20卷1期

• Link 公衛論壇 Public Health Forum
• 從衛生教育到健康促進從衛生教育到健康促進
• 李蘭
  Lee-Lan Yen
• 無none
  無none
• 無none
  無none
• 1-4
• 10.6288/TJPH2001-20-01-01

• Link 綜論 Review Article
• 為什麼高血壓不是第一大死因？－談原死因選擇規則的相關問題Why hypertension is not the first leading cause of death? –the problems related to the selection rules for underlying cause of death
• 呂宗學
  Tsung Hsueh Lu
• 死因統計 ； 死亡證明書 ； 國際疾病分類 ； 原死因選擇規則
  cause of death statistics ; death certificate ; International Classification of Disease ; selection rules for underlying cause of death.
• 死因統計是公共衛生計畫與評估最常使用的參考數據。為了瞭解為什麼台灣重要的盛行疾病高血壓不是主要死因，本文首先介紹死因統計製表所依據的原死因理念及原死因選擇規則。選擇規則中的連結規則是造成高血壓不易成為原死因的主要理由，該規則規定當高血壓與缺血性心臟病、腦血管疾病、腎炎徵候群同時出現於死亡證明書上時，原死因不選高血壓。本文接著回顧過去死因譯碼過程的信效度研究，研究顯示國與國間譯碼差異的可能原因為：各國死因統計資料收集過程的差異(死因診斷格式差異、開具醫師的資格要求、醫院死亡與非醫院死亡之比率、對屍體解剖的要求、查證的要求不同)；各國醫師填寫死因診斷的習慣不同、不同國家譯碼員對疾病因果關係的解釋不同、原死因選擇規則本身有模糊不清與自相矛盾的地方。多重死因製表與電腦化原死因選擇系統是目前國際上解決前述過程所衍生問題的方法。(台灣衛誌2000;20(1):5-14)
  Cause-of-death statistics are the most highly used reference in public health planning and evaluation. To understand why hypertension, a highly prevalent disease in Taiwan, is not the leading cause of death, this article first introduces the concept of underlying cause-of-death (UCOD), and the selection rules that guide the tabulation of cause-of-death statistics. The linkage rule of the selection rules is the main reason that hypertension would not be selected as the UCOD. According to this rule, when a death certificate lists hypertension with mention of ischemic heart disease, cerebrovascular disease, and nephritic syndrome, hypertension would not be selected as the UCOD. His article also reviews previous studies on the reliability and validity of UCOD coding processes. Reasons explaining the variation in UCOD coding among different countries include 1) differences in the procedure of collecting cause-of-death information (e.g., certifier requirements, format of cause-of-death diagnosis, percentage of deaths in hospitals, autopsy rates, criteria of query); 2) Differences in customs of diagnosing cause of death; 3) differences in interpretation of disease causal relationships; and 4) vague and paradox of selection rules. Two solutions to the abovementioned problems are tabulation of multiple causes of death, and automation of UCOD selection.
• 5-14
• 10.6288/TJPH2001-20-01-02

• Link 原著 Original Article
• 省立醫院體制轉型評估－高階主管意見調查The Transitions of the Taiwan Provincial Hospital – A Survey of High Ranking Officials
• 郎慧珠、李丞華
  Hui-Chu Lang, Cheng-Hwa Lee
• 省立醫院 ； 轉型 ； 過程觀點 ； Kaluzny模式
  Provincial Hospital ; transition ; process perspective ; Kaluzny model.
• 目標:：本研究是以Kaluzny的轉型理論為基礎來瞭解台灣省省立醫療機構之轉型，以了解省立醫療機構的轉型歷史及型態，並調查高階主管對轉型所持之態度。方法：研究對象為全省省立醫療院所之高階主管，以問卷調查之方式來收集所需的資料。問卷調查悉利用87年10、11月間省府衛生處所舉辦之「省立醫院經營管理專案計畫」精進研習會之聚會時間，進行問卷調查。結果：研究結果顯示轉型方案的優先權排序為(1)體制內改革，政府仍然繼續予以預算補助。(2)先朝體制內改革，以達自給自足之後，在適當時刻再轉變為公設財團法人醫院。(3)先朝體至內改革，以改變營運體質並自負盈虧。結論：省立醫院目前最適的轉型模式仍是以體制內的改革為優先考量，若是法令上的鬆綁的確無法解決，再行考量直接的組織再造，轉變為法人機構。(台灣雜誌2001;20(1):15-26)
  Objectives: This study used Kaluzny's transition theory to analyze transitions in Taiwan's Provincial Hospital in order to determine medical, legal and historical implications. Methods: A survey of high ranking officials was performed to obtain data concerning their attitudes toward these transitions. The study surveyed high ranking officials at provincial medical organizations throughout Taiwan using a questionnaire. The questionnaires were distributed from October to November 1998 at the Provincial Department of Health's ”Provincial Hospital Management Plan” seminar. Results: The results of the study indicate that the preferred modes of transition were: I) Change within the existing system, with the government continuing to provide budgetary assistance; 2) Transition which promoted internal change first in order to reach self-sufficiency, with the aim of further transition to status as a public hospital corporation at a suitable later date. Conclusion: The results of this study indicate that change to an internal system model should be the first priority for most provincial hospitals. If a relaxation of legal ties fails to solve transition-related problems, then direct reorganization should be considered. This would involve changing the status of the hospital to a corporate entity. (Taiwan J Public Health. 2001 ;20(1): 15-26)
• 15 - 26
• 10.6288/TJPH2001-20-01-03

• Link 原著 Original Article
• 台灣小型醫院新設與歇業之影響Factors Affecting Opening and Closure of Small Hospitals in Taiwan
• 劉容華、江東亮
  Jung-Hua Liu, Tung-Liang Chiang
• 小型醫院 ； 醫院新設 ； 醫院歇業
  Small Hospitals ; Hospital Opening ; Hospital Closure.
• 目的：本研究旨在分析1987至1997年間，100床以下小型醫院新設與歇業的分布及其決定因素。方法：本研究採用次級資料分析方法，資料來源為行政院衛生署的「臺灣地區公私立醫療院所現況調查」，以及內政部出版的「臺閩地區人口統計」。本研究利用對數複迴歸分析，探討醫院組織特性與環境因素兩類變項，與醫院新設或歇業的關係。結果：1987至1997年間，臺灣醫院自802減少為624家，雖然有193家醫院新設，但歇業醫院卻高達371家。就醫院規模而言，89.6%的新設醫院與99.7%歇業醫院，都在100床以下。對數複迴歸分析顯示：新設醫院的規模傾向小於50床，並且蓋在都市化程度中等、各類型醫院數皆少的次醫療區；但歇業醫院傾向為舊設醫院、私立、及規模50床以下，並且位於大型醫院數多，以及賀芬達指標低的次醫療區。結論：臺灣小型醫院的新設和歇業，與醫院組織特性及環境因素均有顯著相關。(台灣衛誌2001;20(1):27-33)
  Objective: This study aims to examine the factors associated with the establishment of new hospitals and hospital closures (all with less than 100 beds) in Taiwan from 1987 to 1997. Methods: Secondary data were used for analysis. These data were obtained from “The Annual National Hospital Survey”, conducted by the Department of Health, and the “Taiwan-Fukien Demographic Fact Book”, published yearly by the Ministry of the Interior. Multiple logistic regression was applied to explore whether hospital characteristics and environmental factors were associated with opening and closure of hospitals. Results: Between 1987 and 1997, there were 193 new hospitals and 371 hospital closures. As a result, the total number of hospitals in Taiwan decreased from 802 to 624. In terms of size, 89.6% of the new hospitals and 99.7% of the closed hospitals were with to 624. In terms of size, 89.6% of the new hospitals and 99.7% of the closed hospitals were with less than 100 beds. Our multiple regression models reveals that, compared with existing hospitals, most of the newly opened hospitals had less than 50 beds. Similarly, a majority of the hospitals that closed between 1987-1997 were privately owned with less than 50 beds. Moreover, these hospitals tended to be located in districts where medical centers and regional hospitals already exist, as well as in districts with a lower Herfindahl index. Conclusions: Both hospital characteristics and environmental factors were associated with the opening and closure of small hospitals in Taiwan.
• 27 - 33
• 10.6288/TJPH2001-20-01-04

• Link 原著 Original Article
• 勞保被保險人腦血管疾病成本分析Estimating the Costs of Cerebrovascular Disease for the Insured Labors Under he Labor Insurance, 1991
• 林璟鈺、楊銘欽、劉紹興
  Ching-Yu Lin, Ming-Chin Yang, Saou-Hsing Liou
• 腦血管疾病 ； 勞工保險 ； 疾病成本 ； 人力資本法 ； 疾病盛行情形
  cerebrovascular disease ; labor insurance ; cost of illness ; human capital approach ; prevalence-based approach.
• 目標：預防保健服務為全民健保的特殊設計，實施以來一直難以取得簡便而具代表性的樣本以反映各項服務的使用率，全民健保學術研究資料庫的開放使用提供了此一機會。本研究之目的在於估計1996-1997年全民健保提供之四種預防的使用率。方法：擷取1996年和1997年全民健保學術研究資料庫門診處方及治療明細檔，案件分類為預防保健服務者，依照各項服務之健保卡就醫序號，輔以健保規定服務之年齡性別條件，計算各序號出現之頻率，扣除重複申報者，乘以抽樣倍數，再除以該年各項服務對應之目標人口服務量，求得該項服務之使用率。結果：各項服務除子宮頸抹片有1%以下的重複外，均未發現重複申報。孕婦第一孕程第一次服務1996年為92.1%，1997年為86.7%，之後除第三孕程後段外均達80%以上。兒童預防保健服務以一歲內第一次為最高，1996年為39.6%，1997年為54.3%，第二次之後逐漸下降，一歲至三歲之服務使用率略有回升，1996年為38.1%，1997年為42.6%，滿三歲至四歲之服務則二年度均不到20%，而一歲內第四次與三歲之服務延遲的情況較為多見。成人預防保健40-64歲(三年一次)者二年分別為27.1%及27.9%，65歲以上(一年一次)者自1996年之14.5%上升到1997年之21.7%。子宮頸抹片(30歲以上一年一次)1996年為21.4%，1997年上升為26.9%。結論：本研究首次根據涵蓋全國之全民健保申報資料估計各項預防保健服務之使用率，發現除孕婦產前檢查使用率較高外，其餘均有待加強，使用率較低之項目，多有服務人口負荷高、支付金額低、無指引或手冊等問題，醫師與民眾認知亦為可能的影響因素，應針對這些問題加以改進以提高使用率。(台灣衛誌2001;20(1):43-51)
  Objectives: The provision of preventive services is a special design in the National Health Insurance in Taiwan. However, it is very difficult to obtain a simple and representative sample to assess the utilization rates of these services since the implementation of this policy. The opening of the National Health Insurance Research Database (NHIRD) offered a good opportunity to do this assessment. Methods: We identified all claims whose case classification numbers indicated preventive services from the sampled outpatient files of the 1996 and 1997 NHIRD, counted the frequencies of utilization of each service, and removed duplication to obtain the utilization numbers. These frequencies were multiplied by the sampling fraction, and calculate the utilization rate according to the predicted service quantity of e target population. Results: Only in Pap smear we found a less than 1 % of duplication. The utilization rates of first prenatal service of the first trimester were 92.1% in 1996 and 86.7% in 1997. The utilization rates of all prenatal services remained higher than 80% until the last services of the third trimester. The utilization rates of child preventive services were high in the beginning service under age l year, 39.6% in 1996 and 54.3% in 1997, and declined thereafter. Rates raised in the service between age 1 and 3 year, 38.1 % in 1996 and 42.6% in 1997, but declined again and were less than 20% in the service after age 3 year. Delay of services was common in the fourth service at age below 1 year and the service after 3 years old. The utilization rates of adult preventive service were low: 27,1 % for 40-64 years in 1996 and 27.9% in 1997, 14.5% in 1996 and 21.7% in 1997 for 65 years and above. The utilization rates of Pap smear were 21.4% in 1996 and 26.9% in 1997. Conclusions: This is the first nationwide assessment of the utilization rates of preventive services of the National Health Insurance. The utilization rates were low except that of the prenatal services. Services with low utilization rates maybe due to high population load, low payment, and poor pamphlet provided such as guidelines and handbooks. Lacking awareness of physicians and population is also a possible cause. We suggest the Burean of the Hational Health Insurance to solve these problems to Improve the utilization rates.(Taiwan J Public Health. 2001;20(1);43-51)
• 34 - 42
• 10.6288/TJPH2001-20-01-05

• Link 原著 Original Article
• 全民健保預防保健服務使用率之分析Utilization of preventive services of the National Health Insurance
• 季瑋珠、賴佳君
  Wei-Chu Chie, Chia-Chun Lai
• 全民健保 ； 預防保健服務
  National Health Insurance ; preventive health services
• 目標：預防保健服務為全民健保的特殊設計，實施以來一直難以取得簡便而具代表性的樣本以反映各項服務的使用率，全民健保學術研究資料庫的開放使用提供了此一機會。本研究之目的在於估計1996-1997年全民健保提供之四種預防的使用率。方法：擷取1996年和1997年全民健保學術研究資料庫門診處方及治療明細檔，案件分類為預防保健服務者，依照各項服務之健保卡就醫序號，輔以健保規定服務之年齡性別條件，計算各序號出現之頻率，扣除重複申報者，乘以抽樣倍數，再除以該年各項服務對應之目標人口服務量，求得該項服務之使用率。結果：各項服務除子宮頸抹片有1%以下的重複外，均未發現重複申報。孕婦第一孕程第一次服務1996年為92.1%，1997年為86.7%，之後除第三孕程後段外均達80%以上。兒童預防保健服務以一歲內第一次為最高，1996年為39.6%，1997年為54.3%，第二次之後逐漸下降，一歲至三歲之服務使用率略有回升，1996年為38.1%，1997年為42.6%，滿三歲至四歲之服務則二年度均不到20%，而一歲內第四次與三歲之服務延遲的情況較為多見。成人預防保健40-64歲(三年一次)者二年分別為27.1%及27.9%，65歲以上(一年一次)者自1996年之14.5%上升到1997年之21.7%。子宮頸抹片(30歲以上一年一次)1996年為21.4%，1997年上升為26.9%。結論：本研究首次根據涵蓋全國之全民健保申報資料估計各項預防保健服務之使用率，發現除孕婦產前檢查使用率較高外，其餘均有待加強，使用率較低之項目，多有服務人口負荷高、支付金額低、無指引或手冊等問題，醫師與民眾認知亦為可能的影響因素，應針對這些問題加以改進以提高使用率。(台灣衛誌2001;20(1):43-51)
  Objectives: The provision of preventive services is a special design in the National Health Insurance in Taiwan. However, it is very difficult to obtain a simple and representative sample to assess the utilization rates of these services since the implementation of this policy. The opening of the National Health Insurance Research Database (NHIRD) offered a good opportunity to do this assessment. Methods: We identified all claims whose case classification numbers indicated preventive services from the sampled outpatient files of the 1996 and 1997 NHIRD, counted the frequencies of utilization of each service, and removed duplication to obtain the utilization numbers. These frequencies were multiplied by the sampling fraction, and calculate the utilization rate according to the predicted service quantity of e target population. Results: Only in Pap smear we found a less than 1 % of duplication. The utilization rates of first prenatal service of the first trimester were 92.1% in 1996 and 86.7% in 1997. The utilization rates of all prenatal services remained higher than 80% until the last services of the third trimester. The utilization rates of child preventive services were high in the beginning service under age l year, 39.6% in 1996 and 54.3% in 1997, and declined thereafter. Rates raised in the service between age 1 and 3 year, 38.1 % in 1996 and 42.6% in 1997, but declined again and were less than 20% in the service after age 3 year. Delay of services was common in the fourth service at age below 1 year and the service after 3 years old. The utilization rates of adult preventive service were low: 27,1 % for 40-64 years in 1996 and 27.9% in 1997, 14.5% in 1996 and 21.7% in 1997 for 65 years and above. The utilization rates of Pap smear were 21.4% in 1996 and 26.9% in 1997. Conclusions: This is the first nationwide assessment of the utilization rates of preventive services of the National Health Insurance. The utilization rates were low except that of the prenatal services. Services with low utilization rates maybe due to high population load, low payment, and poor pamphlet provided such as guidelines and handbooks. Lacking awareness of physicians and population is also a possible cause. We suggest the Burean of the Hational Health Insurance to solve these problems to Improve the utilization rates.(Taiwan J Public Health. 2001;20(1);43-51)
• 43 - 51
• 10.6288/TJPH2001-20-01-06

• Link 原著 Original Article
• 新設大型醫院對當地基層診所的影響評估－第一部分：供給與利用的變化The impact of a new hospital on the operation of local clinics Part I: changes in supply and utilization
• 鄭守夏、劉林義、張毓宏
  Shou-Hsia Cheng, Lin-I Liu, Yu-Hung Chang
• 醫療市場 ； 門診服務 ； 競爭 ； 全民健保 ； 影響評估
  health care market ; outpatient services ; competition ; National Health Insurance ; impact evaluation.
• 目的：本研究旨在評估一個大型醫院的成立，對當地基層診所造成的影響，藉以推論醫療市場的競爭情形。方法：以健保申報資料為依據，觀察台北市某一大型醫院成立前後四年，對該區基層診所服務量與申報金額的影響，並以鄰近性質相近的一區為對照，進行比較分析。結果：本研究發現，在新醫院成立後，該區整體的門診服務量與申報金額明顯上升，醫院部分的門診量第一年即增加一倍，其後二年也持續成長。然而當地基層診所的營運狀況也呈現正成長，與對照組區比，並未發現因競爭激烈而有營運萎縮的現象。結論：基層診所的營運未受新醫院成立的影響，可能因為當地原有供給不足的問題，也可能有醫師誘發需求的現象，而真正的原因仍有待進一部分析。(台灣衛誌2001;20(1):52-60)
  Objectives: This study is to evaluate he impact of a newly opened hospital on the operation of local clinics and to understand the competition in health care market. Methods: A Taipei local area with a new hospital opening was chosen. Four years of outpatient services claim data from all local health care providers to the Bureau of National Health Insurance were analyzed. A nearby comparison area was employed in the analyses. Results: After the opening of the new hospital, the outpatient services volume doubled in the first year and kept increasing in the following years in the research area. However, the operation of local clinics was not affected. Their service volume and expenses increased every year, which were comparable to the comparison area. Conclusion: The opening of a new hospital did not affect the operation of local clinics. Several possible explanations were discussed.(Taiwan J Public Health 2001;20(1);52-60)
• 52 - 60
• 10.6288/TJPH2001-20-01-07

• Link 原著 Original Article
• 新設大型醫院對當地基層診所的影響評估　第二部分：病人流向與醫師誘發需求的可能The impact of a new hospital on the operation of local clinics Part II: patient flow and physician-induced demand
• 鄭守夏、劉林義、張毓宏
  Shou-Hsia Cheng, Lin-I Liu, Yu-Hung Chang
• 醫療市場 ； 門診服務 ； 競爭 ； 病人流向 ； 醫師誘發需求
  health care market ; outpatient services ; competition ; patient flow ; physician-induced demand.
• 目的：本研究旨在了解一大型醫院的投入對當地民眾就醫流向的影響，同時觀察對當地診所造成的競爭壓力，是否會導致基層醫師在診療行為上的改變，包含誘發病人需求。方法：針對台北市一新設醫院所在地區的居民，利用自然實驗的設計，在醫院成立前後，以問卷訪視的方式對一群成人民眾進行訪談，了解其就醫選擇之變化，並探討西醫診所醫師的某些診療行為是否有改變。結果：本研究發現受訪民眾習慣於區外就診的比例，則由47.7%升高為58.0%。另外，研究也發現，民眾最近一次看門診時，醫師要求複診或自費買藥或做檢驗的比例有些微下降的情形，而到診所看病的自付費用則沒有明顯的改變。結論：新醫院的成立，明顯地改變了當地居民的就醫流向，但並未造成該區西醫門診市場的激烈競爭，也沒有發現醫師誘發需求的現象。
  Objectives: This study is to evaluate the impact of a newly opened hospital on local patient flow and to examine the possibility of physician-induced demand due to increased market competition. Methods: A natural experimental study design was employed. Local residents were selected and interviewed before and after an opening of a nearly hospital. A questionnaire was designed to detect the changes of interviewees’ selection of health care providers and local physicians’ behavior. Results: The proportion of cross-area outpatient visits decreased from 42.2% to 30.9%. The rate of hospital-based outpatient visits increased from 47.7% to 58.0%. The rates of physician-initiated re-visit and required laboratory examination both decreased. Patients’ out-of-pocket price for a visit was not changed in the research area. Conclusion: The opening of the new hospital changed the interviewees’ selection of health care providers, but did not make the local market more competitive. Therefore, this study found no evidence concerning physician-induced demand.
• 61 - 68
• 10.6288/TJPH2001-20-01-08

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• 實驗室廢液處理不當爆炸導致氫氟酸灼傷事件Hydrofluoric Acid Burns Caused by Incompatible Laboratory Wastes
• 蕭秋勇、陳保中、王榮德、鄭尊仁
  Chiou-Yeong Shiau, Pau-Chung Chen, Jung-Der Wang, Tsun-Jen Cheng
• 氫氟酸灼傷 ； 廢液回收
  hydrofluoric acid burns ; waste disposal.
• 目標：本報告陳述實驗室因廢液處理不當爆炸導致氫氟酸灼傷案例。事件輕過及處理：某大學實驗室，因操作人員疏忽，將不相容廢液混合，產生劇烈反應，使廢液桶爆炸，至氫氟酸噴濺灼傷操作人員。隨後進入之急救人員，亦因未穿戴適當防護具，導致呼吸道灼傷。氫氟酸爆炸後皮膚灼傷病患，立即以葡萄酸鈣製劑治療，一週後恢復。結論：廢液回收為廢棄物處理重要一環，處理過程應注意廢液相容問題。而不同途徑氫氟酸暴露，可造成不同型態的傷害，但以不同製備型態葡萄酸鈣處理，可達治療效果。(台灣衛誌2001;20(1):69-73)
  Objectives: Two case reports present the clinical manifestations and management of hydrofluoric acid burns resulting from an explosion caused by incompatible laboratory liquid wastes. Case reports: The explosion occurred at a university laboratory when a technician placed isopropyl alcohol liquid waste into a waste receptacle containing hydrofluoric acid. The technician received hydrofluoric acid burns in this accident. She was immediately treated with calcium gluconate paste and recovered within 3 months. The second case was a school nurse who came to the scene to help the technician and subsequently developed laryngeal swelling. She was treated with steroids and a nebulized form of calcium gluconate and recovered in 1 week. Neither of them were wearing adequate personal protective equipment. Conclusions: Although liquid waste pooling is a common practice for waste disposal, careful attention should be paid to the compatibility of various liquid wastes. Furthermore, hydrofluoric acid may cause a variety of injuries resulting from different routes of exposure. However, timely treatments with appropriate preparations of calcium gluconate may produce a satisfactory recovery.(Taiwan J Public Health. 2001;20(1);69-73)
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• 10.6288/TJPH2001-20-01-09