23卷4期

• Link 綜論 Review Article
• 社區老人跌倒的危險因子與預防Risk Factors and Prevention of Falls Among Community-dwelling Older People
• 林茂榮、王夷暐
  Mau-Roung Lin, Yi-Wei Wang
• 社區 ； 老人 ； 跌倒 ； 傷害預防 ； 危險因子
  community ; elderly ; falls ; injury prevention ; risk factors
• 老人跌倒是公共衛生重要的議題之一。跌倒是我國老人事故傷害的第二大死因，也導致老人身體功能與獨立活動能力喪失、心理的傷害與社會功能損失等，因而產生巨大的社會成本。本文回顧常見的跌倒的定義、國內外老人跌倒的發生率與死亡率、可能的嚴生的跌倒後果、常被報告的跌倒危險因子（包括個人特性、急性與慢性疾病、藥物以及環境因素）及常用的跌倒預防方法（包括平衡評估、運動、教育、藥物改變、減少環境危害以及復健與轉介）。另外，我們也討論老人跌倒研究中需注意的一些議題，包含多重跌倒的定義與分析、跌倒發生的測量問題、疾病與症狀對藥物使用的干擾以及運動種類與安全。最後並提出對未來老人跌倒研究與老人跌倒預防實務的建議。
  Falls among older people are one of the most important public health issues in the world. Falling is the second leading cause of injury-related death among older people in Taiwan. In addition, they lead to severe physical injuries, lack of independence in daily living, psychological trauma, and social dysfunction that results in enormous social costs. This review paper summarizes definitions, incidence and mortality, major consequences, common risk factors (including human factors, acute and chronic diseases, medication, and environment), and common preventive methods (including balance assessment, exercise, education, medication change, reduction of environmental hazards, and rehabilitation and referral care) of falls among older persons in Taiwan and other countries. Besides, research issues related to multiple definitions, data analysis, and measurement of falls, confounding of medication by indication, and type and safety of exercise are further discussed. Finally, some suggestions are provided for future studies and clinical practices for fall prevention among older people.
• 259 - 271
• 10.6288/TJPH2004-23-04-01

• Link 綜論 Review Article
• 測量工具的效度與信度Validity and Reliability of an Instrument
• 李中一
  Chung-Yi Li
• 信度 ； 效度 ； 流行病學 ； 偏差 ； 測量誤差
  Reliability ; Validity ; Epidemiology ; Bias ; Measurement error
• 目標：介紹測量工具的信度與效度概念與評估的方法，討論使用缺乏信度與效度的工具對研究結果的影響，並針對某些測量實務上的議題提出建議。
  方法：透過文獻探討，摘要其內容，列舉實例或假想之數據，說明測量工具的信度與效度概念及其評估方法。
  結果：測量工具效度的高低取決於測量所牽涉系統誤差大小，而信度大小則與隨機誤差有關；評估測量工具信效度的方法依測量資料的屬性而定，而流行病學研究將會因為所使用測量工具的信效度不完善而產生訊息偏差，此偏差的程度與方向則與測量誤差的本質有關。
  結論：研究者在使用測量工具前有必要選擇適當的方法評估其相關之效度與信度，以了解使用該測量工具對研究結果的可能影響，如此方能對研究結果作正確的闡釋。
  Objectives: This paper illustrates the concept of validity and reliability associated with an instrument and how the validity and reliability are assessed. We also included a discussion on how an instrument with unsatisfactory validity and reliability may affect study results, and provide suggestions for certain practical problems encountered by investigators.
  Methods: We reviewed the literature and provided real-world or hypothetical examples.
  Results: The level of validity of an instrument is related to the magnitude of systematic errors associated with that instrument, while the level of magnitude of reliability is determined solely by the degree of random errors involved in the measurement. The choices of methods used for the assessment of validity and reliability depend on the attribute of research data. Results from epidemiological studies that used an instrument with non-perfect validity and reliability might entail certain degrees of bias, for which the direction and magnitude are associated with the nature of measurement errors.
  Conclusions: Researchers should assess, using appropriate methods, the validity and reliability of an instrument before it can be used. This would help to appreciate the potential effects on the study results caused by measurement errors, and lead to correct interpretations of the study results.
• 272 - 281
• 10.6288/TJPH2004-23-04-02

• Link 綜論 Review Article
• 衛生資源配置策略－國際發展及對台灣的啓示Fundamentals of and Strategies for Health Resources Allocation-international Development and Taiwan's Prospects
• 梁玲郁、黃旭明、藍忠孚
  Ling-Yu Liang, Shiuh-Ming Huang, Chung-Fu Lan
• 衛生資源配置 ； 疾病負擔 ； 健康綜合測量 ； 失能調整人年 ； 公平
  health resource allocation ; GBD(Global Burden Disease) ; DALYs(Disability-Adjusted Life Years) ; SMPH(Summary Measures Population Health) ; equity
• 背景：衛生資源配置雖不是新議題，但在政府財務愈趨緊縮與貧富不均日益嚴重的情況下，此議題日趨重要。決策者需尋求所有可資運用的模式，將有限資源做更有效的配置與應用。 目的：本文乃回顧衛生資源配置之基本理論，並探討近年來國際間再度與起之健康綜合測量的原理方法及其應用，亦分析比較各種評估方法之差異，用以探究台灣現況與問題，並對未來資源配置提出具體可行的建構方向。 結論：台灣目前衛生資源配置仍有相當改善的空間。配置原則除了以各類疾病別、性別及年齡別的流行病學資料為基礎，發展本土化全國疾病負擔外，同時考量實際醫療費用支出、健康公平性原則，與方案執行的可行性，提出衛生資源配置的架構。為促進資源使用效率，以厚植民眾健康，運用模式能因時制宜，做動態的應變，才能隨時達成全民最大的期望。
  Background: Issues in Health Resource Allocation (HRA) are not new but are of growing importance. The increasing demands for health care has led policy makers to address this issue more directly than in the past, facing limited government funding and the widening gap between the rich and the poor. Objectives: Fundamental HRA theories are reviewed in this paper. The paper presents the current trend for the summary measures of population health and the methodology used in health outcome measurement. It compares analyses among different evaluation approaches and also evaluates the current government HRA strategies and specifically proposes an outline of HRA for Taiwan. Conclusions: Health care reform is a continuous undertaking. This research developed a modified Global Burden Disease method for the HRA utilizing national epidemiologic data as well as the national health insurance data for Taiwan. This HRA tool shall be modified dynamically over time and with changing locations in order to achieve both efficiency and equity in its application.
• 282 - 291
• 10.6288/TJPH2004-23-04-03

• Link 綜論 Review Article
• 臺灣結核病防治政策與相關議題：組織發展與通報政策變革TB Plicy and Related Issues in Taiwan: Organizational Developments and Notification Policy Changes
• 莊志杰、許玫玲
  Jyh-Jye Jaung, Mei-Ling Sheu
• 結核病防治 ； 政策變遷
  TB control ; Policy Change
• 結核病在台灣及全世界都有反?趨勢，如何建構有效的防治體系是二十一世紀的重要課題。本文首先回顧台灣結核病防治體系的發展，介紹新體制之下結核病通報系統之變革，最後探討新制度下的重要議題，以作為未來結核病防治政策之參考。
  The prevalence of tuberculosis is increasing in Taiwan as well as in the World. How to set up an effective TB control infrastructure is a crucial issue in the 21st century. This paper first reviews the historical development of the TB control system, and then introduces the new TB notification policy in Taiwan. Finally, key issues are raised for the reference of future TB policy.
• 292 - 296
• 10.6288/TJPH2004-23-04-04

• Link 原著 Original Article
• 臺灣六十五歲以上榮民住院之相關因素分析An Analysis of Factors Associated with Hospital Utilization for Senior Veterans in Taiwan
• 朱慧凡、吳肖琪
  Hui-Fan Chu, Shiao-Chi Wu
• 六十五歲以上榮民 ； 住院利用 ； 兩部門模式
  senior veterans ; hospital utilization ; two-part model
• 目標：探討六十五歲以上榮民之住院利用情況及其影響因素，以提供相關單位制定榮民醫療政策之參考。 方法：以六十五歲以上榮民為研究對象，連結88年健保住院申報資料，採兩部門模式（two－part model）分析影響榮民是否住院與住院次數之因素。 結果：88年六十五歲以上榮民住院使用率為24%，每百人住院人次為45人次，迴歸分析發現男性、年齡較大、有重大傷病、投保類別為第五類、教育程度較低、退伍軍階較低、內住就養、與未婚之榮民在是否住院與住院次數上皆顯著較高。 結論：榮民持續老化將使住院醫療需求快速增加，建議衛生署與退輔會應加強提供榮民服務並規劃長期照護，確實了解榮民就醫之需求，以提升榮民的照護品質。
  Objectives: To explore the factors of hospital utilization in senior veterans as a reference for medical policy to be used by the government. Methods: Using veteran population files and national health insurance inpatient claim data to analyze the factors associated with hospital utilization. A two-part model was used to examine the factors leading to hospitalization and the number of hospitalizations. Results: In 1999, the user rate was 24 per 100 veterans, and the discharge rate was 45 per 100 veterans. The regression results indicated that senior veterans who were male, unmarried, category 5 beneficiaries, having severe illness, lower educated, lower military rank, and living in nursing home, have a significantly higher rate and number of hospitalization. Conclusions: With the aging of senior veterans, the Department of Health and the Veterans Affairs Commission should reinforce the supply of medical services and long-term care for senior veterans.
• 297 - 304
• 10.6288/TJPH2004-23-04-05

• Link 原著 Original Article
• 論病例計酬實施前後冠狀動脈繞道道手術病患死亡情形The Changes in Mortality Rate in Patients with Coronary Artery Bypass Surgery before and after the Implementation of a Casebased Prospective Payment System
• 李冬蜂、吳肖琪
  Tung-Feng Lee, Shiao-Chi Wu
• 冠狀動脈繞道手術 ； 論病例計酬 ； 醫療品質 ； 死亡率
  coronary artery bypass grafting surgery(CABGs) ; case-based prospective payment system(CPS) ; medical quality ; mortality rate
• 目標：為探討論病例計酬實施前後，冠狀動脈繞道手術病患死亡情形的變化及相關因素。 方法：為介入前後自然實驗研究，以全民健保88年7月實施冠狀動脈繞道手術論病例計酬前18個月與後10個月中，接受冠狀動脈繞道手術患者為研究對象，共5,607人次；以住院期間死亡率與住院併出院後30日內死亡率作?測量指標。 結果：論病例計酬實施後，冠狀動脈繞道手術之住院期間及住院併出院後30日內死亡率，在控制其他因素後並無統計上的顯著不同，顯示國內實施論病例計酬後，冠狀動脈繞道手術品質未顯著受到影響。在醫院特質方面，公立醫院住院雖住院期間死亡率較私立醫院高，然住院併出院後30日內死亡率則是私立醫院較高。而女性、年齡大於65歲、患有急性心肌梗塞、充血性心衰竭、週邊血管疾病、糖尿病或中風等病史，住院期間?發症、住院日較短，及由服務量較低之醫院或工程師執行手術之病患，其住院併出院後30日內死亡率較高。 結論：住院併出院後30日內死亡率較適合用來監控CABGs用術品質之指標，且高服務量醫院及醫師的手術品質較佳。建議：健保局未來應加強低服務量醫院或醫師的審查與輔導，並持續監控醫療品質。此外，醫療供給者除應加強醫院低服務量醫師的手術訓練外，對於患有相關合併症之高危險群病患，亦應特別留意其照顧品質，以降低術後死亡的風險。
  Objective: To investigate the risk factors and changes in the mortality rate in patients with coronary artery bypass grafting surgery (CABGs) before and after the implementation of a casebased prospective payment system (CPS) in July 1999. Methods: The 5,607 patients who received CABGs from January 1998 (18 months before CPS) to April 2000 (10 months after CPS) were extracted from the National Health Insurance data. Their mortality rate of in-hospital and in-hospital plus within 30-days of discharge before and after the implementation of CPS was analyzed using a natural experiment study. The relative factors of mortality rate were also analyzed in this study. Results: After controlling for the confounding factors, the mortality rate of in-hospital and in-hospital plus within 30-days after discharge did not change significantly following the implementation of CPS for the patients received CABGs. It showed that CPS might not influence the medical quality of CABGs. The in-hospital mortality rate of public hospitals is higher than private hospitals. However, the mortality rate of in-hospital plus within 30-days of discharge was higher in the private hospitals. The factors such as female gender, being older than 65 year-old, acute myocardial infraction, congestive heart failure, cerebrovascular disease, diabetes, stroke, in-hospital complication, shorter length of stay, and hospitals or physicians with a lower volume of CABGs were related to a higher mortality rate. Conclusions: The mortality rate of in-hospital plus within 30-days of discharge could be used for monitoring medcial quality of CABGs. The Bureau of National Health Insurance should monitor the medical quality of low-volume hospitals or physicians. Health care providers should also pay attention to the surgery training for the low-volume physicians to reduce mortality rate
• 305 - 315
• 10.6288/TJPH2004-23-04-06

• Link 原著 Original Article
• 民衆對醫院新設院區之認知及就醫意願調查研究－以某醫學中心爲例An Investigation of the Perception of Residents toward a Newly-opened Branch Hospital and Their Intentions to Seekmedical Care-a Case Study
• 黎伊帆、楊銘欽
  Yi-Fan Li, Ming-Chin Yang
• 新設院區 ； 醫院形象 ； 民就醫選擇
  newly-opened hospital ; hospital image ; hospital choices
• 目標：瞭解某醫學中心之新設院區開始營運後兩年，其附近社區民眾對於個案院區的認知情形，並瞭解民眾赴該院區就醫之意願。 方法：採橫斷式調查研究，於民國91年3月關間電訪居住該院區週邊的1,020位民眾。 結果：有56.4%的受訪民眾知道有個案院區，多數民眾是透過傳播媒體（報紙、宣傳海報等）得知個案院區。而「曾至該院區就醫」之受訪民眾至個案院區就醫之意願較高；主要選擇之因素?醫院距離住家較近(74.1%)，對總院的印象好而至該院區就醫則佔24.1%。有25.7%的民眾表示在親友有醫療需求時，會推薦至個案院區就醫，其中又以「家庭月總收入在9萬元以下」、「曾經至該院區就醫」之受訪者，較傾向會將個案院區推薦給親友。 結論：受訪民眾對於個案院區之認知及就醫意願，與其前傾因素及其過去經驗有顯著相關。
  Objective: To investigate the residents' perception about a newly opened branch hospital of a medical center, and to understand the nearby dwellers' inclination to go to that hospital when needed. Method: This study was a cross-sectional survey. Data were collected by telephone interview 1,020 dwellers around that branch hospital in March 2002. Result: 7About 56.4% of the respondents knew about the branch hospital. Mass media was the main sources of information about the hospital. Those who previously had been to this branch hospital had higher intentions to select this hospital. The major factors related to choosing the branch hospital included the proximity of the branch hospital to the home (74.1%) and the good reputation of the main hospital (24.1%). Those with family income under ninety thousdands pre month or received care from the branch hospital were more likely to recommend this branch hospital to others. Conclusion: The perception of residents toward a Newly-Opened Branch Hospital and their intentions to seek medical care were significantly associated with the predisposing factors and experiences of the residents.
• 316 - 323
• 10.6288/TJPH2004-23-04-07

• Link 原著 Original Article
• 影響原住民對巡迴醫療及保健服務利用之因素探討－以仁愛鄕爲例An Exploration of Access to Mobile Medicine Program and Factors Affecting Medical Utilization in Aboriginal Areas
• 洪錦墩、葛梅貞、李卓倫、梁亞文
  Chin-Tun Hung, Mei-Chen Ko, Jwo-Leun Lee, Yia-Wun Liang
• 巡迴醫療 ； 原住民 ； 醫療利用 ； 滿意度
  Mobile medicine program ; Aboriginal ; utilization ; Satisfaction
• 目標：巡迴醫療服務一直是衛生單位與中央健康保險局作?解決山地與偏遠地區原住民基本醫療服務之策略之一。其策略通常是增加醫療服務提供者之經濟誘因，促使較具規模之醫院運用巡迴方式提供原住民醫療與保健服務，提供山地及偏遠地區更完整之醫療服務藉經改善居民之健康。本研究希望藉著探討原住民對巡迴醫療及保健服務利用之影響因素，作?提供原住民巡迴醫療及保健服務之決策參考。 方法：以結構式問卷以訪員親自拜訪方式，取得原住民對健康狀態及對巡迴醫療之認知與滿意度等三方面進行調查。並進一步以逐步迴歸分析影響其醫療利用次數與滿意之因素，並以Two-part model分析求得各相關因素對巡迴醫療利用次數之邊際效果。 結果：知道巡迴醫療時間、知道有夜間急診醫療、身體疼痛程度較高者，巡迴醫療利用的次數也愈多。對於巡迴醫療時間、地點之認知情形對於巡迴醫療的使用有顯著性影響的結果，顯示相關資訊宣導傳播對於提升巡迴醫療之使用狀況有其重要性。而分析利用巡迴醫療保健服務次數與其滿意度之相關性，民眾對醫療滿意度愈高，則巡迴醫療服務之利用次數也顯著愈高。利用Two-Part Model公式計算出自變項對巡迴醫療利用次數之邊際效果顯示：對於巡迴醫療時間及服務內容的認知影響原住民之醫療利用呈顯著水準，瞭解巡迴醫療者較不知道者多利用1.5420次。 結論：原住民對於巡迴醫療服務之認知也會影響其對巡迴醫療保健服務之利用。因此在提供巡迴醫療保健服務時也應提高民眾對於巡迴醫療保健服務之認知，將有助於提高住民對於巡迴醫療服務之利用。
  Objectives: The implementation of National Health Insurance (NHI) has given relief for most people of the economic risk of medical care. However, for residents in mountain areas, distance barriers and lack of medical resources result in lower accessibility to medical care utilization and lower satisfaction. To help these medically deprived populations, the Bureau of National Health Insurance contracted a mobile medicine program with a Christian hospital to deliver primary health care for a rural area in the middle of Taiwan. The purpose of this study is to explore the factors of mobile medicine program on access and medial utilization by residents in mountain areas. Methods: Primary data sets were collected by the household interviewed survey to obtain information from residents concerning their health status, satisfaction, and understanding of mobile medicine programs. Stepwise regression was further adopted to explore the significant factors in explaining the utilization and satisfaction. Also, a two-part model was used to understand the marginal effects of possessed medicine program on utilization. Results: (1) utilization increased significantly if residents have more information about the mobile medicine program; (2) people with a higher satisfaction with the mobile medicine program tended to have a higher utilization of mobile medicine program; (3) people with a higher opinion of the mobile medicine program used its services 1.5 times more than those with a lower opinion. Conclusions: All the results imply that the mobile care program has improved the equity of access to health care.
• 324 - 333
• 10.6288/TJPH2004-23-04-08