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  • Link 公衛論壇 Public Health Forum
  • 全民健保財務負擔的幾點迷思與困境全民健保財務負擔的幾點迷思與困境
  • 楊志良
    Chin-Liang Yaung

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  • 85 - 86
  • 10.6288/CJPH1999-18-02-01
  • Link 原著 Original Article
  • CAGE酗酒篩檢問卷在台灣基層醫療院所的跨文化效度測試Validity of the CAGE Questionnaire in a Primary Care Setting in Taiwan: A cross-cultural Examination
  • 郭千哲、陳為堅、鄭泰安
    Chian-Jue Kuo, Wei J. Chen, Andrew T.A. Cheng
  • 跨文化差異 ; 酒精傷害性使用 ; 酒精依賴 ; 基層醫療
    Cross-cultural difference ; Harmful use of alcohol ; Alcohol dependence ; Primary care
  • 本研究的目的在於檢驗CAGE酗酒篩檢問卷在台灣地區的跨文化效度。研究樣本(N=198)來自一基層醫療院所門診個案的隨機抽樣。研究者加入與台灣飲酒文化相關,且在跨文化心理語言表達上與原CAGE的”Cut-down''(C1,C2)和”Annoyance''(A1)對等的三題,形成實驗性中文版CAGE(the experimental Chinese CAGE, C-CAGE);該問卷可以用來評估五種計分方法:CAGE, C1A1GE, C1AGE, C2A1GE and C2AE。所有樣本在完成C-CAGE之後均接受臨床醫師的半結構性臨床面談,以獲得酗酒的診斷。和過去西方國家的報告比較,原CAGE在本研究所表現的篩檢效能位於下限值。C2AGE的特異度和整體準確性,顯著優於原CAGE,而C2A1GE則有較好的敏感度和較大的ROC曲線下面積值。以上均顯示從心理語言性的對等考量下,原CAGE仍有進一步改進的空間。
    An easy to use screening instrument for drinking behavior or alcohol-related illness has not been established in Taiwan. The authors examined the cross-cultural validity of the CAGE questionnaire in Chinshan, Taipei County in Taiwan. Study subjects (N=198) were outpatients randomly drawn from the primary care setting in the township. Three psycholinguistic items, equivalent to ”Cut-down” (C1, C2) and ”Annoyance” (A1) of CAGE, thought to be culturally relevant for people in Taiwan, were added to form an experimental Chinese CAGE (C-CAGE). This allowed for tests of five types of scoring combination, CAGE, C1A1GE, C1AGE, C2A1GE and C2AGE. Each subject received a semi-structured clinical interview for diagnosis of alcoholism after he or she completed a C-CAGE questionnaire. The performance of CAGE in our sample was at the lowest limit among those reported in Western countries. Compared to CAGE, C2AGE was superior in robustness for specificity and overall accuracy. C2A1GE tended to be better in sensitivity and performance for the value of the area measured by receiver operating characteristics curve analysis. This indicates that CAGE has room for further improvement under the assumption of psycholinguistic equivalence.
  • 87 - 94
  • 10.6288/CJPH1999-18-02-02
  • Link 原著 Original Article
  • 利用馬可夫鏈模式評估臺灣地區多中心乳癌高危險群篩檢計畫A Markov Chain Model to assess a multi-centered Screening Project for Breast Cancer in Taiwan
  • 嚴明芳、陳秀熙、郭旭崧、賴美淑、 張金堅
    Ming-Fang Yen, Tony Hsiu-Hsi Chen, Hsu-Sung Kuo, Mei-Shu Lai, King-Jen Chang
  • 乳癌篩檢 ; 高危險群 ; 疾病自然史 ; 馬可夫鏈模式
    breast cancer screening ; high risk group ; natural history ; Markov chain model
  • 制定篩檢政策時,常面臨篩檢頻率究竟應該多長的問題。一般而言,疾病的臨床症前可偵測期(PCDP, Preclinical Detectable Phase)愈短、疾病病程愈快者,其篩檢頻率應該要愈頻繁。因此臨床症前期之平均長很重要之角色。本研究自1995年至1996年10月止利用台灣地區12家大型醫院,鎖定出2629名高危險群婦女接受乳癌篩檢,第一年篩檢到的31名病病例之實證資料,推估得婦女乳癌之臨床症前期發生率(preclinical incidence rate)為每年每千人5.7人(0.0057/年),依據這些資料。結果發現婦女乳癌臨床症前期平均長短約為1.90年(95% CI: 1.18-4.86)。根據乳癌之病理分期,第一期者由臨床症前期至臨床期約為8年,第二期及以上者則約為3個月。應用此結果模擬不同篩檢間隔之成效發現篩檢間隔個案(interval cases)之比例隨間隔增加而增加(1年間隔為22.8%;3年間隔為50%),病理分期第二期及以上者比例亦有比(3年間隔為6.45%;1年間隔為3.1%)。配合存活資料可得現行一年之篩檢間隔政策可以降低乳癌死亡率36%(RR=0.64,95% CI=0.32-0.97)。本研究所發展之馬可夫鏈模式(Markov chain model)亦可應用於缺乏篩檢間隔發現個案(interval cases)之其他篩檢計畫評估。
    The optimal screening frequency is highly dependent on the duration of pre-clinical detectable phase (PCDP, also called sojourn time). This parameter is difficult to estimate partly because the progression from PCDP to clinical phase is unobservable and partly because data on interval cases is hardly available from screening project. To tackle these problems, 2629 women of high risk group aged 35 and above identified until October 1996 from 12 large hospitals in Taiwan received their first screening exams, and 31 individuals were detected with breast cancer. Among 575 women who had returned for the second year screening exam, three persons were found with positive results. The progress intervals between stages of the disease were estimated using left-censored and interval censored Markov chain models with a 6-year follow-up simulation. Results showed an annual preclinical incidence rate of 5.7 per 1000 for the high-risk group. The mean sojourn time (MST) was 1.90 years (95% CI=1.18-4.86). The proportion of interval case increased with the screening interval. A similar situation was also observed for the proportion of stage II+. Applying the Swedish Two-County trial experience, the one-year screening regimen would be able to reduce the mortality from breast cancers for 36% (RR=0.64, 95% CI=0.32-0.97). The breast cancer screening policy for high risk group initiated by department of health is justified by a high pre-clinical incidence rate estimated in this study. According to the estimated MST and the relationship between screening interval and the proportion of both interval case and mortality reduction, it is advisable that the screening interval for this high-risk group be no longer than two years. Finally, a left-censored and interval-censored Markov chain developed in this study could be applied to other screening projects short of data on interval cases.
  • 95 - 104
  • 10.6288/CJPH1999-18-02-03
  • Link 原著 Original Article
  • 父母親社經狀態與低出生體重嬰兒、早産兒、及生長遲滯嬰兒之相關性探討Parental Socioeconomic Status and Low Birthweight, Preterm Delivery, and Small for Gestational Age in Taiwan
  • 陳保中、 Patricia E Doyle、白璐、王榮德
    Pau-Chung Chen, Patricia E Doyle, Lu Pai, Jung-Der Wang
  • 教育程度 ; 社經狀態 ; 低出生體重嬰兒 ; 早兒 ; 生長遲滯嬰兒
    education ; socioeconomic status ; low birthweight ; preterm delivery ; small for gestational age
  • 本研究的目的是以嬰兒父母親教育程度、職業、及其家庭收入為社經指標探討與低出生體重嬰兒、早?兒、及生長遲滯嬰兒之關系。1984至1987年間聘用三位經訓練的訪視員,針對在台北市立婦幼醫學?前檢查的所有懷孕六個月以上孕婦進行訪問,使用結構化問卷以蒐集孕婦本人及其配偶的詳細背景及有關暴露資料;研究期間亦進行暴露資料的?確度評估。有關出生結果的資料則於嬰兒出生後,由一位研究助理閱覽孕婦及新生兒的病歷進行摘錄。總共使用12,273單胞胎少?兒進行出生結果的分析,包括低出生體重嬰兒、早?兒、及生長遲滯嬰兒,最後使用多項logistic迴歸進行分析。母親教育程度?小學或以下的婦女出生生長遲滯嬰兒的危險性為大專以上程度婦女的兩倍高(相對危險性=1.80,95%依賴區間=1.26-2.56),而父親教育程度為小學或以下者亦有較高低出生體重嬰兒的危險性(相對危險性=1.68,95%依賴區間=1.02-2.77);但父母親職業與家庭收入對異常出生結果並非明顯的預測因子。因此在探討台灣地區異常出生結果的影響時父母親教育程度是一較好的社經狀態指標。
    The associations between socioeconomic factors and reproductive health in Taiwan were measured by examining the relationship between birth outcomes versus parental education, occupation and family income. Women at the six-month pregnancy and receiving prenatal care at the Taipei Municipal Maternal and Child Hospital (TMMCH) during 1984-87 were enrolled. Three trained interviewers, using a structured questionnaire, obtained detailed information of subjects and their husbands. One medical assistant abstracted information on birth outcomes from medical records after the delivery of newborns. A total of 12,273 singleton live births in this ethnically homogeneous Chinese population were analyzed. Birth outcome variables included low birth weight (LBW), smallness for gestational age (SGA), and preterm delivery (PTD). Potential risk factors associated with these outcomes were investigated using multiple logistic regression models. Women with less education were associated with approximately twice the odds of having a SGA infant (RR=1.80, 95% CI=1.26-2.59) compared to women with a higher education. Fathers with low levels of education also had a higher risk of having a LBW infant (RR=1.68, 95% CI=1.02-2.77). Parental occupation and family income were not significant predictors for adverse birth outcomes. We conclude that education is a more favorable socioeconomic indicator in Taiwan for examining birth outcome than is occupation or family income.
  • 105 - 115
  • 10.6288/CJPH1999-18-02-04
  • Link 原著 Original Article
  • 全民健保兒童健檢服務施行初期評估A Preliminary Report of Children's Physical Examinations in the National Health Insurance
  • 黃月桂、林勤豐
    Yueh-Guey Huang, Chin-Feng Lin
  • 兒童健康檢查 ; 利用率 ; 滿意度
    children's physical exam ; utilization rate ; satisfaction
  • 為了解全民健保兒童健檢服務的使用情形,本研究於1996年5月至7月間使用結構性問卷,依醫療院所之評鑑等級,比例隨機抽出醫療院所訪問5歲以下受檢兒童之家長,共訪問863位,其內容包含社經地位、小孩看診次數及滿意度。另外並參酌受檢「兒童健康手冊」之紀錄資料,以了解全民健康保險兒童健檢的服務內容。在有效的837份問卷中,有63%的小孩接受1-2次的服務,平均看診時間為5-10分鍾,約有60%的父母並無接受衛生教育。但滿意度在5分左右(總分7分)。父親學歷越高者,對兒童健檢服務滿意度之要求越高。對於兒童健檢之提供之選擇主要以方便性和熟悉度為考量。本次研究發現,兒童健檢的利用率偏低,滿意度方面尚可。故中央健保局在兒童預防保健政策改善方面應著重於父母和提供者之間的溝通。
    A survey of parental satisfaction was conducted to determine also frequency and factors associated with the use of Children's Physical Examination (CPE), National Health Insurance Program for children under the age of five years. Medical facilities with pediatric care were stratified according to accreditation level and randomly selected into the sample pool. Parents (n=863) were interviewed at the waiting areas of pediatric clinics by public health students. The interview covered parents' social demographic status, number of children's visits at the clinics and satisfaction of care provided. The CPE information specified in ”children's health handbook” was also extracted for the analyses of examination domains. Data analysis was based on questionnaires with complete information (n=837). Most children (63%) received CPE service for once or twice, compared to the recommended 6 times by the age of five. The average time spent in each service by a physician was 5-10 minutes. Approximately 60% of the parents received no health education. However, the average satisfaction score was 5 in a scale of 7. The education level of fathers was negatively correlated with the satisfaction score. Convenience and familiarity with a specific clinic were considered in the selection of CPE providers. Besides, many clinicians complained about the insufficient reimbursement. In conclusion, the CPE utilization rates were lower than the designated estimates, even though parental satisfaction level was above average. Effective strategies that focus on the promotion of CPE should be communicated to parents and care providers.
  • 116 - 122
  • 10.6288/CJPH1999-18-02-05
  • Link 原著 Original Article
  • 全民健保對各科醫師消長影響之初探The Impact of NHI Payment System on Manpower among Medical Specialties in Taiwan
  • 張友珊、楊志良
    Yu-Shan Chang, Chih-Liang Yaung
  • 健康保險 ; 支付制度 ; 醫事人力 ; 專科
    Health insurance ; payment ; medical manpower ; medical specialty
  • 全民健保實施後,不少醫界人士及醫務管理人員反應,各科間住院醫師的招收情形有明顯之變化。本研究藉由蒐集健保實施前、後各科醫師人力之相關資料,與健保實施後各科費用申報情形進行比較,以探討費用申報金額高低對醫師選擇執業科別之影響。研究結果顯示,健保各科申報費用、件數與醫學中心各科住院醫師申請人數與錄取人數之消長,及設置診所家數之變化相關性最高,各專科醫師人數之消長則次之;各科間醫師數的增長又以復健科、家庭醫學科、小兒科、眼科、耳鼻喉科、皮膚科尤為明顯。根據研究結果,健保對各科醫師支付金額之高低,具有引導醫學生對日後選擇行醫科別及設置診所科別之作用。雖然財務誘因並非影響各科醫師人數轉移的唯一因素,但其所產生之衝擊值得注意。為免長期以往影響醫療生態之正常發展,建議有關單位於調整支付標準或改變支付制度時,需更加重視科別間平衡發展之考量。
    Since the implementation of National Health Insurance (NHI) program in 1995, hospital executives and medical professional groups have constantly complained about the dilemma in recruiting physicians for certain specialties. To confirm this unbalanced supply in medical manpower, we reviewed and analyzed data on the patterns of demand and training in medical specialties and the growth of practitioners before and after launching NHI. Changes, in numbers of practitioners and health care institutions and reimbursement claims between 1992 and 1997, were compared by specialty to determine whether the NHI payment policy has exerted influence on medical graduates in their career decision. The results showed significant variations amongst all specialties in both monetary reimbursement and number of claims filed to NHI. A significant correlation between the payment policy and the number of resident applications, by specialty, among medical centers was observed as well. Newly established clinics were thus varied by specific specialty. Compared with the number of clinics available by specialty in 1992, the largest growth in specialty until 1997 was Rehabilitation (93.3%), followed by Family Medicine (22.1%), Pediatrics, Ophthalmology, ENT and Dermatology. There was only 1.0% of growth in surgery. The NHI payment schedule did affect both medical graduates' career decisions and the growth of clinics in selected specialties. Although financial incentive was not the only factor influencing the medical manpower structure among all specialties, its impact can not be overlooked. The results suggest that the NHI should carefully review and consider a balanced development across all specialties before any change or reform of the payment system can be undertaken.
  • 123 - 137
  • 10.6288/CJPH1999-18-02-06
  • Link 原著 Original Article
  • 民眾就醫選擇之研究-分析層級程序法之應用The Aplication of Analytic Hierarchy Process in the Selection of Hospital
  • 王乃弘
    Nai-Phon Wang
  • 分析層級程序法 ; 醫院選擇 ; 成偶比對
    analytic hierarchy process ; hospital choice ; pair-wise comparison
  • 以本研究以「分析層級程序法」評估民眾就醫時選擇要素的相對重要性及選擇決策之過程。本研究於中部海線6鄉鎮進行訪視,以930份資料進行受訪者對選擇要素重要性之探討,再分析民眾對醫院屬性(選擇要素)之相對偏好程度,綜合運算出醫院總偏好值-選擇決策。本研究結果發現,選擇要素重要性之優先順序依序為:醫德醫術、醫療儀器、服務態度、環境設備、醫院位置、等候時間及親友醫師轉介。研究結果同時發現用成偶比對法比用單項權數法所得之選擇要素相對重要值差距加大,可見「醫德醫術」及「醫療儀器」是民眾就醫時之決定性選擇要素。民眾對醫院的總偏好值之優先順序依序為:C(醫學中心)、B(區域)醫院工、A(區域)醫院,但民眾對醫學中心的七項屬性偏好值並非全部最高;例如「等候時間、醫院位置」C醫院較A,B醫院低,而B醫院除「等候時間」外其餘屬性均高於A醫院。三家醫院各具其特色;C醫院的「醫德醫術、醫療儀器」、A醫院的「服務態度」、及B醫院的「醫德醫術、服務態度」。
    By means of the analytic hierarchy process (AHP), this study assessed the relative importance of the factors affecting consumers' selection of hospital service preference, and explored their decision-making process. Interviews in person were performed in 1997 with 1212 men and women aged 18 and above randomly selected from six coastal towns in central Taiwan. Respondents were asked to recall and evaluate previous health care encounters at three local hospitals: hospital A has been characterized by its marketing strategy; hospital B by its long history and medical ethics; and hospital C, a medical center, the largest of all. With 930 valid questionnaires the results showed that factors affected consumers' selection of hospitals were in the priority order: (1) medical care quality, (2) medical equipment, (3) interpersonal relationship-service attitude, (4) environment and facilities, (5) hospital location, (6) waiting time and (7) others' recommendations. The pair-wise comparison, instead of the monadic point rating method, was conducted to enhance the contrast in importance among selection criteria of hospital preference. Medical care quality and medical equipment were thus found the most significant factors. Overall, the respondents ranked the highest preference to the medical center C followed by district hospital B and district hospital A. However, medical center C wasn't rated the highest on all seven factors. For instance, it was ranked lower than hospital A and hospital B on ”waiting time” and ”location”. Hospital B was rated higher than hospital A on all factors except ”waiting time”. In general, the medical center C was selected for its ”medical quality” and ”medical equipment”. Hospital A attracted consumers with ”service attitude”, whereas ”medical quality” and ”service attitude” were regarded as the features of hospital B.
  • 138 - 151
  • 10.6288/CJPH1999-18-02-07
  • Link 原著 Original Article
  • 醫師如何看待醫院的企業化經營管理趨勢How Do Physicians Regard Managerial Intervention in Hospitals?
  • 丁志音
    Chih-Yin Lew-Ting
  • 管理 ; 醫師 ; 專業性 ; 商業化 ; 醫病關係
    Managerial interventions ; physicians ; professionalism ; commercialization ; patient-physician relationship
  • 管理之應用於醫院及其他醫療機構已成一種世界趨勢,台灣也不例外。本研究試圖探索1702名醫師對此一趨勢的態度及批判。研究資料來自於一項對全省執業西醫師的郵寄問卷調查。以質性方法對其中之698名醫師的書面意見分析後發現:(1)經濟誘因,如效率、成本效益、善用資源及提昇服務品質等,是對企業化經營管理予以正面評價之醫師最關注之處,(2)商業化、缺乏人性及情感、專業自主權的喪失、以及醫病關係之惡化乃持負面價值之醫師最詬病之處,(3)不過,另有一些持肯定看法的醫師提出兩類論點,一為譴責大型企業與政府;另一類則恰好相反,對此趨勢抱著悲觀的、宿命的看法,認為此趨勢只不過反映了大環境的變遷罷了,是「無法避免」的。本研究結果顯示,在企業化經營管理之策略下,醫師之調適不佳。進一步探索衛生專業人員對管理的反應,將有助於在目前的健康照護環境中造就正向的文化與互動關係。
    The application of management interventions in hospitals and other health care settings is a worldwide phenomenon, and Taiwan is no exception. This study explored 1702 physicians' perceptions of and criticism towards current managerial strategies in hospitals in Taiwan. Data for the analysis came from a nation-wide mail survey of active physicians. Qualitative analysis of the comments from 698 out of 1702 physicians revealed that: (1) economic appeal-efficiency and cost-benefit in the use of resources and therefore improving quality of care-is the highest concern among physicians who held a positive stance towards managerial intervention, (2) commercialization, lack of humanitarianism and compassion, erosion of professional autonomy, and deterioration of the physician-patient relationship were adverse effects which were of great concern to physicians who held a negative stance toward managerial intervention, (3) among a subgroup that professed pro-management attitudes, two types of comments were disclosed: one radically condemned the large corporations and the government, and the other, somewhat fatalistic and pessimistic in tone, considered that managerial intervention in health care reflects a global trend of social change and is thus ”inevitable.” The results of this study indicate that most physicians are not well adjusted to the corporatized health care system. Further exploration of the health professionals' responses to a corporate managerial techniques is instructive to construct a positive culture and improve worksite interaction in current health care community.
  • 152 - 166
  • 10.6288/CJPH1999-18-02-08
  • Link 原著 Original Article
  • 台北都會區大氣氣膠所含正烷類之特性Gaseous and Particulate n-alkanes in the Taipei Aerosol
  • 林紫嵐、王秋森
    Suzan Lin, Chiu-Sen Wang
  • 大氣中懸浮微粒 ; 正烷類 ; 整體特性 ; 氣相/微粒相分布
    ambient aerosol ; n-alkanes ; bulk characteristics ; vapor/particle partition
  • 本研究重點在於探討台北都會區大氣中氣相及微粒相C15-C36正烷類之濃度分布形態。由於正烷類依不同污染源而呈現不同的整體特性,因此可利用其整體特性探討大氣有機成分組成的可能來源與季節性變異。本研究使用Model PS-1 PUF採樣器,以石英纖維濾紙收集總懸浮微粒,並在濾紙下游以PUF及XAD-2吸附氣相中的半揮發性有機成分。從1996年六月起至1997年三月止,每季進行五至六天的密集採樣。每一樣本採集24小時。採樣地點為環保署空氣品質監測站中山測站。採得樣本用CH2Cl2溶劑在索氏萃取器中進行萃取後,以GC/FID做定性及定量分析。研究結果顯示,採樣期間台北都會區大氣中微粒相與氣相的正烷類總濃度範圍分別?9.4~236.89ng/立方公尺地0.27~5.38μg/立方公尺。微粒相正烷類的總濃度隨季節而有顯著變化,以秋季為最低。正烷類之氣相/微粒相濃度比隨氣溫及碳數而改變。根據微粒排放源的追蹤指標,台北都會區四季的氣懸微粒樣本顯示有大量來自汽機車排放的化石燃料燃燒廢氣的人為衝擊。
    The objective of this study is to determine the bulk characteristics of n-alkanes and their vapor/particle partition in the Taipei aerosol. We focused the study on n-alkanes which are semivolatile, nonpolar and stable in chemical behavior, and exist at relatively high concentrations in urban aerosols. Because the bulk characteristics of n-alkanes are origin-specific, the n-alkane profile has been used to identify the origin and to explain seasonal variations in atmospheric organic aerosols. We used a Model PS-1 PUF Sampler (Graseby GMW, Village of Cleves, OH, USA) to collect samples of total suspended particulate and n-alkanes in the gas phase. Particles were collected on quartz fiber filters. Gaseous n-alkanes were adsorbed by PUF and XAD-2 in a cartridge placed downstream of the filter holder in the sampler. In each of the four seasons between July 1996 and March 1997, we conducted an intensive sampling operation lasting 5 to 6 days. Each sample was collected over 24 hours. The sampling site was located in the vicinity of the Taiwan Environmental Protection Administration Chung Shan Monitoring Station. The sample were extracted by CH2CI2 in a Soxhlet apparatus and then analyzed for n-alkanes by gas chromatograph/flame ionization detector (GC/FID). The results of analyses for ambient samples show that the concentration of n-alkanes in the total suspended particulate and in the gas phase ranged from 9.4~236.8 ng/m^3 and 0.27~5.38 µg/m^3, respectively. The concentration of particulate n-alkanes varied with the season, with the lowest concentration appearing in the autumn. The vapor-to-particle ratio of n-alkanes depends on the ambient temperature and the carbon number. The results for distribution profile and other bulk characteristics of n-alkanes in the Taipei aerosol indicate that they mainly came from vehicular emissions.
  • 167 - 175
  • 10.6288/CJPH1999-18-02-09