22卷3期

• Link 原著 Original Article
• 職業傷害健保住院病患特性之分析Characteristics of Occupational Injury Inpatients Covered by the National Health Insurance in Taiwan
• 張朝煜、郭育良、張雅倫
  Chao-Yo Chang, Yue-Liang Leon Guo, Ya-Lun Chang
• 健康保險 ； 職業傷害 ； 住院
  health insurance ; occupational injury ; admission
• 目標：本研究為描述性研究，分析台灣全民健保資料，探討職業傷害的相關因素與特性，以提供職場傷害的預防參考。方法：以民國85年至民國88年職傷健保住院的資料，選取「非實禍、非依賴人口的健保職傷住院病患」為對象。將年齡、年齡組、性別、就醫機構、傷病種類與給付等變相進行研究分析。結果：職傷健保住院的樣本共有51,925人次，佔總健保職傷住院比率85%，平均住院天數是10.1天，平均費用是新台幣48,723元。中年、男性與醫學中心就診病患之平均費用比其他族群高。五大傷病是骨折、上肢開放性傷害、壓輾傷、燒傷、顱外傷，佔職傷住院的65%。骨折病患佔總住院人次與費用的比率最高。燒傷病患之平均住院天數與費用最高。結論:住院天數是影響費用的主要因素，減少住院天數將減少職傷住院醫療費用。本建議易發生骨折或燒傷之行業宜加強職場安全教育，以期減低職傷的發生。
  Objectives: This was a descriptive study. Factors of occupational injury were analyzed with admission data of health insurance in Taiwan. The purpose was to offer a priority order recommendation of occupational injury prevention, Methods: Admission data of occupational injury and others between 1996 and 1999 were translated, summarized, and rebuilt into a new database. The group was” the population of non-traffic accident, and non-dependent occupational injury from admission data of health insurance”, The study analyzed the correlation of age, age group, sex, types of occupational injury, and payments. Results: Of admission data, 85% belonged to this group. The mean of admission was 10.1 days, and mean of payments was NT$ 48,723. The mean of payments of male, admitted to medical center, and middle-age group were higher than others. Bone fracture, open wound of upper limb, crushing injury, burn, and cranial injuries were the major types of disease. Sixty-five percent of cases belonged to the five major occupational injury subgroups. The subgroup of bone fracture had the highest total payments. The patient of burn had the highest average payments and the longest average admission days. Conclusions: The number of admission days was the major factors for payments. We suggest that reducing severity of injury possibly will reduce the number of admission days and reduce payments. We recommend that we must focus on prevention of events of bone fracture, and burn to minimize the damage of individuals by effectively controlling the safety of environment of work and education.
• 147 - 154
• 10.6288/TJPH2003-22-03-01

• Link 原著 Original Article
• 誰使用了非西醫的補充與另類療法？社會人口特質的無區隔性與健康需求的作用Who Uses Non-Biomedical, Complementary and Alternative Health Care? Sociodemographic Undifferentiation and the Effects of Health Needs
• 丁志音
  Chih-Yin Le-Ting
• 補充與另類療法 ； 健康狀況 ； 健康需求 ； 社會人口特質
  Complementary and alternative medicine ; health status ; health concerns ; sociodemographic characterstics
• 目標：對「補充與另類療法」(complementary and alternative medicine，CAM)的使用型態加以描繪並檢視其與社會人口特質及健康需求間的關係。方法：本研究資料來自2002年九月所進行的全國性家戶電話調查，共收集1517名20至70歲成人的資料(回應率＝87.1%)。結果：75.5%於受訪前一年使用了至少一種樣式的CAM，這些CAM所屬的範疇及被使用率分別為：(1)物質攝入及吸收(64.2%)，(2)以外來力量操弄身體部位(50.6%)，(3)體能活動及身心靈的修持與調和(1.6%)，以及(4)超自然調控(14.9%)。整體而言，性別、年齡、教育程度、及居住地區都市化程度等社會人口特質，與CAM的使用關係極微;然而個人的健康需求(包括健康狀況與健康關切）等，卻與CAM的使用有極強的關係。結論：民眾對CAM的使用相當普遍，而且並非侷限於特定的人口群。CAM的相關議題應納入衛生計劃的過程中予以考量；而未來的研究則應進一步深入探究價值與信念在CAM的使用中所扮演的角色。
  Objectives: To document the pattern of complementary and alternative medical (CAM) therapy use among the general population and delineate use pattern along socio-demographic characteristics and health needs. Methods: A nation-wide household telephone survey was conducted during September 2002. A total of 1517 valid interviews with persons 20 to 70 years of age were accomplished (response rate= 87.1 %). Results: The use of CAM, by being conceptualized as non-biomedical therapy use in the present study, was so prevalent that 75.5% of respondents reported CAM use in the past year. More than 20 CAM modalities were used and the domains to which these CAM modalities belonged and rate of use were: (l) Substance absorption and intake (64.2%), (2) Manipulative and body-based intervention with physical forces (50.6%), (3) Physical activities and body-mind techniques (1.6%), and (4) Regulation of supernatural power (14.9%). Socio-demographic variables such as sex, age, education and urbanization of residential areas were not able to differentiate users versus nonusers. However, strong associations were found between CAM use and health needs (including health status and health concerns). Conclusion: CAM use was a commonplace practice and was not limited to specific social groups. It is suggested that CAM related issues should be taken into account in the process of health planning. While health needs played critical roles in CAM use, personal beliefs and values should be addressed in future research.
• 155 - 166
• 10.6288/TJPH2003-22-03-02

• Link 原著 Original Article
• 員工及組織目標之一致性與其組織承諾關係之探討－以醫院中層主管為例Relationship Between Goal Congruence and Organizational Commitment of Hospital Middle Managers
• 邱瓊萱、鍾國彪、魏中仁、楊志良
  Chiung-Hsuan Chiu, Kuo-Piao Chung, Chung-Jen Wei, Chih-Liang Yaung
• 目標一致性 ； 組織承諾 ； 中層主管
  Goal congruence ; organizational commitment ; middle manager
• 無
  Objectives: To understand the relationship between goal congruence and organizational commitment of hospital middle managers, this study conducted a survey research on middle managers and CEOs in selected hospitals. Methods: This study used Meyer & Allen's three-factor organizational commitment questionnaire (affective commitment, continuance commitment, and normative commitment). Absolute difference in organizational goals was also calculated to measure the goal congruence between middle managers and CEOs. Result: Response rates of CEOs and middle managers were 58.7% and 34.2%, respectively after follow-up. This study revealed that the relationship between goal congruence and affective commitments was significant after controlling other variables through multiple regression. The relationship between goal congruence and calculated commitment as well as normative commitment was also positive, but not significant. As for the relationship between control variables and three-factor commitments, there are some interesting findings. Hospital. strategic implementation was significantly associated with three-factor commitments, Hospital ownership was also associated with affective and normative commitment. Moreover. the identity of physician or not and organizational tenure of middle manager had significant associations with calculated commitment. This study showed that middle managers who are non-physicians and higher in tenure tends to have higher calculated commitment. Conclusion: Goal congruence between middle managers and CEOs was associated positively with affective commitment. This implied that CEOs should focus more on how to align goal through better communication and respect for middle managers.
• 167 - 180
• 10.6288/TJPH2003-22-03-03

• Link 原著 Original Article
• 民眾對基層診所評價與就醫選擇影響因素Consumers' Assessment of Clinic Services and its Affecting Factors
• 蔡文正、龔佩珍
  Wen-Chen Tsai, Pei-Tseng Kung
• 基層診所 ； 診所就醫評價 ； 就醫選擇因素
  Primary Care Clinics ; Assessment of Clinic Services ; Medical Care Choices
• 目標：為提升民眾至基層診所就醫意願，以減少民眾小病看大醫院的現象，本研究探討民眾對基層診所各項醫療服務之評價及分析其就醫選擇影響因素，以提出提升民眾至基層診所就診意願的方案。方法:本研究以問卷調查方式，依各層級醫院領藥號碼採隨機系統抽樣，有效樣本1148份，並應用描述性統計分析、逐步迴歸分析探討民眾對基層診所之整體評價與主要影響因素。結果:影響民眾對基層診所評價之因素除了包括教育程度與分級就醫觀念外，另包括醫術、護士或藥師的服務態度、醫師診斷時間、醫師對病情的解說等之滿意度。在民眾對選擇診所就醫因素重要性評價方面，以病情解說、環境衛生與醫術為最重要。而對診所醫療服務滿意度評價方面，前三名為醫師看病態度、醫病關係、醫術。結論：本研究依研究結果提出下列兩方面建議：一、對基層診所:病患導向之推廣活動、改善服務品質、設立聯合診所或聯合門診、醫師專業能力的強化；二、對衛生主管機關:調高越就醫之部分負擔、分級就醫觀念的推廣、加強基層醫師專業教育。
  Objectives: In order to decrease the utilization of hospital outpatient services by patients with minor illnesses and to increase the willingness to visit primary care clinics, this study investigated the consumers' assessment of the types and quality of services delivered by clinics. The study also examined the factors determining the low preference for clinic-based services compared o hospital outpatient care. Based on the results, a number of policy interventions are proposed to improve the utilization of clinic-based care. Method: Structured questionnaires were used to interview patients selected randomly from four levels of the health service delivery system. A total of 1148 patients were interviewed. Descriptive statistics provide the basic information about patient's opinion and assessment of services received from clinics and the stepwise regression method was used to identify the factors affecting the assessment scores of clinics. Results: Factors affecting the patient's preference include the educational status of individuals, perception about physician's referral pattern, satisfaction with physician's competence, attitudes of nurses and pharmacists, time needed to diagnose illnesses, and the patient satisfaction with physician's explanation about the illness. From the patient's point of view, the three most important factors determining the quality of clime care were the explanations given by physicians about the illnesses, cleanliness of the clinic and perceived knowledge and competence of the physician. The top three factors affecting patients' satisfaction with clinics were the physician's manner and attitude, rapport between physicians and patients, and the physician's knowledge and competence. Conclusion: The results indicate that the utilization of clinics win improve if the physicians perform patient-oriented promotional activities, improve service quality, establish group medical practice, and enhance physician's competence. The health policy decision makers may also consider increasing the out-of-pocket payment for patients at the hospital level if not referred by a primary care physician. The health care delivery system can also promote the adoption of a well-defined protocol for patient referrals from primary to secondary and tertiary levels. Finally, continuing educational programs to update the knowledge and skills of clinic physicians will he1p to improve the confidence of patients in physicians in the primary care clinics.
• 181 - 193
• 10.6288/TJPH2003-22-03-04

• Link 原著 Original Article
• 台灣精神分裂症患者精神醫療利用與費用之分析探討The Utilization and Expenditure of Psychiatric Services for Patients with Schizophrenia in Taiwan
• 葉玲玲、藍忠孚、鄭若瑟
  Ling-Ling Yeh, Chung-Fu Lan, Joseph Jror-Serk Cheng
• 精神分裂症 ； 精神醫療利用 ； 全民健保 ； 申報資料
  schizophrenia ; utilization ; national health insurance ; claim data
• 目標：本研究希望藉著瞭解精神分裂症患者使用精神醫療服務與醫療費用相關資料，作為發展精神醫療照護體系的參考。方法：利用國家衛生研院全民健保資料庫抽樣歸人檔，10萬人從1996至2000年全民健保門、住診申報資料，取出精神分裂症患者五年精神醫療住院治療就醫資料進行資料。並以1996至1998年精神分裂症患者第一次就醫門診後滿一年與滿二年就醫資料，進行患者門診與住院醫療利用與費用之分析探討。結果：1996至2000年平均住院日數與平均醫療費用大致呈現下降的趨勢。平均住院日數由40.8天下降為36.0天；平均醫療費用由64089元下降為57276元。1996至1998年第一次門診後滿一年與滿兩年使用門診比率為75.7%與77.9%，平均門診人次為9.0與15.3；使用住院治療比率為10.9與15.4%，再住院率則為10.3%與32.7%。結論：本研究精神分裂症患者之精神醫療服務利用與醫療費用分析結果的資訊可提供檢討精神醫療照護體系改革之用。
  Objectives: The objective of this study was to investigate the utilization of psychiatric care of patients with schizophrenia. It hoped that these findings will contribute to the development of the mental health care system. Methods: The study used the claims data of the Bureau Of National Health Insurance (BNHI) from hospitals throughout Taiwan between 1996 and 2000. Results: The average length of stay and average expenditure of hospitalization has a decreased tendency from 40.8 days and 64089 NT dollars in 1996 to 36.0 days and 57276 NT dollars in 2000. During one-year and two-year periods after the first outpatient visit since 1996 to 1998, the proportion of using ambulatory care was 75.7% and 77.9%, respectively, while the average outpatient visit was 9.0 and 15.3, respectively. The admission rates of total subjects were 10.9% and 15.4%, respectively, while the readmission rates were 10.3% and 32.7%, respectively. Conclusions: These study results revealed very important information as guidance to reform mental health care systems.
• 194 - 203
• 10.6288/TJPH2003-22-03-05

• Link 原著 Original Article
• 全民健保中醫門診總額支付制度實施前醫療服務品質之研究A Study of the Quality of Care of Traditional Chinese Ambulatory Care Before the Implementation of the Global Budget Payment System in Taiwan
• 林美珠、李玉春
  Mei-Chu Lin, Yue-Chune Lee
• 總額支付制度 ； 中醫 ； 醫療服務品質 ； 病人滿意度 ； 差額負擔
  Global budget payment system ; Traditional Chinese medicine ; Quality of Care ; patients' satisfaction ; balance-billing
• 目標：為提昇醫療服務品質、合理控制醫療費用，提高專業自主性，全民健保中醫門診總額支付制度於八十九年七月正式實施。為避免總額支付制度實施後，醫療服務品質降低，本研究在該制度實施前以病人滿意度的觀點建立一套評估的工具，以了解病患對中醫門診醫療服務品質及收費合理性滿意度現況及其影響因素。方法：以89年6月中醫門診總額實施前之門診就醫病患為研究對象，先依縣市及院所分層抽取中醫院所(醫院抽50%，診所抽40%)，復就抽中院所提供之八十九年六月十六日之所有病人名單以系統抽樣，電訪成功之有效樣本1837人(完訪率77%)。資料鍵入電腦後，藉由事後分層加權法以使樣本分布與母群體一致，資料以SPSS for windows9.0版進行描述性及T檢定、ANOVA、相關分析、卡方檢定與複迴歸分析等推論性統計。結果：中醫門診病人整體醫療服務品質滿意度平均達78.5分，醫療品質各構面滿意度得分差異不大，以照護可近性最高(平均值80.5%)，醫療設備及環境最低(平均76.1分)；收費合理性滿意度(平均值71.09分)又較醫療品質滿意度低。就診台北分局之病人滿意度較其他分局低。經控制病人及院所特性後，針灸治療有採拋棄式用針者、給藥天數較長者、由中醫師親自執行傷科處置或針灸治療者、醫師主動提供保健說明及醫師看診時間較長者滿意度較高；反之，交通及候診時間較長及被差額收費者滿意度較低。結論：(1)中醫醫療品質大致可為病人接受，惟仍應落實由醫師親自執行針灸及傷科醫療，避免不當之差額收費。(2)本研究發展之問卷可作為健保局定期監控民眾對中醫門診就醫可近性、醫療服務品質滿意度及差額負擔之工具。
  Objectives: To evaluate the quality of care (QOC), the extent of balance billing and the associated factors before the implementation of the Global Budget Payment System of Ambulatory Chinese were conducted on samples based on stratified random sampling of the providers, and their lists of patients on June 16, 2000. A total of 1837 interviewed were completed (response rate 77%)during June 20 to 30, 2000. Post-stratification was conducted to adjust the age-county distribution of the samples: Multiple linear regressions were conducted. Results: (1)The average overall patients' satisfaction on QOC was 78.6 out of 100; among the different dimensions of QOC, ”accessibility” ranked the highest (80.5) whereas the” medical equipment” ranked the lowest (76.1). The satisfaction on “ reasonableness of the charge” was lower than QOC(7l.1). In general hospital patients were less satisfied than that of clinics. Patients in the Taipei Branch Bureau of NHI were less satisfied than others. (2)After contro1linl! for the patients' and providers' characteristics, the following factors were related to higher satisfaction of QOC: use disposable needles in acupuncture; more days on prescription; Physicians conduct traditional traumatic procedures, acupuncture or moxibustion by themselves; or provided more preventive or self care information; longer visiting time; shorter traffic time / waiting time; no extra-charge. Conclusions: (l)The overall .patients' satisfaction of quality of care and balance-billing were acceptable. However, to improve satisfaction, physicians should conduct traditional traumatic; acupuncture/moxibustion therapies by themselves, to avoid the extra-charge to patients if possible.(2)The instrument developed by this study could be used to monitor the accessibility ,quality and balance-billing of the providers after the implementation of the GB-CM.
• 204 - 216
• 10.6288/TJPH2003-22-03-06

• Link 原著 Original Article
• 由全民健保西醫門診資料探討台灣民眾的感冒求醫特性Outpatient Care-Seeking of Colds and Influenza Under the Health Insurance System in Taiwan
• 林宜平、丁志音
  Yi-Ping Lin, Chih-Yin Lew-Ting
• 台灣 ； 感冒 ； 健保資料 ； 門診求醫
  Taiwan ; colds and influenza ; National Health Health Insurance ; outpatient care-seeking
• 目標：由全民健保門診資料探討台灣民眾的感冒求醫特性。方法:利用行政院衛生署所公佈的1999年與2000年「全民健康保險醫療統計年報」，擷取其性別、年齡別與疾病別門診人次、人數與費用等報表資料，再分別除以台灣地區的性別與年齡別人數，據以描述台灣地區民眾因感冒(包括上呼吸道感染與流行性感冒)使用健保門診的求醫特性，並進行討論。結果：1999年與2000年台灣地區民眾因感冒而使用健保西醫門診，其醫療費用分別佔健保西醫門診總費用的14.23%與14.30%，求醫人次佔總人次的27.92%與28.80%，平均每人每年因感冒使用西醫門診3.35次與3.42次。2000年曾因急性上呼吸道感染至健保西醫門診求醫者佔總人口的64.45%，其中14歲以下的兒童不但求醫的人口比例高，次數也最多；而女性急性上呼吸道感染門診求醫的人口比例與次數也較男性高。台灣地區民眾感冒的健保門診求醫人次有九成以上在診所。結論：台灣地區民眾的感冒門診求醫，無論就每人平均次數或是其所佔的門診人次比例而言，都高於美國與加拿大。由公共衛生的角度看來，或可由增進台灣地區感冒患者的自我照護能力與健康素養著手，並且積極預防感冒的發生，以降低台灣民眾非必要的感冒門診求醫。
  Objectives: To explore the characteristics of outpatient care-seeking for colds and influenza in Taiwanese National Health Insurance (NHI). Methods: We obtained our data from the 1999and 2000 NHI annual reports to calculate the annual expenses and average outpatient visits for colds and influenza. Age and gender differences in the frequencies of outpatient visits of cold and influenza and the patients' preferences of outpatient services were explored. Results: In 1999 and 2000, Taiwanese people spent 14.23% and 14.30% of total NHI outpatient expenses on outpatient care for colds and influenza. The outpatient visits for cold and influenza accounted for 27.92% and 28.80% of total outpatient visits. Taiwanese people had an average of 3.35 and 3.42 outpatient visits per person in 1999 and 2000 for colds and influenza. Children under 14 years of age had the highest proportion of outpatient visits for their acute respiratory infections and were the most frequent users in such visits. Females also had a higher proportion of outpatient visits for acute respiratory infections and were more frequent users than males. More than 90% of Taiwanese patients preferred family clinics to hospitals for the care of their colds or influenza. Conclusions: or the outpatient visits for colds and influenza in Taiwan, the frequency of service utilization and the percentage in total outpatient visits were all higher than those in the US or Canada. In order to reduce unnecessary outpatients visits for colds and influenza in Taiwan, we suggest, from public health perspectives, to improve the general public's self-care ability and their health literacy, and also to prevent the colds and influenza epidemics.
• 217 - 226
• 10.6288/TJPH2003-22-03-07

• Link 實務 Public Health Practice
• 台灣地區癌症死亡率與發生率電子地圖的建構及使用The Construction and use of the Electric Atlas of Cancer Mortality and Incidence in Taiwan
• 廖勇柏、陳建仁、李文宗、徐書儀
  Yung-Po Liaw, Chien-Jen Chen, Wen-Chung LeeShu-Yi Hsu
• 地理資訊系統 ； 死亡率 ； 發生率 ； 補點式卜瓦松趨勢面分析 ； 電子地圖
  georaphic information system ; mortality ; incidence ; imputed Poisson trend surface ; electric atlas
• 目標：利用全國死亡檔及發生檔資料透過地理資訊系統(GIS)編纂台灣地區1972-2001年癌症死亡率及1995-1998年癌症發生率的電子地圖。方法：採用三種指標繪製死亡率及發生率彩色地圖，分別是「直接年齡標準化死亡/發生率等級圖」、「直接年齡標準化死亡/發生率與全人口死亡/發生率比較圖」及「補點式卜瓦松趨勢面分析圖」。當各種圖形繪製完成後，再利用Visual Basic 6.0版程式及Map Objects LT 2.0版將各種圖形整合，收錄於同一張光碟片中。結果：提供地理特徵圖及各種癌症死亡/發生率的電子地圖，並提供一系列的功能按鈕，包括地圖放大、縮小、平移、癌症資料顯示工具、恢復原大小、死亡率/發生率切換扭、男女按扭、三種繪製指標按扭、國際比較圖、性別年齡別曲線圖、死亡率長期趨勢圖、自定圖例數值及列印等功能。結論：電子地圖具有製作成本低廉、傳播速度快、數據更新容易、可顯示圖上每一點相關數據、可更改圖例及整合多種圖形界面等優點，有助於闡明台灣地區重要癌症的危險因子。
  Objective: To construct an electric atlas of cancer mortality (1972-2001) and incidence (19951998) in Taiwan by using a Geographic Information System (GIS), Methods: Three sets of color maps were made based on ”Age-Adjusted Mortality by Rate”, ”Age-Adjusted Mortality by Rank” and ”Imputed Poisson Trend Surface”. For the production of the electric atlas, the Visual Basic (version 6.0) and Map Objects LT (version 2.0) software were used to integrate the three sets of color maps. Results: The electric atlas provides the information with regard to the population density, birth rate, ethnic distribution, geology, topography, soil and mortality/incidence rate, with a series of functions buttons including Zoom In, Zoom Out, Pan, Auto Identify, Zoom to Full Extent, mortality/incidence switch button, sex button, index button, international comparison, age-specific rate, secular trend of cancer mortality, legend and print button. Conclusion: The electric atlas is a cheap and fast tool. The electric atlas integrates various cancer maps. Therefore, it becomes more powerful for examining spatial patterns, quicker for comparing the various maps, and easier for updating and identifying the data. Using the electric atlas in Taiwan could elucidate the risk factors of cancer.
• 227 - 236
• 10.6288/TJPH2003-22-03-08

• Link 研究紀要 Research Brief
• 臺灣人口的老化對未來健康面的影響Population Aging in Taiwan :Future Health Implications
• 藍祚運
  Tzuo-Yun Lan
• 老化 ； 癌症 ； 失能 ； 醫療支出
  Aging ; cancer ; disability ; medical expenditure
• 目標：針對經建會提出之臺灣未來人口推估，本研究嘗試了解未來人口結構轉變對健康方面可能的影響。方法：以現有癌症或失能率及健保醫療支出及未來人口結構，推估未來將癌症或失能的人數及健保醫療支出。結果：毫無疑問，隨著臺灣人口老化，老年人口罹患慢性病如癌症及失能的絕對人數及相對比例將明顯增加，在醫療費用需求亦增加下，這些轉變將變成整個社會沉重的負擔。結論：相對於人口結構調整策略，運用健康促進來降低及預防疾病及失能應為一有效方法。
  Objectives: As the projections of Taiwan's future population have recently been proposed, this analysis is aimed to understand the possible health impacts of the change in population structure. Methods: Based on the current age-specific cancer and disability rates, age- sex- specific total medical expenditure, and the future population structure, the numbers of people with cancer and disability and the total medical expenditure for older people are projected. Results: Not surprisingly, as Taiwan's population is aging, a substantial increase in the absolute numbers and the relative proportions of cancer and disability for older people can be seen. As a result of these adverse outcomes, future medical expenses needed for older people will create a huge burden for society, Conclusions: Rather than trying to change the future population, health promotion and disability and disease prevention will be a more effective way of coping with these problems.
• 237 - 244
• 10.6288/TJPH2003-22-03-09