28卷1期

• Link 綜論 Review Article
• 職災補償制度的發展與台灣制度現況Development of Workers' Compensation and the Current System in Taiwan
• 王嘉琪、鄭雅文、王榮德、郭育良
  Chia-Chi Wang, Ya-Wen Cheng, Jung-Der Wang, Yue-Liang Guo
• 職業災害 ； 職業災害補償 ； 社會保險 ； 歷史沿革
  occupational accident ; workers' compensation ; social insurance ; historical transformation
• 職業災害是現代工業化國家重要的社會問題，職災受害者應如何給予補償救濟，也是各國勞動政策爭議的核心。本文回顧西方資本主義國家職業災害補償制度之歷史緣起，並回顧我國制度的發展歷程與現況。西方國家職災補償制度的形成深受政治社會因素影響，其演化過程大略是經歷「過失主義」民事損害賠償責任、「過失主義」雇主賠償責任、「無過失主義」雇主補償責任，至社會保險等階段。目前大多數國家採「無過失主義」社會保險制，除了有避免勞雇衝突、分攤雇主財務風險的功能之外，也較能確保受災勞工獲得基本的補償。我國職災補償制度以勞工保險條例為主，亦以「無過失主義」及「社會保險」為立法精神；但另又有勞動基準法加諸於雇主的「無過失主義」補償責任，以及民法與勞工安全衛生法加諸於雇主的「過失主義」民事賠償與刑事責任。我國整體制度設計與相關法令十分繁複，不僅給付計算方式不一，彼此間適用性與連帶互動關係也相當複雜，並不利於職災者。
  Occupational accidents and diseases have always been major social concerns in all industrialized countries. How to compensate injured workers has also been the center of controversy in labor affairs. In this paper, we review the development and transformation of workers' compensation systems in western countries. We also review the development and current condition of the system in Taiwan. Workers' compensation systems in western countries were forged under the influence of social and political factors. Such systems represent a major legal reform that shifts liability for workplace accidents from negligence liability to a no-fault principle, and from an individual employer's responsibility to shared responsibility covered by social insurance. Most countries have adopted social insurance systems with a no-fault principle. These systems have been designed to reduce labor conflicts, to share employers' financial burden, as well as to ensure that injured workers are compensated in a timely manner. The present system in Taiwan is social insurance system with a no-fault principle and is based on the ”Labor Insurance Act”. However, this system is complicated by other co-existing legislation, including the ”Labor Standard Law” that requires individual employers to compensate their affected employees, as well as the ”Occupational Safety and Health Act” and other civil laws that make employers liable for workplace accidents. The system in Taiwan is complicated and problematic, and might pose difficulties for injured workers.
• 1-15
• 10.6288/TJPH2009-28-01-01

• Link 原著 Original Article
• 比較不同生產方式婦女產後60天內的門診醫療利用Comparison of Ambulatory Utilization among Women at 60-day Postpartum with Different Mode of Delivery
• 陳楚杰、劉得泰、王本仁、陳靖宜、張琇珺
  Chu-Chien Chen, Te-Tai Liu, Pen-Jen Wang, Chin-Yi Chen, Hsiu-Chun Chang
• 生產方式 ； 產後 ； 醫療利用
  delivery method ; postpartum ; medical utilization
• 目標：本研究旨在比較不同生產方式婦女產後60天內的門診醫療利用。方法：本研究材料來自國家衛生研究院發行之20萬人全民健康保險承保抽樣歸人檔於1996-2003年之申報資料，以4,995位產婦為研究對象，並採用二部模型對產後有就醫的產婦進行分析，比較不同生產方式婦女產後60天內的門診醫療利用。結果：剖腹產婦女產後60天內有就醫者的平均門診就醫次數及門診就醫費用均高於自然產婦女，且平均門診就醫間隔天數則比自然產婦女短。結論：剖腹產可能會增加產後60天內門診醫療利用。
  Objectives: The purpose of this study was to compare the mode of delivery and utilization of ambulatory care by women at 60-days postpartum. Methods: Claims data between 1996 and 2003 for a representative sample of 200,000 people randomly selected from all beneficiaries enrolled in Taiwan's NHI program in 2000 were analyzed. A total of 4,995 women were included to estimate ambulatory care utilization 60-days postpartum with the different modes of delivery using a two part model. Results: Women at 60-days postpartum with Caesarean delivery had higher average numbers of outpatient visits and expenditures with shorter intervals between visits, than women with vaginal births. Conclusions: The findings indicated that ambulatory care utilization may increase among women with Caesarean delivery at 60-days postpartum.
• 16 - 25
• 10.6288/TJPH2009-28-01-02

• Link 原著 Original Article
• 台灣醫院護理人力增長的初步分析A Preliminary Analysis of the Increasing Workforce of Hospital Nurses in Taiwan
• 范國棟、陳美霞
  Kuo-Tung Fan, Meei-Shia Chen
• 護醫比 ； 醫院產業
  nurse-physician ratio ; hospital industry
• 目標：護理人員是台灣醫療產業中的主要照護人力，也是醫療團隊中執行醫師醫囑的關鍵成員，本研究試圖藉由護醫比值的變動，探討護理人力變遷在醫院產業發展上的特殊意涵。方法：本研究以南台灣一家私立醫學中心的人力變化與醫事人員薪資分佈，和全國醫院護醫人力的變動為材料，藉由檢視醫療產業中護醫人力比值的歷史變遷，我們分析護理專業人力變化與醫院經營策略之間的關係及其社會意涵。結果：我們發現，該醫學中心護醫比從1975年的1.03上升至2007年的2.52；然而，護理人員的平均薪資卻相對比醫師及其他醫療及非醫療人員低。1989至2007年之全國醫院護醫比變動也大致呈現上升趨勢。結論：我們認為，上述護醫比值的上升趨勢主要反映醫院利用薪資較低的護理人員為主要人力以節省投資成本的經營策略，然而，台灣護理人員工作環境或福利並未因護理專業人數增加而增進。
  Objectives: Nurses are the majority of the workforce in the medical industry in Taiwan, and are key medical team members in carrying out physicians' orders. In this study, we examined trends in the nursing workforce and discussed special implications for the hospital industry by analyzing the changing ratio of nurses to physicians in Taiwan's hospitals. Methods: This study is based on data on workforce changes and differences in wages among different medical professionals in a medical center in southern Taiwan, and on governmental data about changes in the hospital medical workforce in Taiwan as a whole. We examined historical changes in the nurse physician ratio, and analyzed the relationship between the changes in nursing workforce and hospital management strategies and their social implications. Results: We found that the nurse physician ratio increased from 1.03 in 1975 to 2.52 in 2007 in this medical center. Additionally, we found that the average wage for nurses was much lower than that of physicians and other medical and non-medical professionals. The changes in this ratio for all hospitals in Taiwan generally show similar increasing trends. Conclusions: We argue that this increasing trend of nurse physician ratio in both the southern Taiwan medical center and in all of Taiwan's hospitals mainly reflects the hospitals' management strategy of employing nurses with lower wages in order to decrease investment costs. The increase in the nursing workforce has not been accompanied by an improvement in the nursing profession's working conditions or welfare.
• 26 - 34
• 10.6288/TJPH2009-28-01-03

• Link 原著 Original Article
• 觀察勒戒毒品犯之戒癮動機評估Assessment of Motivations of Drug Addicts in Detention Centers to Change Their Addictive Behaviors
• 劉明倫、楊延壽、吳四維、吳承江、 許鶯珠
  Ming-Lun Liu, Yen-Shou Yang, Szu-Wei Wu, Chang-Chiang Wu, Ying-Chu Hsu
• 觀察勒戒 ； 戒癮動機
  involuntary detoxification in detention center ; motivation to change
• 目標：探討毒品犯觀察勒戒制度的評估結果與毒品犯戒癮動機間的關係。方法：本研究評估470位接受觀察勒戒的毒品犯，以「觀察勒戒評估紀錄」及「戒癮動機階段評估表」為工具，由資深精神科醫師進行半結構式會談，進行動機狀態的評估與資料收集。結果：1.毒品犯戒癮動機以處於懵懂期最多(78.82%)；2.戒癮動機與有無繼續施用毒品傾向間無顯著相關；3.在11個評估項目中，僅「毒品犯罪相關司法紀錄」以及「戒斷症狀」兩個項目就解釋評估總分變異量的69%，但是只有「短期內再犯」與「注射使用毒品」兩個項目與戒癮動機間呈現顯著的相關。結論：目前觀察勒戒評估的結果，無法反應出毒品犯的戒癮動機，其中「毒品犯罪相關司法紀錄」以及「戒斷症狀」兩個項目評分比重過大，明顯影響繼續施用毒品傾向之判定，但這兩個項目與戒癮動機的關連性卻不顯著。未來在修訂評估分數時建議增加與動機有關連的「短期內再犯」與「注射使用毒品」兩個項目的評分比重。
  Objectives: To evaluate the relationship between the tendency to relapse of drug addicts in detention centers and their motivation to change addictive behaviors. Methods: Semi-structured interviews using two instruments, the ”Relapse Tendency Assessment Record” and the ”Stage of Motivation Form,” were conducted by senior psychiatrists to assess 470 drug addicts. Results: 1. Most of the drug addicts were found to be in the pre-contemplation stage (78.82%). 2. The tendency to relapse and their motivation to change addictive behaviors were not significantly correlated. 3. Among the 11 assessment items, the ”drug-related criminal justice records” and ”withdrawal symptoms” accounted for 69% of the variance in tendency to relapse, but only ”short-term recidivism” (p<0.05) and ”injection drug use” (p<0.01) were significantly correlated to motivation to change. Conclusions: The tendency to relapse did not clearly reflect the drug addicts' motivation to change. The scores for the ”drug-related criminal justice records” and ”withdrawal symptoms” items were excessively weighted, had no significant correlation with motivation to change, and affected the result of assessment. In the future, we suggest more weighting of the scores for ”short-term recidivism” and ”injection drug use” in the ”Relapse Tendency Assessment Record” to increase the accuracy of the overall assessment.
• 35 - 45
• 10.6288/TJPH2009-28-01-04

• Link 原著 Original Article
• 台灣地區25-44歲民眾的生育知識與態度調查The Knowledge of and Attitudes towards Childbirth among the General Public Aged 25-44 in Taiwan
• 陳慈慧、許甘霖、吳孟興、 劉志鴻
  Tzu-Hui Chen, Kan-Lin Hsu, Meng-Hsing Wu, Chi-Hong Liu
• 生育率 ； 子女價值 ； 不孕 ； 生育政策 ； 生育力
  birth rate ; the children valuation ; infertility ; fecundity policy ; fecundity
• 目標：了解(1)國人的婚育規劃與子女價值，及其與生育的關係；(2)國人對不孕及不孕治療的認知與態度；(3)國人對政府獎勵生育措施的看法。方法：於2006年，以台灣地區25-44歲民眾為對象，以電腦電話訪問輔助系統進行問卷調查，共取得1,033個有效樣本，成功回收率為17.53%。結果：(1)現代的子女價值已漸取代傳統的子女價值；(2)受訪者對不孕及其治療的基本認知大致正確，但對年齡與生育力的關係及不孕治療的成功率之認知不足；(3)民眾普遍認為改善社會、經濟環境是鼓勵生育最有效的方法。結論：(1)民眾對於不孕及其治療若有足夠的認知，並據以調整婚育規劃，或能減少不孕的遺憾；(2)醫界有責任提供各項不孕治療的正確成功率，作為政策宣導及民眾參考並作好正確的衛教。
  Objectives: To examine (1) the relevance of the general public’s parenthood planning and their values of having children to their childbirth behavior, (2) their knowledge of and attitudes toward infertility and its treatment, and (3) their responses to government's policy on the encouragement of childbirth. Methods: A nation-wide survey among residents aged 25-44 was conducted by using computer assisted telephone interview (CATI) in 2006. The final data were collected from a total of 1033 valid samples, with a response rate of 17.53%. Results: (1) ”Modern” childbirth values have superseded the ”traditional” ones (2) the participants' knowledge about infertility and its treatment was generally acceptable, whereas they tended to underestimate the effect of age on fertility and overestimate the success rate of infertility treatments. (3) Improving social and economic environments was considered as the best way to encourage childbirth. Conclusions: (1) Enhancing the general public's knowledge about infertility and related treatments and preparing their own child birth plans accordingly might reduce the prevalence of infertility. (2) Physicians should provide reliable information about the success rate of infertility treatments to support for effective health education and campaign.
• 46 - 52
• 10.6288/TJPH2009-28-01-05

• Link 原著 Original Article
• 輔助與替代療法之使用及其相關因素之全國性調查Prevalence, Pattern, and Predictors of Use of Complementary and Alternative Medicine in Taiwan
• 林寬佳、陳美麗、葉美玲、許中華、陳逸倫、周碧瑟
  Kuan-Chia Lin, Mei-Li Chen, Mei-Ling Yeh, Chung-Hua Hsu, Yi-Lun Chen, Pesus Chou
• 輔助與替代療法 ； 全國性調查
  Complementary and alternative medicine CAM ; National survey
• 目標：本研究乃為建立國人對於輔助與替代療法之使用資料。方法：研究對象為全省18歲以上之民眾。研究採取以樣本大小比率為基準的機率抽樣。資料收集乃採用電腦輔助電話訪問系統進行調查研究。正式調查於2006年5月，有效樣本數2457，完訪成功率為76.5%。其中男性(n=1237,50.3%)，女性(n=1220,49.7%)，平均年齡43.1歲。結果：使用過一種以上之輔助與替代療法的一年使用率為85.65%，若扣除身心靈調和與體能活動之範疇，則使用率為76.4%。近47.9%的受訪民眾在過去一年使用至少三種樣式的輔助與替代療法。結論：對照2003年之全國性調查，國人使用輔助與替代療法比率多數是成長於身心靈調和與體能活動之範疇。相關因子方面，在社會人口特質以及地理區域上，已逐漸出現差異性與區隔性。自述看西醫卻無效果的經驗是唯一各類輔助與替代療法使用之共同影響變數，而其他相關因子則與不同類別輔助與替代療法的使用產生交互作用。
  Objectives: A population survey among residents aged =18 in Taiwan was carried out to characterize the epidemiology of complementary and alternative medicine (CAM) use. Methods: Probability proportional to size (PPS) sampling was applied in multi-stage cluster sampling. A computer-assisted telephone interview (CATI) was then conducted to collect data in May 2006. A total of 2,457 subjects (1,234 men and 1,220 women) were surveyed, and their mean age was 43.1 y. Results: Subjects were asked to circle which CAM they used, as many as they used. The use of at least one type of CAM in the past year was 85.5%; it was 76.4% if mind-body interventions were excluded. Approximately 47.9% of the participants reported the use of 3 or more mixed CAM therapies in the past year. Conclusions: Compared with the results of a national report in 2003, the largest increase in CAM use was found in body-mind techniques and physical activities. In addition, CAM users tended to be different in regard to demographics and geographic area. Furthermore, dissatisfaction with conventional medical outcomes was the major factor associated with initiation of CAM use. Finally, there were significant interrelationships between other factors and type-specific CAM use.
• 53 - 68
• 10.6288/TJPH2009-28-01-06

• Link 原著 Original Article
• 冠狀動脈繞道手術量與療效關係之實證研究The volume-outcome Relationships in Coronary Artery Bypass Graft Surgery
• 許碧峰
  Pi-Fem Hsu
• Cox比例危險模型 ； 醫療品質 ； 醫院手術量
  Cox proportional hazard model ; hospital quality ; surgical volume-outcome relationships
• 目標：本文利用2000-2005年全民健保資料庫之冠狀動脈繞道手術(CABG)病患資料，探討醫院手術量與病患療效之關係。二者的關係是因醫院的熟能生巧效果？亦或是各醫院的醫療品質差異？方法：本文利用Cox比例危險模型探討病患死亡危險率之影響因素。另外，為考量各醫院因醫療品質差異對病患療效之影響，在病患的存活模型中加入各醫院的個別效果。結果：在病患的存活模型中發現每增加1%的醫院手術量將使病患死亡的危險率下降17.5%。但是，若在病患的存活模型中加入各醫院的個別效果，以醫院手術量與病患療效的時間變化量衡量二者關係，將發現二者的關係不再顯著。結論：醫院手術量與病患療效的關係主要是反映各醫院醫療品質的差異，並非是熟能生巧效果。當醫院有較佳的醫療品質時，不僅使其病患有較佳的療效，也因常被選擇與推薦而擁有高手術量，使得手術量與病患療效產生正向關係。
  Objectives: To investigate the surgical volume-outcome relationships for patients undergoing coronary artery bypass graft (CABG) surgery. Methods: We analyzed the records in Taiwan’s National Health Insurance Research Database for CABG patients during the period 2000-2005. Cox proportional hazard was used to identify factors relevant to patient survival. The hospitalspecific effects are also included in the model to account for quality differences between hospitals. Results: Our initial estimates showed that surgical volume was negatively associated with hazard rate such that a 1% increase in surgical volume was associated with a 17.5% lower probability of dying in the hospital. However, when we re-estimated the model accounting for quality differences between hospitals by including hospital-specific effects, the effect of volume disappeared. Conclusions: The volume-outcome relationship for CABG patients appears to reflect quality differences between high-and low-volume hospitals, rather than the principle of ”practice makes perfect.”
• 69 - 77
• 10.6288/TJPH2009-28-01-07

• Link 實務 Public Health Practice
• 建構醫療機構病人安全監測指標之前驅實證研究Establishing of Patient Safety Monitoring Indicators for Healthcare Institutions in Taiwan: a Pilot Study
• 楊哲銘、邱文達、林靖瑛、許英娟
  Che-Ming Yang, Wen-Ta Chiu, Jessica Lin, Ying-Chuan Hsu
• 病人安全 ； 指標 ； 醫療品質
  patient safety ; indicator ; healthcare quality
• 目標：病人安全乃全球關注之焦點，目前台灣尚無一套客觀適用的病人安全監測工具，本研究擬建構一套適用、客觀及可量化的病人安全指標系統。方法：彙整國內外病人安全相關指標，進行專家會議，再以德菲法進行病人安全指標適用性與資料取得難易度調查，最後透過臨床前驅測試，建議一套台灣病人安全監測指標系統。結果：產生47項病人安全指標，依衛生署95-96年病人安全年度目標進行指標系統的分類，分為7大類2級，分別是用藥安全（5項）、醫療機構感染控制（9項）、手術正確性（1項）、病人辨識（2項）、預防病人跌倒（1項）、異常事件通報（3項）、醫療照護監測（5項）。第一級可選指標10項、第二級基礎指標37項。結論：本研究經由建立各項病人安全指標定義之共識，初步發展出適用於台灣的病人安全指標系統，研究產生之指標仍需在臨床使用後持續增修，以作為醫療機構促進病人安全的工具。
  Objectives: A campaign to improve patient safety is being conducted globally. Taiwan does not have an objective patient safety monitoring indicator system. This research was designed to develop a patient safety monitoring system appropriate for implementation in Taiwan. Methods: The development processes included literature review and expert focus group meetings incorporating the Delphi method, and pilot testing to evaluate the validity and reliability of the potential indicators. Results: The 47 indicators selected were classified according to the 2006-2007 patient safety goals of the Department of Health (Taiwan). The indicators, which consisted of 7 categories separated into 2 levels, included medication safety (5 items), infection control (9), surgical site accuracy (1), patient identification (2), fall prevention (1), incident reporting (3) and healthcare monitoring (5). Of the 47, 10 indicators are at the optional level and 37 are at the basic level. Conclusions: We developed a patient safety indicator monitoring system through a consensus-building process for use in healthcare institutions in Taiwan. We believe that the system needs constant evaluation during clinical application. We hope that this system can be used in healthcare institutions in Taiwan as a tool to promote patient safety.
• 78 - 84
• 10.6288/TJPH2009-28-01-08