religious activities had better general health than those without. Females with religious beliefs had worse physical, mental, and general health than those without, and those with more religious activities had worse physical and mental conditions than those without. Conclusions: For males, the empirical findings were in complete accord with the literature. For females, however, the regression results were quite different from those of previous studies. One possible reason is that, because of poor original health status, females look for comfort and relief through religion. As a result, females with poor health are more religious or more likely to participate in religious activities.
• 123 - 136
• 10.6288/TJPH201736105101

• Link 原著 Original Article
• 「家庭醫師整合性照護計畫」對民眾越級就醫之影響Impact of the "Family Doctors’ Integrated Care Initiative" on patients’ behavior in seeking care at higher level health care institutions
• 徐婕、李玉春
  Chieh Hsu, Yue-Chune Lee
• 家庭醫師整合性照護計畫 ； 越級就醫 ； 自行轉診
  Family Doctors Integrated Care Initiative ; upgrading health seeking behavior ; selfreferral
• 目標：民眾不經轉診，越級就醫在台灣是重要問題，中央健保局於2003年開始實施「家庭醫師整合性照護計畫」，簡稱家醫計畫，以提升基層照護的品質與持續性，並促進落實分級轉診制度，故本研究目的為探討家醫計畫對越級就醫的影響。方法：以事前事後控制組比較研究設計與差異中的差異法，以每半年皆有適合在基層就醫的疾病（A類疾病）就醫之病人為對象，以2007-2010初次加入家醫計畫者為實驗組，並以性別、年齡、重大傷病、共病症指數、收入與控制組1:1配對，探討加入家醫計畫者與未加入者在介入前後越級就醫的變化。結果：家醫計畫可以改善2007至2009年加入民眾的越級就醫情形，但加入時間越長，效果越差，且退出計畫後民眾越級就醫情形顯著上升。然而，計畫無法改善2010年加入者的越級就醫情形。結論：家醫計畫可短期降低民眾越級就醫情形，但此政策對慢性病患者及過去醫療花費較高的族群較無影響。
  Objectives: Seeking care at higher level health care institutions than should be (up-graded healthcare) is an important issue in Taiwan; therefore, National Health Insurance (NHI) has implemented the ”Family Doctors’ Integrated Care Initiative (FDICI)” since 2003 to enhance the quality and continuity of primary care and to enhance the referral system. The aim of this study was to evaluate the effect of the FDICI on patients’ behavior in seeking upgraded healthcare. Methods: The study used the pretest-posttest control group design and difference in differences method on patients who received medical care with a diagnosis which could be dealt with in primary care. The intervention group included patients who initially participated in FDICI between 2007 and 2010. This group was 1:1 matched with a control group of patients, who had never participated in FDICI during the same period, by gender, age, catastrophic illness or not, Charlson comorbidity index, and income. Results: The FDICI reduced the rate of patients seeking upgraded healthcare during 2007-9; yet, the effect decreased over time. Moreover, after people dropped FDICI, their rate increased. Besides, the FDICI showed no effect for people who initially joined in 2010. Conclusions: The FDICI can reduce the rate of patients seeking upgraded healthcare within a short period; however, the plan showed no effect on patients with chronic illnesses or those with high medical costs.
• 137 - 147
• 10.6288/TJPH201736105073

• Link 原著 Original Article
• 論質計酬對於思覺失調症患者急診及急性再住院的影響The impact of pay for performance on emergency department visits by and acute readmissions of patients with schizophrenia
• 陳麗尼、龔佩珍、張鏸云、蔡文正
  Li-Ni Chen, Pei-Tseng Kung, Hui-Yun Chang, Wen-Chen Tsai
• 思覺失調症 ； 論質計酬 ； 差異中的差異法 ； 急診 ； 再住院
  schizophrenia ; pay-for-performance program ; difference-in-difference ; emergency department visits ; readmission utilization
• 目標：全民健康保險2010年1月1日實施思覺失調症論質計酬方案，本研究旨在探討有無加入論質計酬方案，比較其急診及6個月內急性再住院發生的風險及其相關因素。方法：資料來源為全民健康保險研究資料庫，擷取2009年至2010年固定就診之思覺失調症重大傷病患者（6,713人），依其所屬院所分為有加入及未加入論質計酬方案兩組，採傾向分數（propensity score）1：1配對後，應用差異中的差異法（Difference-in-Difference）設計，以條件式羅吉斯迴歸模型（conditional logistic regression model）進行分析。結果：急診利用方面，加入論質計酬方案組在方案實施前為12.21%，方案後降為12.01%（p＜0.05）；未加入論質計酬方案組在方案前為13.3%，方案後降為11.80%（p＜0.05）。6個月內急性再住院加入論質計酬方案組在方案前、後皆為1.71%（p＞0.05）；未加入論質計酬方案組在方案前為2.01%，方案後降為1.19% （p＜0.05）。控制其他變項後，在條件式羅吉斯迴歸模型中之交互作用變項急診利用之勝算比（OR）為1.15倍（p＞0.05）、急性再住院之勝算比（OR）為1.89（p＞0.05），顯示加入論質計酬方案組在加入方案後急診利用及再住院下降幅度比未加入論質計酬方案組少。結論：患者經過配對後，院所加入思覺失調症論質計酬方案第一年，降低固定就診病患之急診利用及6個月內再住院之成效不佳。
  Objectives: On January 1, 2010, Taiwan began implementation of the Schizophrenia Payfor- Performance (P4P) program. The objective of this study was to investigate the impact of the P4P program on emergency department (ED) visits and acute readmissions within six months after discharge. Methods: The research data were obtained from the National Health Insurance Research Database. The study sample was made up of schizophrenic patients in the catastrophic illness registry for 2009-2010, whose regular visit institutions did or did not join the P4P program (n=6,713). The groups were matched using propensity scores in a ratio of 1:1. The conditional logistic regression model with difference-in-differences approach was then used. Results: For the P4P patients, the number of ED visits was 12.21% before the program and 12.01% after it (p < 0.05). For the non-P4P patients, the number of ED visits was 13.3% before the program and 11.80% after it (p < 0.05). Acute readmission utilization of the P4P patients both before and after the program was 1.71% (p > 0.05). In the non-P4P patients, acute readmission utilization was 2.01% before the program and 1.19% after it (p < 0.05). After adjustment for other variables, the interaction variable of ED visits in the conditional logistic regression model revealed that the odds ratio (OR) was 1.15 (p > 0.05) and that of acute readmission utilization was 1.89 (p>0.05). This finding showed that the reduction in the P4P patients was less than that in the non-P4P patients. Conclusions: When patients were matched, hospitals participating in the P4P program for patients with schizophrenia were ineffective in reducing emergency care and readmission within 6 months after discharge in the first year.
• 148 - 160
• 10.6288/TJPH201736105089

• Link 原著 Original Article
• 急性心肌梗塞病患照護連續性與照護結果及醫療費用之關係Association of continuity of care with healthcare outcomes and expenses among acute myocardial infarction patients
• 江蕙如、董鈺琪
  Hui-Ju Chiang, Yu-Chi Tung
• 急性心肌梗塞 ； 照護連續性 ； 照護結果 ； 醫療費用
  acute myocardial infarction ; continuity of care ; outcomes of care ; medical expenses
• 目標：過去研究發現，急性心肌梗塞（acute myocardial infarction, AMI）出院病人住院前有較高照護連續性，會有較佳的出院後照護結果；然未有研究探討AMI出院病人出院後照護連續性，是否與出院後照護結果有關，再者，未有研究同時探討AMI出院病患住院前與出院後的照護連續性，對出院後照護結果及費用之相對影響強度。方法：本研究利用全民健康保險研究資料庫全國代表性樣本，分析2007年至2011年AMI出院病人，共1,884位。本研究採用廣義估計方程式（generalized estimating equation, GEE）及Cox比例風險穩健夾擠估計模式（Cox proportional hazards model with robust sandwich variance estimates），探討住院前、出院後照護連續性對出院後1年再住院次數、死亡以及醫療費用之影響。結果：住院前照護連續性與出院後照護結果及醫療費用無顯著相關；出院後照護連續性高之病患，有較低的出院後1年死亡風險、再住院次數與醫療費用。結論：AMI病人出院後而非住院前照護連續性，與出院後照護結果及醫療費用有關，因此為改善出院後照護結果及醫療費用，健康政策制定者及醫療服務提供者可著重提升AMI病人出院後照護連續性。
  Objectives: Previous research has shown that discharged patients following acute myocardial infarction (AMI) who had higher continuity of pre-admission care had better post-discharge care outcomes; however, no study has determined whether or not discharged patients following AMI who had higher continuity of post-discharge care had better post-discharge care outcomes. Moreover, no study has determined the relative strength of influence of pre-admission and postdischarge care continuity on post-discharge outcomes and expenses. Methods: This study utilized data from the nationwide representative sample through the National Health Insurance Research Database, and analyzed 1,884 AMI patients discharged from the hospital between 2007 and 2011. Generalized estimating equation and Cox proportional hazard models with robust sandwich variance estimates were performed to examine the effects of pre-admission and post-discharge care continuity on 1-year post-discharge mortality, readmissions, and medical expenses. Results: There was no significant relationship of continuity of pre-admission care to post-discharge care outcomes and medical expenses. Patients with a high continuity of post-discharge care had lower 1-year post-discharge mortality, readmissions, and medical expenses. Conclusions: Among AMI patients, post-discharge care continuity, rather than pre-admission care continuity, is associated with post-discharge care outcomes and medical expenses. Therefore, to improve postdischarge care outcomes and medical expenses, health policy makers and providers might focus on enhancing continuity of post-discharge care for patients with AMI.
• 161 - 173
• 10.6288/TJPH201736105105

• Link 原著 Original Article
• 醫師、醫院PCI服務量閾值與死亡之關係The relationship between physician and hospital PCI volume thresholds and mortality
• 周盈邑、杜裕康、 董鈺琪
  Ying-Yi Chou, Yu-Kang Tu, Yu-Chi Tung
• 經皮冠狀動脈介入性治療 ； 醫院服務量 ； 醫師服務量 ； 照護結果
  percutaneous coronary intervention ; hospital volume ; physician volume ; outcomes of care
• 目標：過去研究發現，醫師或醫院經皮冠狀動脈介入性治療（percutaneous coronary intervention, PCI）服務量與病人結果有關，美國心臟病學院、美國心臟學會及美國心血管造影和介入學會推薦，醫師與醫院服務量一年最少各為50及200例，以維持治療能力，然過去少有實證研究探討，醫師及醫院PCI服務量與病人結果間關係是否有服務量閾值存在，故本研究目的為決定PCI之醫師及醫院服務量與病人死亡關係間之閾值。方法：資料取自全民健康保險研究資料庫，研究對象為2009年接受PCI之病人，共30,905人。本研究以限制性立方截斷式（restricted cubic splines）模型，決定醫師及醫院PCI服務量與30日死亡關係之閾值，以多階層邏輯斯迴歸，控制病人、醫師及醫院特質後，檢測醫師及醫院服務量閾值對30日死亡之影響。 結果：醫師PCI服務量達一年50例後，風險校正後30日死亡率下降趨勢呈現平滑，且病人由醫師執行PCI服務量達50例者醫治，相較未達50例者，有53.6%較低的30日死亡勝算。結論：病人由執行PCI一年達50例之醫師醫治，可降低死亡風險。
  Objectives: Previous studies have found that physician volume or hospital volume has been associated with outcomes for percutaneous coronary intervention (PCI). The American College of Cardiology, The American Heart Association, and The Society for Cardiovascular Interventions recommend that the minimum annual PCI volumes for physicians and hospitals are 50 and 200 cases, respectively, in order to maintain competency. Few empirical studies have explored whether a relationship exists between physician or hospital PCI volume threshold and patient outcome; therefore, the objective of this study was to determine the relationship between physician and hospital PCI volume thresholds and mortality. Methods: This study used the Taiwan National Health Insurance Research Database. The study subjects were 30,905 patients who underwent PCI in 2009. A restricted cubic spline model was utilized to determine thresholds for the relationship between physician and hospital PCI volume and 30-day mortality. After adjustment for patient, physician, and hospital characteristics, a hierarchical mixed-effect logistic model was used to examine the impact of physician and hospital volume thresholds on 30-day mortality. Results: Once the annual physician volume reached 50 cases, the declining trend in risk-adjusted 30-day mortality rates began to flatten. Moreover, patients treated by physicians with volumes reaching 50 cases had 53.6% lower odds of 30-day mortality compared with those treated by physicians with volumes of fewer than 50 cases. Conclusions: Patients who are treated by physicians who perform 50 PCIs or more a year are at decreased risk for mortality.
• 174 - 186
• 10.6288/TJPH201736105127

• Link 實務 Public Health Practice
• 石綿暴露工作者的職業健康檢查制度與惡性間皮瘤監測機制：國際經驗與台灣現況Occupational health examination for asbestos-exposed workers and surveillance system for malignant mesothelioma: international experiences and conditions of Taiwan
• 蕭汎如、鄭雅文、 李俊賢
  Fan-Ju Hsiao, Yawen Cheng, Lukas Jyuhn-Hsiarn Lee
• 石綿；惡性間皮瘤；職業健康檢查；疾病通報；國際比較
  asbestos ; malignant mesothelioma ; occupational health examination ; surveillance ; international comparison
• 目標：石綿相關疾病潛伏期漫長，自暴露到發病可長達數十年。由於過去石綿被廣泛使用，導致至今石綿疾病仍持續出現，在許多國家，其認定與補償已成為重要職業健康議題。不少國家針對石綿暴露工作者建立離職後健康檢查制度，亦有些國家針對與石綿暴露有明確因果關係的惡性間皮瘤建立監測機制。方法：本文回顧文獻與政府網頁，探討先進國家的石綿工作者職業健檢制度與惡性間皮瘤監測機制。結果：日本、英國、德國、法國以職災保險或公共基金籌措財源，對石綿作業的現職工作者與離職者提供定期健康檢查服務，並對確認罹病者提供醫療照顧與補償。澳洲、法國與南韓對於惡性間皮瘤設有疾病監測機制，並對罹病者進行石綿暴露史調查，蒐集的資料成為政府制訂石綿疾病預防與補償政策的實証依據。結論：台灣應針對石綿作業工作者建立離職後職業健檢機制，並應考慮針對惡性間皮瘤建立監測機制，以全面了解石綿疾病的發生狀況與影響。
  Objectives: Asbestos-related diseases (ARDs) occur years or decades after the first exposure to asbestos. Secondary to its widespread use, the prevalence of ARDs continues to increase, making its recognition and compensation a major occupational health issue. Many countries have expanded occupational health examination programs to include workers currently and/ or previously exposed to asbestos. In addition, some countries have established surveillance systems for malignant mesothelioma (MM), a sentinel tumor for asbestos exposure. Methods: We reviewed existing literature and official websites of selected countries to understand the design of asbestos-related occupational health examination programs and MM surveillance systems. Results: In Japan, the United Kingdom, Germany and France, workers with ongoing or past occupational exposure to asbestos are eligible to participate in occupational health examination programs. These programs are financed either through workers' compensation insurance or public funds. Medical care and compensation are provided for individuals with ARDs. Surveillance programs for MM were established in Australia, France and South Korea, and MM cases identified through the programs were investigated on asbestos exposure history. Surveillance programs provide empirical evidence for prevention and compensation policies of ARDs including MM. Conclusions: The government of Taiwan should expand the scope of its occupational health examination program to include individuals with a history of occupational exposure to asbestos, and establish a surveillance mechanism for MM. This will allow Taiwan to understand the scope and impacts of ARDs.
• 187 - 196
• 10.6288/TJPH201736105123