20卷4期

• Link 綜論 Review Article
• 情人眼裡出西施－衛生政策分析中的規範研究之本質與準則Eyes of Beholder-the Nature and Rules of Normative Research in Health Policy Analysis
• 紀駿輝
  Chun-Huei Chi
• 規範研究 ； 實證研究 ； 政策分析 ； 衛生經濟學
  normative research ; positive research ; policy analysis ; health economics.
• 衛生政策研究在公共衛生界已成為一重要研究課題，並影響衛生政策的制訂。問題是，有不少的衛生政策研究，其方法或過程中央雜著實證與規範研究。當衛生政策分析是建立在含有主觀假設的規範研究時，其結論是無法去證實或推翻的。但是多數讀者，甚至於部分學者，均易誤以為這些研究為客觀的科學研究。本文旨在探討如何於衛生政策研究中區分實證研究與規研究，並特別著重在探討如何執行規範研究。在釐清規範議題及研究的本質後，本文嘗試建立一套規範研究的準則。在這準則中最重要的，為作者應該在論文的一開始，就公開且清楚的表明自己的規範性假設。在應用上，本文討論到如何規範性議題從事「類實證研究」，以及在衛生政策及衛生經濟學上如何進行規範研究。本文除了探討規範研究的原則供研究人員參考外，亦提供決策者判斷及解讀規範研究結果的方法。
  Public health policy analyses often incorporate normative research that was based on subjective assumptions. Its conclusion, as a result, often cannot be proved or rejected on the empirical ground. Unfortunately, many readers, even some researchers, are having difficulty in distinguishing between positive and normative analysis. This article tries to clarify the nature of normative research, provides guidance on how to differentiate normative from positive research, and to establish a norm for normative research. Among those norms for normative research, the most important one is that the researcher should state his or her normative assumptions explicitly upfront. Further, this article proposes an approach to conduct ”quasi-positive research” on normative research questions, and its application in health policy analysis and health economics research. Finally, this article also attempts to help policy makers understand how to read and interpret normative research.
• 249 - 258
• 10.6288/TJPH2001-20-04-01

• Link 綜論 Review Article
• 互斥、非互斥？診斷組合(DRGs)分類結構之辨An Exptanatory Analysis of DRGs' Mutual Exclusive Theory
• 韓揆
  Kuei Han
• 診斷組合（DRGs） ； 論病例計酬 ； 醫院管理
  DRGs?;?case mix?;?hospital administration.
• DRGs（診斷組合），作為一個醫院管理及醫療費用支付制度，其分類之周延性及互斥性甚為重要，由於DRGs是綜合疾病分類、臨床分類、病人分類及醫院作業分類而產生的一個新結構，一般醫療及醫院管理學者不易了解其分類邏輯及功能，甚至誤認其分類之互斥性。導致盲從迴響。本文藉一位臨床醫師的質疑詳細剖析DRGs的設計精神及為何一般人容易對它產生誤識，期望對學界，有關業者及學生產生新認知及提升認真作學問的精神。
  Exhaustive and Exclusive are the base that constructs the classification system of DRGs. Some surgeon physician, however, published and argued that at the standpoint of a clinician's view, it, including the ICD-9-CM system, is not structurally exclusive. The article is referred by some chief medical record technician at a large hospital as well as hospital administration students in Taiwan. The author analyzed the article's argument and made clear how the DRGs grouping behavior was formulated. It is hoped that readers of this paper can gain a broader insight of DRGs theory and avoid misleading or being misled.
• 259 - 264
• 10.6288/TJPH2001-20-04-02

• Link 原著 Original Article
• 牙醫師臨床處置操作時間之探討Procedure Time for Dental Treatment Procedures in Taiwan
• 陳琇玲、黃文駿、溫信財、楊志良
  Hsiu-Ling Chen, Wen Jiun Huang, Hsyien-Chia Wen, Chih-Liang Yaung
• 牙醫師 ； 臨床操作時間 ； 支付標準
  Dentist ; procedure time ; payment system.
• 目標：本研究試圖探討牙醫師臨床操作各項處置之時間，作為進一步修訂牙科診療支付標準之基礎。方法：由牙醫師全聯會推薦專家小組，選定25個處置項目，以之從事問卷調查。問卷調查係以全體會員為研究對象，依執業場所及地區別，分層隨機抽取360個牙醫師樣本，進行德菲法(Delphi Technique)二輪問卷調查，請求樣本醫師依據具體病例描述及Ｘ光片或照片、圖片，估測每個處置在臨床操作時所需要的時間。問卷結果再由第二個專家小組成員外推至其餘未調查之處置的臨床操作所需時間。結果：（１）問卷調查結果信度頗佳(R=0.883)，並由專小組據以外推後，獲得79個牙科處置之醫師所需要的臨床操作時間。（２）79項牙科處置所需醫師時間雖未包含執業成本，但結果與現行健保支付標準表之相關性高達0.772。結論：（１）以問卷調查及專家外推之方法，可合理建立我國牙科79個處置的醫師臨床操作時間。（２）問卷調查25項處置之牙醫師臨床操作時間，不因執業場所在醫院或診所而有所差異。（３）問卷調楂25項處置中，大部份處置（22項）之牙醫師臨床操作時間，不因執業地點位於城鄉與否而有所差異。（４）健保支付標準尚能合理反應問卷調查中19項處置之牙醫師臨床操作時間。外推後79項處置時間值與健保支付標準的相關性亦高。
  Objectives: The purpose of this study was to investigate the duration of various dental procedures, In order to establish a basis for reasonable reimbursement of dentists in hospitals or dental clinics in the future. Methods: Upon recommendation of the National Dental Association of the Republic of China, the first Technical Consulting Group (TCG) was formed to select the dental services and procedures (S/Ps) to be investigated. After stratified random sampling by practice setting and region, a questionnaire was developed for the survey. Using the Delphi Technique with a two round questionnaire, we asked dental practitioners to estimate the length of time required for each of the S/Ps. We then asked the second TCG to evaluate the results and to estimate the duration for on-surveyed S\Ps. Results: (l) Showing excellent validity (r=0.883), the time required for 79 dental procedures was established. (2) Although other factors such as costs were not included, the results of the present study correlated well (r=0.772) with the dental payment system of the National Health Insurance (NHI). Conclusions: (1) We have established the usual duration of 79 dental procedures by questionnaire and TCG exploring. (2) Procedure duration was not affected by the location of the practice in hospital or clinic. (3) In most cases, 22 items, procedure duration was not affected by the location of the practice in urban or rural. (4) The NHI dental fee schedule matched adequately the duration of 19 surveyed procedures. The time required for all 79 procedures also correlated highly with the NHI fee schedule.
• 265 - 274
• 10.6288/TJPH2001-20-04-03

• Link 原著 Original Article
• 主治醫師價值觀契合度與組織承諾關係的探討－以六家醫學中心為例A Study of the Relationship Between Person-Organization Fit and the Organizational Commitment of Attending Physicians
• 邱瓊萱、鐘國彪、陳瑞容、魏中仁、楊志良
  Chiung-hsuan Chiu, Kuo-Piao Chung, Duan-Rung Chen, Chung-Jen Wei, Chih-Liang Yaung
• 主治醫師 ； 價值觀契合度 ； 組織承諾
  attending physicians ; person-organization fu ; and the organizational commitment.
• 目的：為暸解主治醫師的價值觀契合程度與組織承諾間的關係，本研究利用問卷調查法，針對台灣地區六家醫學中心的專任主治醫師進行普查，調查其認為工作醫院所重視的價值觀（以下稱實際價值觀）以及其認為醫院應該具備的價值觀（以下稱期望價值觀），並以兩者的減差（期望－實際）與醫師的組織承諾作相分析及複迴歸分析，藉以暸解價值觀契合度與組織承諾間的關係。方法：對台灣地區公立醫院、財團法人醫院及宗教財團法人醫院等三類型醫院中各取二家醫學中心，對1527位專任主治醫師進行問卷調查，回收有效問卷計239份，回收率為15.7%。結果：對實際價值觀進行因素分析，萃取出兩個因素－分別是「對醫師的尊重與照顧」實際重視程度大於期望時，則組織承諾愈高（正向關係）；當醫師認為「醫院的成長與延續」實際重視程度大於期望時，則組織承諾愈低（負向關係）。並且在控制年齡、教育程度與醫院別之後，價值觀差距對組織承諾的影響的舊顯著。結論：當主治醫師認為醫院愈重視「對醫師的尊重與照顧」，則醫師的組織承諾會愈高；當其認為醫院愈重視「醫院的成長與延續」，醫師的組織承諾會愈低。
  Objectives: In order to explore the relationship between value congruence and the organzational commitment, this study used a survey to collect attending physicians’ expected and perceived value for their working hospital from six selected medical centers in the Taiwan area. The purpose of this study. Was to examine the relationship between person-organization fit and the organizational commitment of attending physicians. Methods:This study selected two medical centers each from three separate types of ownership of hospital-public hospitals, corporate hospitals, and religion corporate hospitals. 1529 full-time attending physicians from six hospitals were selected and mailed questionnaires. 239 valid questionnaires were returned. The response rate was 15.7%. Results: Two value factors were retrieved through performing factor analysis. They were named “respect to employees” and “hospital growth and perpetuity”. The value gap in “respect to employee” was positively associated with organizational commitment. That is, organizational commitment. Would be high when physicians perceived this real value was ranked as more important than an ideal one. The value gap in “hospital growth and perpetuity was negatively associated with organizational commitment. That is, organizational commitment would be low when physicians perceived this real value was ranked as more important than an ideal one. After controlling for employee and hospital characteristics through performing multiple regressions, this study still suggested the same result. Conclusions: When hospitals placed more emphasis on “respect to employees” than employees’ expectations, the organizational commitment of attending physicians was higher. When hospitals placed more attention on “hospital growth and perpetuity” than employees’ expectations, attending physicians’ organizational commitment was lower. Therefore, this study suggested that hospitals placed more attention to improve what employees expected, and communicated what and why they were necessary to carry out in order to survive. Better under-standing enhanced the organizational commitment.
• 275 - 290
• 10.6288/TJPH2001-20-04-04

• Link 原著 Original Article
• 入院適當性工具AEP之信效度評估To Evaluate an Admission Review Tool-the Reliability and Validity of AEP
• 溫信財、鐘國彪、薛亞聖、楊志良、季瑋珠
  Hsyien-Chia Wen, Kuo-Piao Chung, Ya-Seng Hsueh, Chih-Liang Yaung, Wei-Chu Chie
• mAEP ； 信度 ； 效度 ； 實用性
  reliability ; validity ; practicality ; modified Appropriateness Evaluation Protocol.
• 目標：本研究目的評估mAEP(modified Appropriateness Evaluation Protocol)在國內使用之信度、效度及實用性，並嘗試了解國內不適當入院之主要原因。方法：研究設計是以三個月時間自健保台北、北區分局抽取申覆病歷426份，並以單盲技術(single bind technique)將影印病歷供本研究四位審查者(reviewers)以mAEP評估，最後再請總局醫審小組之各臨床專科醫師依其專業判斷入院之過當性，研究結果是以SPSS 10.0統計軟體分析。結果：本研究四位審查者中使用mAEP之一致性，有三位之kappa值為0.4左右，但在審查者計論並修正原判定後，kappa值增加為0.486-0.661，達到再現性佳(good reproducibility)之水準。在敏感度及特異度比較上，本研究最高值與分複審醫師之判定均在70%左右，顯示此部份在後續研究仍有相當改進空間。不適當入院原因以「任何診斷處置或（和）治療應可於門診完成」之比率最高，與國外研究相符。以mAEP審核病歷所花時間，平均值為2.6分鐘，與國外實證AEP為一簡易省時審查工具之結果相符。結論：本研究初步結果顯示mAEP在國內之信度、效度及實用性尚佳，mAEP若要成為健保局醫審及醫院入院之參考準則，須有後續研究進一步予以證實。
  Objectives: The purposes of our study are to evaluate the reliability, validity and practicality of mAEP (modified Appropriateness Evaluation Protocol) in Taiwan, and try to find the major reasons for Inappropriate admission. Methods: We collected 462 appeal claim medical records from Taipei and the Northern branch of the Bureau of National Health Insurance (BNHI). The copies of the medical records were dispensed by a single blind technique to 4 reviewers who used mAEP to judge the appropriateness of admission. Then the result was compared to the BNHI medical review physicians' judgement. The data was analyzed by SPSS 10.0 statistics software. Results: Three of the four reviewers' original Cohen's kappa were around 0.4. However, after reviewers discussion and revision of their appropriateness judgements. The kappa increased be tween 0.486 to 0.661. This represents a good reproducibility of mAEP. With regard to the sensitivity and specificity, the branch of BNHI medical review physicians and some of our reviewers were around 70%. Therefore, mAEP's validity still has room for improvement. The major reason for inappropriate admission is that the ”diagnostic procedures and/or treatment could be done on an outpatient basis”. This is the same as the studies in Western countires. The mean time to review the medical records with mAEP was 2.6 minutes. This is similar to Western studies and suggests that mAEP is a fast, easy and timesaving utilization review instrument. Conclusion: The preliminary result proved that the reliability, validity and practicality of mAEP are all good. However, if mAEP could become a tool for the BNHI's medical review and hospitals' admission protocol, further studies are needed.
• 291 - 300
• 10.6288/TJPH2001-20-04-05

• Link 原著 Original Article
• 全人工髖關節置換術病人之療效與生活品質評估－以三家醫學中心主要THR主治醫師病人為例Outcomes and Health-Related Quality of Life in Total Hip Replacement
• 邱亨嘉、李易蓁、王俊聞、黃志賢、張瑞根
  Herng-Chia, I-Chen Lee, Jun-Wen Wang, Chi-Yin Wong, Je-Ken Chang
• 全人工髖關節置換 ； 療效評估 ； 健康相關的生活品質 ； SF-36
  Total hip replacement (THR) ; outcome assessment ; health-related quality of life ; SF-36
• 無
  Objectives: The major purpose of the study was to examine the outcomes and health-related quality of life for Total Hip Replacement (THR) patients following the operation. Furthermore, to explore the difference in the degree of patients’ improvement among the three medical centers in southern Taiwan.Methods:A prospective study was designed. The study sample was derived from one orthopedic surgeon from each medical center. In total, 200 THR patients (hips) had the preoperative and postoperative assessments. The Chinese version of the Harris Scale and the Chinese-version of the Short-from 36-item Health Survey (SF-36) were used as measures. The assessments were conducted before and six months after the operation by orthopedists and trained interviewers. Results: In terms of the Harris Hip Score and the SF-36 scores, the THR patients in the three hospitals showed improvements before and after the operation (p<.001). In each domain of the Harris Hip Scale, the improved score for pain relief was the highest. This was followed by gait function and activity function. In the SF-36, the most significant improvement was found in the domain of role limitations due to emotional problems (RE), and followed by role limitation due to physical problems (RP). Among the three study hospitals, significant differences were found in the total Harris Hip Score and scores on three domains of the SF-36 (physical functioning, role limitation due to emotional problems, and social functions) (p<.05). Conclusions: The present study confirms that THR did enhance patients’ physical functioning and health-related quality of life. The degree of improvement in several dimensions of outcome measurement varied significantly by hospital. It is suggested that using generic measures should be considered as a supplemental measurement for the outcome study.
• 301 - 310
• 10.6288/TJPH2001-20-04-06

• Link 原著 Original Article
• 社會關係、身體意象與婦女自服美容或減肥藥品之相關性The Correlations Between Social Relationships, Body Images and Non Prescription Cosmetic/Weight-Loss Medication Taking Behavior Among Women in Taiwan
• 陳端容、黃文鴻
  Duan-Rung Chen, Weng-Foung Huang
• 美容或減肥藥品 ； 服藥行為 ； 社會關係 ； 身體意象
  ?Cosmetic/weight-loss medication?;?non-prescription medication taking?;?social relationship?;?body images.
• 目的：探討婦女自服非經醫師處方之美容或減肥藥品的種類、時間長短和使用狀況，瞭解有關美容或減肥藥品訊息、資源與協助是否透過親密的社會關係取得，並探討在控制人口與心理變項後，婦女社會關係與其服用美容或減肥２品之相關性。方法：採立意與配額取樣，以臺北市五家（準）醫學中心之門診中心，面對面訪問20歲以上300位服用與300位未服用婦女，以研究者計計之結構式問收集資料。結果：在所有服用美容或減肥藥品的婦女(n=326)中，服用美容藥品者，均佔41%；服用減肥藥品約55%，服用二者佔4%。婦女平均服用1.52種不同的美容藥品及1.74種減肥藥品；平均持續服用美容藥品9.48個月；減肥藥品3.37個月。婦女獲取藥品訊息來源主要為「親戚」、「朋友」或媒體廣告，然服用美容藥品的婦女較常透過人際關係管道取得藥品。多變項分析結果顯示，在控制人口與心理變項後，婦女自服美容或減肥藥品的勝算比與其有較多交往對象討論藥品好壞、較多交往對象鼓勵服用、較多交往對象提供購買管道、較多六往對象也服用相同藥品有關。婦女人際圈愈小，服用美容藥品的勝算比愈高。討論：婦女的社會關係與其服用美容或減肥藥品的行為有顯著相關，社會關係的作用力因藥品性質不同而不同，說明社會關係的探討在公共衛生預防上的重要性。
  Objectives:The purpose of this study is to examine the variations in patterns of women's use of non-prescription medication for cosmetic or weight-loss purposes, as well as the social and psychological factors associated with their use. Methods: A purposive and quota sampling method was used to select 300 women who have used and another 300 women who have never used medication for cosmetic and weight-loss purposes. Using self administered questionnaires, we conducted face-to-face interviews with women aged over 20 years waiting in the outpatient de-partment in five medical centers located in Taipei City. Results: Among women who reported having used non-prescription medication for cosmetic or weight-loss, 41% used it for cosmetic purpose; 55% used it for weight-loss purpose, and only 4% of them reported having it for both purposes. Women who use non-prescription medication for cosmetic purpose tend to obtain the related information and the medication itself from family and friends, while those who use non-prescription medication for weight-loss purpose tend to obtain the above mentioned from family, friends and the mass media. With socio-economic and psychological variables controlled, women friends and the mass media. With socio-economic and psychological variables controlled, women who use non-prescription medications tend to have more related support from family and friends. Conclusions: The characterstics of social relationships are found to be associated with women’s use of non-prescription medication for cosmetic or weight-loss purposes. The effect of social relationships varies with the type of non-prescription medication taken. Such effect on health behaviors should be taken into consideration when promoting public health.
• 311 - 320
• 10.6288/TJPH2001-20-04-07

• Link 原著 Original Article
• 台北都會區室內外細粒徑氣懸微粒的特性及汽機車污染源之探討A study of Characteristics and Vehicular Sources of Aerosol in Typical Indoor and Outdoor Environments in Taipei
• 楊慈定、王秋森
  Tzu-Ting Yang, Chiu-Sen Wang
• 換氣率 ； 微粒沉積損失率 ； 穿透因子 ； 追蹤劑 ； 正烷類
  urban aerosols ; indoor environments ; PM2,5 ; vehicular emissions.
• 目標：本研究主要在探討台北都會區不同類型建築物在自然通風及無室內污染源狀況下其室內與室外環境中細粒徑氣懸微粒的質量濃度，並利用質量平衡方法，探討微粒的穿透因子、空氣換氣率、及微粒沉積損失率對室內與室外微粒濃度比值的影響；另外，以含碳數C23至C26的正烷類，當作機動車輛排放微粒的追蹤劑，探討室內外氣膠源自機動車輛排氣的百分率。方法：本研究採樣儀器為Model 400 Micro-environment Monitor (MSP Corporation, Minneapolis, MN, USA，以下簡稱MEM)，其50%的切開粒徑是2.5μm。採樣地點及時段分別為：（１）台北市南港區一般典型三樓住家，陽台及客廳；日間時段為8:00am至5:30pm，夜間為7:00pm至次日7:00am；（２）台北縣新店市大豐國小三樓教室，教室走廊及室內；時段為8:00am至3:30pm；（３）台北市徐州路台大公共衛生學院新址一樓辦公室，後方圍牆上和辦公室內；時段為8:00am至5:00pm。除測量微粒質量濃度外，樣本並以300ml二氯甲烷經15分鐘超音波震盪萃取後，以GC/FID分析C23至C26的正烷類含量。結果與結論：台北都會區在日間門窗皆開啟狀下的三種不同類型建築物（住家、教室與辦公室）其(I/O)PM2.5在統計上並無顯著的差異，因在室內無細粒徑微粒污染源情況下，室內PM2.5微粒主要源自外滲入。三種不同類型的室內外環境微粒樣本中C23~C26正烷類濃度總和佔PM2.5的質量分率，其室內外比值大於１。即PM2.5微粒中汽機車排放所貢獻的比率室內高於室外，因為微粒相C23~C26正烷類主要來源為汽機車微粒相排放，其粒徑分佈集中於較小的粒徑區間0.1~1μm，故較不易沈降。另外，根據追蹤劑推估住家、教室與辦公室的室內PM2.5微粒大約有50%源自汽機車排放。
  Objectives: The primary objective of this study was to investigate the mass concentrations of outdoor and indoor aerosols in typical Taipei buildings with natural ventilation and no indoor particle sources. Particulate n-alkanes were used as tracers for vehicular emissons to evaluate the contribution of vehicular emissions to the fine particles. Methods: Sampling of fine particles was carried out by two impactors with a cut-off aerodynamic diameter of 2.5µm. The sites selected for sampling included: (1) a third-floor apartment, (2) a third-floor school classroom, and (3) a first-floor office. Sampling was conducted from 8:00 a.m. to 3:30 p.m. in the classroom, from 8:00 a.m. to 5:00 p.m. in the apartment, and in the office from November 1999 to April 2000. After weighing, the samples were extracted with CH2,Cl, and then analyzed for n-alkanes by a gas chromatography/flame ionization detector system Results and Conclusions: The indoor-to-outdoor ratio of PM2.5 concentrations did not differ significant. ly among the three types of buildings during daytime when tile doors and windows were open. These indoor environments had no significant PM2.5sources. Therefore, the fine particles mainly came from outdoors. The regression equation for the mass fractions of C23 to C26 n-alkanes in indoor and outdoor fine particles was y=l.09x+0.02, R2=0.53, where y represented the indoor mass fraction. This implies that the I/O ratio of the mass fractions of C23 to C26 n-alkanes in fine particles was 1.09. The results indicate that particles from vehicular emissions contributed a greater fraction to indoor fine particles than to outdoor fine particles. The results of this study show that vehicular emissions contributed about 50% of indoor aerosols in typical classrooms and residential buildings in Taipei.
• 321 - 330
• 10.6288/TJPH2001-20-04-08