22卷2期

• Link 公衛論壇 Public Health Forum
• 健康體系再造－從基本理念談起健康體系再造－從基本理念談起
• 石曜堂、施淑芳
  Yaw-Tang Shih, Shu-Fang Shih
• 無
  none
• 無
  none
• 79 - 81
• 10.6288/TJPH2003-22-02-01

• Link 公衛論壇 Public Health Forum
• 健康照護體系再造的本土經驗健康照護體系再造的本土經驗
• 楊志良
  Chih-Liang Yaung
• 無
  none
• 無
  none
• 82 - 86
• 10.6288/TJPH2003-22-02-02

• Link 公衛論壇 Public Health Forum
• 臺灣健康照護體系的財務公平性意涵臺灣健康照護體系的財務公平性意涵
• 盧瑞芬
  Jui-Fen Rachel Lu
• 無
  none
• 無
  none
• 87 - 88
• 10.6288/TJPH2003-22-02-03

• Link 綜論 Review Article
• 從效率面談台灣健康體系的再造Efficiency of Health Care System in Taiwan
• 李丞華
  Cheng-Hua Lee
• 健康照護 ； 效率
  Health Care ; Efficiency
• 我國醫療保健體系，從效率面指標與國際經濟合作發展組織的國家相比，我國整體投入較少的醫師、較少的醫院病床，而以極高的醫師生產力及極高的醫院病床生產力，提供民眾大量的門診服務及中度數量的住診服務。整體的醫療體系以高醫療可近性、低醫療費用、中等醫療品質及高醫療滿意度等四項特性著稱。在醫療體系產出結果方面，我國國民平均餘命尚有２至５歲的努力空間，婦女健康指標及傷害事故死亡率均有相當大改善空間。另外在醫療體系以外的預防保健服務、健康促進活動、及長期照護服務的生產效率及投入組合效率尚待進一步研究分析。
  Compared to the OECD countries, Taiwan’s health care system seems to be more efficient. Although there are relatively fewer physicians and acute care beds, these physicians and beds show extremely high levely of productivity, providing a large volume of ambulatory care services and an intermediate amount of inpatient services. Taiwan’s health care system is widely recognized for its high medical care accessibility, low medical care expenditure, average quality of care, and high public satisfaction. In terms of the output of the medical care system, life expectancy could be increased by 2-5 more years. Howevr, for women’s health and accidental deaths, it still needs a large improvement. Furthermore, other than the health care system, productivity and resource integration, efficiency of prevention, health promotion, and long-term care services also need further investigation.
• 89 - 96
• 10.6288/TJPH2003-22-02-04

• Link 綜論 Review Article
• 男性更年期研究的回顧Review on Male Climacteric Studies
• 張玨、張菊惠
  Chueh Chang, Chu-Hui Chang
• 男性更年期 ； 婦女研究觀點 ； 醫療化 ； 性別分析
  male climacteric (andropause) ; perspective of women 's study ; medicalization ; gender analysis
• 女性更年期（停經期）在過去２０－３０年來相關學術研究已有上萬篇，相對於其的男性更年期（或停經期）則研究卻非常少，與女性更年期比是１：１００。本文主旨在於回顧國內外男性更年期研究文獻，從男性更年期是否存在的爭論中釐清不同學門立場的論述觀點，及其對男性更年期的定義，並進一步闡述醫學界對男性更年期需矯治所抱之立場與處理方式，以及反對矯治者對治療可能導致攝護腺癌或其他後遺症的質疑，和男性健康被醫療化的警示，以及從國內外女研究立場探討女性更年期的經驗，評析性別分析對男姓更年期研究的重要。結論提出男性更年期屬於公共衛生領域需關注的一環，也與世界趨勢對男性健康重視相提並論不可忽視。
  Over ten thousand articles on climacteric (or menopause) for women can be found, but relatively less has been done on the male equivalent. The ratio of published studies of climacteric men (or andropause) to climacteric women is of the order of 1: 100. The aim of this paper is to review the literature on the theme of male climacteric both in Taiwan and abroad from: drawing debates on the existence of a male climacteric to clarify the diverse opinions of different perspectives and definitions; describing the perception and handling tl1ethods in medical field for treating male climacteric; probing the prospect of treating male climacteric that might lead to prostate cancer or other side effects; warning the possibility of medicalizing men’s health; and communicating the importance of gender analysis for the male climacteric study based on the experience of women’s studies on female climacteric abroad. It is concluded that male climacteric is of importance in the interests of public health and men’s health as a global trend that is indisputable.
• 97 - 107
• 10.6288/TJPH2003-22-02-05

• Link 原著 Original Article
• 智能障礙者醫療需求評估與就醫障礙之分析A Qualitative Study of Healthcare Needs and Barriers Assessment for Persons With Intellectual Disabilities
• 林金定、嚴嘉楓、李志偉、吳佳玲
  Jin-Ding Lin, Chia-Feng Yen, Chih-Wei Li, Jia-Ling Wu
• 智能障礙者 ； 醫療需求 ； 主要照顧者 ； 質性訪談
  intellectual disabilities ; health care needs ; carer ; qualitative interview
• 目標：衛生政策上對智能障礙者的健康照護，往往忽略其健康需求與服務體系之評估，以致於此群體的健康問題在健康照護體系中僅獲得非常有限的注意；本研究主要目的乃以主要照顧者之觀點探討智能障礙者之醫療需求，以評估智能障礙者之醫療需求概況。方法：以深度訪談方式探討主要照顧者對於智能障礙者相關醫療議題之態度與信念，主要之評估面向包括（１）智障者主要醫療照護／復健需求為何？（２）在醫療照護服務中主要遭遇的問題為何？（３）對於目前的醫療保健制度／全民健保利用之困難何在？（４）自覺理想的醫療照護模式為何？結果：研究結果發現智能障礙者有高於一般人之醫療需求，他們在醫療照護過程中常面臨經濟上之困難，至於理想的醫療照護體系，主要照顧者通常沒有特別的期許，這問題遠超乎他們的想像。結論：為了確保智能障礙者與一般的國民享有同等的健康照護，健康服務體系應該尊重他們的權利與期許，設計提供滿足他們基本的健康服務，以增進他們的生活品質。
  Objectives: The health care needs and problems of persons with intellectual disabilities (ID) have received limited attention in the health care system of Taiwan, and have been largely overlooked in the current health policy debate. The purpose of this study is to identify the health care needs of persons with ID based on the perspective of their main carers. Methods: Semi-structured in-depth interviews were conducted for 14 key informants in the study. The interview questions were open-ended and an interviewing guide was designed to encourage participants to share their experiences of working with and caring for people with ID. The interview questions covered four themes as follows: (1) What are the health needs of people with ID? (2) What are the problems regarding the health care services of people with ID and why? (3) What are the problems regarding the current health care system and National Health Insurance Plan for people with ID? (4) What is your ideal health care system for people with ID and why? Results: The research findings showed that the illness prevalence and health care utilization of people with ID were higher than the general population but their health care needs were not being properly met. The ideal health systems for people with ID were beyond the informants imagination and expectation. Conclusions: To ensure that people with ID enjoy the same rights as the general population, appropriate health care services suited to their needs are critical to the success of efforts to improve the quality of life for people with ID.
• 108 - 117
• 10.6288/TJPH2003-22-02-06

• Link 原著 Original Article
• 醫院、醫師手術量與醫療品質之關聯性探討－以全股（髖）關節置換為例Association Between Hospital and Surgeon Procedure Volume With Outcome of Total Hip Replacement
• 簡麗年、朱慧凡、劉見祥、鍾國彪、曹昭懿、吳義勇、吳肖琪
  Li-Nien Chien, Hui-Fan Chu, Chien-Hsiang Liu, Kuo-Piao Chung, Jan-Yih Tsauo, Yee-Yung Ng, Shiao-Chi Wu
• 全股（髖）關節置換術 ； 手術量 ； 醫療品質 ； 死亡率 ； 再住院率
  THR ; volume ; medical quality ; mortality rate ; readmission rate
• 目標：以全股（髖）關節置換術為例，探討醫院、醫師手術量與病患術後醫療品質的關聯性。方法：利用全國健保申報次級資料，以民國８７年１月至８９年１２月進行單側全股（髖）關節置換住院者為研究對象，控制病患特質（年齡、性別、主診斷、疾病嚴重度）、醫院特質（地區別、公私立與層級別）與住院期間醫療利用及品質（住院日、復健治療次數與併發症發生情形）等，評估手術量與病患出院後９０日及一年內死亡率與再住院率的相關。結果：總手術量≧５０件的醫院之死亡率與再住院率較手術量≦７件的醫院低（９０日內死亡率為０．６６％與１．００％，adjusted OR=０．６９；不分科再住院率為１３．９３％與４８．３１％，adjusted OR=０．６９）。手術量≧２５件之醫師的死亡率與住院再住院率也較手術量≦５件之醫師為低（９０日內死亡率為０．５７％與２．５５％，adjusted OR=０．２３；不分科再住院率為１３．６７％與４２．３４％，adjusted OR=０．７３），結論：手術量較低的醫院與醫師，其病患術後發生死亡與再住院的比率較高，建議健保局可利用手術量作為監控醫院與醫師醫療品質的替代指標，且應避免手術量過低的醫院與醫師執行全股（髖）關節置換術。
  Objective: The goal of this study was to determine whether the volumes of total hip replacement (THR) of the quality of health care at hospitals and surgeons are associated with rate of mortality and complications. Methods: We analyzed claims data from the National Health Insurance (NHI) for patients who underwent elective primary THR procedures between Jan 1998 and Dec 2000. We assessed the relationship between surgeon and hospital procedure volume, as well as the rate of mortality, readmission, and dislocation within ninety days and one year postoperatively. Analyses were adjusted for age, gender, arthritis diagnosis, severity of disease the area, owner and size of hospital, LOS (length of stay), in-hospital rehabilitation and complication. Result: Ninety days after discharge, patients treated in hospitals in which there were more than 50 of these procedures had a lower risk of death and readmission than those treated in hospitals in which there were seven or few procedures (mortality rate, 0.66% compared with 1.00%; adjusted OR=0.69; readmission rate, 13.93% compared with 48.31%; adjusted OR=0.69). Ninety days after discharge, patients treated by surgeons who performed more than 25 of these procedures had a lower risk of death and readmission than those treated by surgeons who performed more than 25 of these procedures had a lower risk of death and readmission than those treated by surgeons who performed less than 10 procedures (mortality rate, 0.57% compared with 2.55%; adjusted OR=0.23; readmission rate, 13.67% compared with 42.34%; adjusted OR=0.73). Conclusion: Patients treated in hospitals and by surgeons with lower caseload of THR had higher rates of mortality and readmission. We suggest that NHI should concentrate THR in high-volume referral centers in order to reduce avoidable mortality and morbidity.
• 118 - 126
• 10.6288/TJPH2003-22-02-07

• Link 原著 Original Article
• 屏東地區婦女接受子宮頸抹片檢查之相關因素Factors associated With Papanicolaou Smear Practice in Women in the Pingtung Area
• 林惠賢、王琳華、 劉淑敏、康啟杰
  Huey-Shyan Lin, Ling-Hua Wang, Shu-Min Liu, Chi-Chieh Kang
• 子宮頸抹片檢查 ； 知識 ； 態度 ； 行為
  cervical cancer screening ; knowledge ; attitude ; behavior.
• 目標：本研究目的為探討影響社區婦女接受子宮頸抹片檢查之相關因素，希望藉此研究結與經驗提供衛生當局作為訂定加強婦女抹片篩檢政策的參考。方法：本研究以屏東縣３０歲以上的婦女為抽樣對象，採多步驟隨機抽樣（包括分層、聚集、等距隨機抽樣），以結構式問卷進行家庭訪視調查，共取得有效樣本為１１０１人。結果：經統計分析後發現，研究對象之子宮頸癌與子宮頸抹片檢查知識正確性不高（答對比率平均為４６．６％），子宮頸癌與子宮頸抹片檢查態度稍偏正向（平均每題３．５５分），而子宮頸抹片檢查行為中，至少每年做一次抹片檢查者佔３５．３％，從來沒有檢查者佔２６．３％。透過向前邏輯斯迴歸分析（forward logistic regression analysis）發現：性經驗年數較多、婦科症狀數目較多、婦女對子宮頸癌及子宮頸抹片檢查的認知較正確及態度較正向者較曾做過抹片檢查；而婦女對子宮頸癌及子宮頸抹片檢查的認知較正確、態度較正向、居住在非都市及配偶有學歷者較會每年定期做一次抹片檢查。結論：由研究結果建議政府應利用大眾媒體及衛生機構對婦女及其配偶進行衛生教育，加強婦女對子宮頸癌與子宮頸抹片檢查的認知及態度，特別是配偶無學歷、年齡較大且寡居之婦女；並結合醫護人員的影響力，走入社區推廣抹片檢查，以增加婦女接受子宮頸抹片檢查的意願。
  Objectives: This study investigated the factors that may affect community women in cervical cancer screening practice. Methods: Using multi-stage random sampling method (including stratified, cluster, and interval random sampling), 1101women aged 30 years and above were interviewed with structured questionnaires in the Pingtung area. Results: The findings revealed that only 46.6% women had adequate knowledge in cervical cancer and Pap smear. Although, they had a positive attitude toward cervical cancer and Pap smear with an average Likert score of 3.55. Among the surveyed women, 35.3% reported having received an annual Pap smear test, and 26.3% women never experienced the test. Based on the results of forward logistic regression analysis, women with positive attitudes and of more knowledgeable toward the disease and Pap test had greater odds of annual screening. Women living in rural areas, having a school educated spouse, having longer sexual experience and having more gynecological ailments were also more likely to have the test. Conclusions: According to the findings, the government should make use of mass media and health institutions to enhance the knowledge and attitude toward cervical cancer and Pap smear, especially for women whose spouses are of lower educational level or who are widows with elder age. Physicians and nurses are encouraged to promote women’s desire of cervical cancer screening.
• 127 - 133
• 10.6288/TJPH2003-22-02-08

• Link 原著 Original Article
• 良辰吉時與剖腹生產Auspicious Time and Cesarean Section
• 羅紀琼
  Joan C. Lo
• 良辰 ； 吉時 ； 剖腹產 ； 文化
  Auspicious Days ; Auspicious Hours ; Cesarean Section ; Culture
• 目標：台灣地區的剖腹產率約為３４％，在國際上名列前矛。以往有關產姨問卷調查的當果顯示，產婦及其家屬對是否施行剖腹產有影響力，而選擇良辰吉時是產婦決定採用剖腹產的最主要非醫療因素。本研究擬檢驗在控制了醫療因素後，良辰吉時與剖腹產的施行間是否有顯著正向關係。方法：本研究以民國８７年的出生證明資料為基礎，在控制了醫療因素後，觀察良辰吉時與剖腹生產間的關係，分析對象並且區分為選擇性剖腹產與非選擇性剖腹產二類，俾進一步觀察良辰吉時在兩者間的影響是否有差異。結果：在選擇性剖腹產中，良辰吉時和剖腹產施行機率間有顯著的正向關係，同時吉時的效果大於吉日的效果；而在非選擇性剖腹產中，良辰吉時的影響力則未達統計顯著性。結論：由於選擇性剖腹產的案件數遠超過非選擇性剖腹產的案件數，文化因素因而對台灣地區剖腹產的施行機率與時間有相當的影響力。
  Objectives: The cesarean-section rate in Taiwan is around 34%, which is relatively high in world standards. The survey results indicate that pregnant women and their family members had influential impact on the choice of cesarean section, and choosing an astrologically auspicious time for delivery was the most important underlying non-clinical factor. Methods: In this study, we used birth certificates to test the re1ationship between auspicious time and cesarean section decision. Observations were further classified into elective and non-elective surgeries. Results: After controlling for all the confounding factors, the regression results indicate that the auspicious time and the probability of cesarean section are highly-positively correlated, and the auspicious hours have stronger impact than the auspicious days in the elective surgeries. However, none of the cultural factors were significantly different from zero in the non-elective cases. Conclusions: ‘ Chinese cultural tradition does have strong effect on the timing of the cesarean sections in Taiwan.
• 134 - 140
• 10.6288/TJPH2003-22-02-09

• Link 原著 Original Article
• 醫師衛教門診評價研究－病人觀點Patients' Perspectives on Health Education Clinics by Physicians
• 葉美玉、康清雲
  Mei-Yu Yeh, Ching-Yin Kang
• 衛教門診 ； 衛生教育 ； 醫病關係
  Health education clinic ; health education ; doctor-patient relationship
• 目標：本研究主要目的在以病人觀點評價醫師衛教門診實施之成效。方法：母群為全國１２２家參與醫師衛教門診的公私立醫院，以分層隨機法選取３０家醫院，訪談醫師衛教門診就診病人，及在同一所醫院的非衛教門診的就診病人，共訪問６５２位。結果：（１）七成以上的受訪病人對醫師衛教門診提供的服務相當滿意。（２）醫師衛教門診的醫師提供衛教的時間以２至１０分鐘為最多。（３）病人對醫師衛教門診的實施，給予相當高且正面的評價，認為可以提升醫病關係以及醫療服務品質，並一致認為應繼續推廣。
  Objective: This study aimed at evaluates the effects of a health education clinic run by physicians according to patients’ perspectives. Method: Out of 122 hospitals with health education clinics in Taiwan, 30 hospitals were stratified and selected randomly for this research. From health education clinics and the ones without health education service in the 30 chosen hospitals, 652 patients were surveyed. Results: (1) Over 70% of the interviewed patients were satisfied with physician’s clinic service; (2) Most physicians spent 2 to l0 minutes per patient on the health education clinic; (3) Respective effects of the health education clinic and non-health education on patients were significantly different in terms of doctor-patient relationship, medical treatment quality, doctor reliability and satisfaction. Conclusions: Most patients think highly of a health education clinic, agree that it can improve both the doctor-patient relationship and medical treatment quality and they hope hospitals can continue this service.
• 141 - 146
• 10.6288/TJPH2003-22-02-10