18卷3期

• Link 公衛論壇 Public Health Forum
• 學術論文發表過程投稿者與評讀者間互動之專業素養要求學術論文發表過程投稿者與評讀者間互動之專業素養要求
• 戴政
  Johe Jen Tai
• 無
  none
• 無
  none
• 177 - 180
• 10.6288/CJPH1999-18-03-01

• Link 原著 Original Article
• 全民健保實施陰道分娩論病例計酬制對醫療資源使用方式的影響－以某財團法人醫學中心為例The Impact of Case Payment System on the Utilization of Vaginal Delivery under National Health Insurance in Taiwan-using Data in a non-for-profit Medical Center
• 莊逸洲、陳怡如、史麗珠、陳理
  Yi-Chou Chuang, Jennifer I-Ru Chen, Lai-Chu See, Lee Chen
• 陰道分娩 ； 論病例計酬制 ； 全民健保
  Vaginal Delivery ; Case Payment ; National Health Insurance
• 目標：文獻指出，將醫療支付制度由論量計酬(Fee-for-Service)改為論病例計酬(Case Payment)可有效控制醫療費用上漲。台灣於1995年3月實施全民健保，同年即對陰道分娩及剖腹?採行論病例計酬制度。本研究希望藉由分析費用消長，了解台灣實施此制度後是否真能節省醫療資源。方法：本研究以某醫學中心為例，採用健保實施前4,234個論量計酬之陰道分娩案例及健保實施論病例計酬制後共4,480個案例為研究對象，分析探討健保實施此制度前後一年醫療資源使用方式的變化。結果：論病例計酬制度實施後，陰道分娩平均總醫療費用和住院日均分別顯著降低，且可能由於中央健康保險局明確規範標準住院日數為三天，促使論病例計酬制產婦之平均住院日比前者更趨近三天。另外，我們懷疑這個新制度可能鼓勵醫師，為了讓產婦儘早出院而更改開藥行為，致藥品費增加約21%。檢驗、檢查費用的下降則似乎是趨向門診化的結果。結論：1論病例計酬付費制度可能有效抑制醫療費用上漲；2制度中明確訂定合理的規範，可以誘導醫療提供者改變其行為，達到制度預期之目標；3設定基本診療程序項目，可促使醫療照護維持一定品質，不致因支付制度的改變而受影響。
  Objectives: It has been demonstrated in literature that Case Payment System (CPS) could control the growth of health expenditures effectively in comparing with Fee-for-service (FFS). Taiwan National Health Insurance (NHI), implemented in March 1995; therefore soon dedicated the adaptation of CPS for vaginal delivery and cesarean section reimbursement in the same year. We want to investigate if it was indeed the case in Taiwan Methods: This study compared the changes in resource utilization at a medical center hospital from January to December 1994 and from May 1995 to April 1996. There were 4, 234 vaginal deliveries categorized as the FFS group, prior to the NHI implementation, and 4, 480 deliveries as the CPS group after the CPS implementation. Results: In the CPS group, the average medical expenditure and average length of maternal postpartum stay (MPS) decreased 6.4% and 12%, respectively compared to the FFS group. A reduction of MPS from 3.4 days to slightly over 3 days was possibly in response to MPS standards set by the NHI CPS program. However, there was a 21% increase in medication expenditures during maternal stay in the hospital. We suspect that this new system modified obstetricians' prescribing patterns in order to discharge patients early. Clinical exam and lab test expenditures also decreased; these expenses seemed to be shifted to outpatient care prior to admission. Conclusions: CPS may indeed contain medical expenditure. Furthermore, it is possible to induce physicians' practice behavior if the policy is precise and reasonable. However, we believe that the NHI CPS program has to establish minimum requirements standard for ensuring service quality and avoiding the possible behavior deviation of physicians in response to the new reimbursement scheme.
• 181 - 188
• 10.6288/CJPH1999-18-03-02

• Link 原著 Original Article
• 影響子女照顧失能父母意願之因子Factors Affecting Adult Children's Willingness to Care for Disable Parents
• 簡雅芬、吳淑瓊
  Ya-Feng Chien, Shwu-Chong Wu
• 家庭照護；照顧意願；子女；父母；代間連結
  Family care ; Willingness to care ; adult children ; parents ; intergenerational solidarity
• 目標：本研究主要目的係瞭解子女照顧失能父母的意願，並進一步探討此一照顧意願的重要影響因子。方法：從設籍台北縣市四個社區65歲以上老人隨機抽取2192位老人進行訪問，對每位完訪的1911位老人的子女中，再隨機抽取一人為研究對象，結果共抽得1661位老人子女樣本，完成訪問調查1152人。結果：調查結果指出895%的成年子女在父母失能時願意提供父母個人照護及整理家務等服務。由對數複迴歸分析結果發現，在控制子女的特質、父母的特質、家庭照護資源等變項下，代間連結變項中的代間交換及孝道觀念顯著影響子女的照顧意願。當父母偶爾提供工具性幫忙的時候，子女照顧父母的意願較高(OR=1.78)；子女的孝道觀念越強，提供父母照顧的意願越高(OR=1.25)。除了代間連結變項外，與父母同住、有兄弟姊妹的照護支持、父母的身體功能較好時，子女的照顧意願較高(OR=1.83，3.07，0.96)。結論：研究結果發現大部分子女願意將父母留在家中，由自己提供家庭照護。而孝道觀念、代間交換、居住安排、父母的身體功能及家庭照護資源均是影響子女照顧意願的重要因子，此為政府政策宜介入之所在。
  To examine the factors which affect adult children's willingness to care for their disabled parents. Methods: A random sample of adults aged 65 and over was selected from 4 communities. Subsequently, an adult child of each adult aged 65 and over was randomly selected, and interviewed on the phone. Altogether 69.4% of adult children completed the interview. Results: Of those adult children 89.5% interviewed, expressed that they were willing to look after their disabled parents and provide them with personal care and instrumental daily help. After controlling for adult children's sociodemographic characteristics, the elder parents' sociodemographic characteristics and family care resources, the results of multiple logistic regression showed that intergenerational solidarity significantly affected adult children's willingness to care for their parents. We also found that children's willingness was higher when their parents had provided them with instrumental assistance (OR=1.78). Adult children's willingness to care was greater when their filial piety was stronger (OR=1.25). When adult children lived with their parents, or could share the care duties with brothers or sisters, or when the elder parents were healthy, adult children's willingness was stronger (OR=1.83, 3.07, 0.96 respectively). Conclusions: Most adult children expressed that they were willing to look after their disabled parents and provide them with personal care and instrumental daily help. Filial piety, intergenerational exchange, living arrangements, health status of parents, and support resources from brothers and sisters affected adult children's willingness to provide care.
• 189 - 198
• 10.6288/CJPH1999-18-03-03

• Link 原著 Original Article
• 台灣地區成年人吸菸盛行率及其與教育和職業之關係：菸害防制法實施前的狀況(1993~1996)Adult Smoking Prevalence and Its Relationships with Education and Occupation in Taiwan: Conditions before the Implementation of the Tobacco Hazards Control Act (1993~1996)
• 潘怜燕、李蘭
  Ling-Yen Pan, Lee-Lan Yen
• 成人 ； 吸菸 ； 盛行率 ； 教育 ； 職業
  adult ; smoking ; prevalence ; education ; occupation
• 目標：吸菸是許多導致過早死亡的原因中能事先予以預防的。群體的吸菸盛行率是反映菸害程度與鑑別高危險群的重要指標。本研究目的在呈現台灣地區菸害防制法實施前的成人吸菸盛行狀況，並探討教育及職業與吸菸的關係。方法：自1993年，1994年及1996年分別完成的全台灣地區抽樣調查資料檔，各挑出年齡、性別、教育程度、職業等經與吸菸行為等五個變項進行統計分析。結果：不論年度，成年男性之吸菸率以25-44歲、國中程度者及技術性工人較高。成年女性吸菸率則是65歲以上較高。經年齡標準化處理後，1993年，1994年及19餡年成年男性之吸菸率分別為5007%、5159%和5189%；女性則分別為282%、635%和463%。控制性別與年齡的影響後，有吸菸的可能性為大專及以上教育程度者顯著地低於小學及以下程度者；技術性工人顯著地高於專業或行政人員。在戒菸的可能性方面，則為大專及以上程度者顯著地高於小學及以下程度者；技術性工人和半技術工人及無業者則顯著地低於專業或行政人員。結論：為監測國人吸菸盛行狀況，定期舉辦且採統一定義的盛行率調查是必須的。教育程度及職業等經與吸菸行為的顯著關係，可供規劃菸害防制介入策略與界定高危險群的參考。
  Objectives: Smoking has been recognized as the single most important preventable causes of premature death. Prevalence of tobacco use in a population is an important measure of the magnitude of smoking problem. The purpose of this study is to understand Taiwanese adults' smoking rates and the associated risk factors for smoking before the implementation of the Tobacco Hazards Control Act in 1997. Methods: Data were obtained from three nationwide surveys. Variables including age, sex, education, occupation, and smoking behavior were selected for analysis. Results: Major findings were: (1) For male adults, the highest current smoking rates were found in the subgroups of those aged 25-44 years, technical workers and those with an educational level of junior high school. For female adults, the highest current smoking rate was found in those 65 years and older. The age-adjusted smoking rates for males who currently smoke in 1993, 1994, and 1996 were 50.07%, 51.59%, and 51.89%, respectively. The age-adjusted smoking rates for females who currently smoke for the same years were 2.82%, 6.35% and 4.63%, respectively. (2)After controlling for sex and age, the smoking rate for individuals who currently smoke and for those who have ever smoked were significantly lower for the subgroup of college graduates than for the subgroup of individuals with only an elementary education. Compared to professionals, technical workers had higher smoking rates. (3) Smokers with higher educational levels and those working as professionals had the highest cessation rates. Conclusions: In order to monitor the smoking prevalence in Taiwan, it is imperative to establish a surveillance system. Since education and occupation have been proved to play important roles, researchers and practitioners should use these findings to identify and develop effective strategies for high risk groups.
• 199 - 208
• 10.6288/CJPH1999-18-03-04

• Link 原著 Original Article
• 中年婦女血中荷爾蒙濃度與停經狀態－橫斷式研究初探Hormone Levels and Menopausal Status in Middle Aged Women: A cross-sectional Study
• 張珏、吳佩樺、 張菊惠、蔡宗仁、徐黎玲、李旻貞
  Chuen Chang, Pei-Hua Wu, Chu-Hui Chang, Tzong-Jen Tsai, Li-Ling Hsu, Ming-Jean Lee
• 卵泡刺激素 ； 雄二醇 ； 停經 ； 荷爾蒙補充療法 ； 健康行為
  FSH ; E2 ; Menopause ; HRT ; Health Behavior
• 目標：欲瞭解醫界建議以荷爾蒙補充療法處理婦女更年期，其所採用的指標與影響荷爾蒙改變的因素。方法：對753位參與某健檢中心健康檢查婦女進行檢測，測量其自述停經不適，以及生化檢測其血中荷爾蒙卵泡刺激灘二作為分析改變血中荷爾蒙值面經婦女其FSH皆大於40mIU/ml，並以停經階段及抽煙、運動等健康行為FSH及E2間相關不大，停經後期與手術停ml高。影響FSH及E2的因素，最大的否使用荷爾蒙、BM-及吸菸的影響，經標準相符，E2介於41-85pd/ml間，較一般標準20pg/ml高。影響FSH及E2的因素，最大的皆是年齡（解釋力約39%及22%）：FSH略有受到經期改變、是否使用荷爾蒙、BMI及吸菸的影響，而E2受年齡與經期影響，對未使用任何藥物婦女則除了年齡與經期因素外，另有BMI與運動的因素。結論：一般婦女不論何種停經階段，其FSH與E2變異性仍大；停經不適與FSH及E2間相關不大。此外對醫界常以症狀作為給藥標準，是否客觀？但若用現運動或不吸菸等保健行?對FSH的維持有部分影響，在公共衛生立場也建議對更年期婦女增加健康促進的行?
  Objectives: Due to the interest in the effectiveness and appropriateness of hormone replacement therapy (HRT) for menopausal women in Taiwan, we investigated the hormone level of follicle stimulating hormone (FSH) and estradiol (E2) for their value and affecting variables. Method: 753 women prior, during, and post to their menopausal periods who checked in at a clinic for routine wellness exams were invited to participate in this study. Measurements included serum level of FSH and E2 and self-reported questionnaires on physical and mental wellness as well as those health behaviors. Results: There were no significant association between the subjects physical and mental discomfort and their FSH and E2 levels. The correlation between FSH and sexual discomfort was significant, but the correlation coefficients were small. The average FSH level for post-menopause women was greater than 40 m 1U/mi. The range of E2 level were 41-85 pg/ml for subjects without or with medication, two times greater than the standard 20 pg/ml, level used to determine need for HRT supplementation. A multivariable regression with the inclusion of age, menopausal status, BMI, use of hormone, and smoking status in the model explained approximately 50% of FSH level for women. Among these variables, age alone explained about 39% of the FSH level, and 22% of the E2 level. Relatively, the menopausal status contribution was minor. Conclusions: hormone level does not explain the menopausal discomfort for women. The E2 level may not be an appropriate indicator for hormonal therapy prescription. Furthermore, how to find objective indicators and attention on health behaviors affecting the level of FSH should be studied in the future too.
• 209 - 221
• 10.6288/CJPH1999-18-03-05

• Link 原著 Original Article
• 某醫學中心職業病環境病門診1987至1995年間之個案分析Analysis of Outpatient Visits at a University Hospital Occupational and Environmental Clinic between 1987 and 1995
• 鄭尊仁、王文正、王榮德
  Tsun-Jen Cheng, Wen-Cheng Wang, Jung-Der Wang
• 環境病 ； 職業病 ； 診斷
  Environmental and occupational diseases ; diagnosis criteria
• 目標：本研究利用某醫學中心環境與職業病門診個案的資料，進行疾病及行業別等特性分析，並對有助於診斷職業病的因素加以探討。方法：研究對象是1987至1995年間到台灣大學醫學院附設醫院環境及職業病門診就醫的病人，利用修正過的Newman問卷表詳細調查每一位病人的病史，包括個人基本資料、過去醫療史和詳細工作史等。職業病的診斷則依據疾病証據、暴露証據、時序性、一致性及排除其它因素等五原則；符合五原則者為職業或環境相關之疾病，符合前四條件者則很可能是環境病或職業病。結果：分析顯示1987至1995年間共673位新病人，其中192人確定是或很可能是職業或環境相關疾病，以呼吸性疾病最多，其次是外傷、鉛中毒及皮膚疾病，而主要危害物為有機化學物。以邏輯式迴歸分析發現診斷為職業病具顯著性的相關因子為工作環境中有其它同事志有相同症狀（勝算比＝313）、醫師轉介（勝算比＝176），工作中使用口罩（勝算比＝1.34），抽菸（勝算比＝1.20）和年齡（勝算比＝1.02）結論：本研究有助於了解臺灣職業病概況及提供職業病診斷之參考。由於研究對象限於一醫學中心門診病人，應進一步分析其他醫學中心職業病門診資料或全國性通報系統，使臺灣職業病現狀更清楚。
  Objectives: This study was designed to investigate the characteristics of environment and occupational seas (EODs) in Taiwan. The factors associated with the characteristics of a diagnosis for EOD were so determined. Methods: A modified Newman questionnaire was administered to outpatients seen in the environmental and occupation medicine clinic at a medical center in northern Taiwan between 1987 and 1995 to obtain personal data and a detailed occupation and medic history. Evidence of disease, evidence of exposure, temporality, consistency, and the exclusion of other common disease causes were used as criteria for making an EOD diagnosis Patients with the first four criteria were classified as probably having an EOD. Those with as five criteria were classified as having an EOD. Results: Among 673 patients registered and reviewed between 1987 and 1995, 192 individuals were diagnosed as having or probably having an EOD. Respiratory tract diseases accounted for most EOD, followed by injuries, lead poisoning and skin diseases. Chemicals were the agents most commonly causing EOD. Logistic regression analysis also showed that significant factors leading to EOD diagnoses were coworkers having similar symptoms (odds ratio [OR] =3.13), referrals by other physicians (OR=1.76), using a mask (OR=1.34), smoking (OR=1.20) and age (OR=1.02). Conclusions: The results provide some insight in understanding the current characteristics of EOD in Taiwan and some clues in reaching a diagnosis of EOD. Because data were collected from only one medic center, further study to include more data from other medical centers and a national surveillance system may show the whole picture of EOD in Taiwan.
• 222 - 227
• 10.6288/CJPH1999-18-03-06

• Link 原著 Original Article
• 青少女懷孕發生低出生體重與早產的危險性探討Increased Risk for Low Birthweight and Preterm Birth in Teenage Pregnancy
• 傳瓊瑤、陸振翮、吳欣玫、王銘賢、陳淑貞
  Chong-Yau Fu, Jen-Her Lu, Hsin-Mei Wu, Ming-Shang Wang, Shu-Jen Chen
• 青少女懷孕；低出生體重；早產
  teenage pregnancy ; low birthweight ; preterm birth
• 目標：近年來青少年社會問題層出不窮：暴力、雛妓、飆車、九月墮胎潮等，其中九月墮胎潮更是項隱憂。根據衛生署的統計資料，19歲以下的青少女生育，約5%左右；此部份不適育青少女，懷孕結果是否更不良，將是本研究探討的主題。方法：本研究的資料基本來源是衛生署民國82年至84年的電腦化出生通報登錄。以20-24歲為參考組，12-17、18-19歲為青少女；資料所屬醫院涵蓋榮總、門諾及馬偕；社經變項資料則另行調閱病歷，補抄錄。研究的選取條件是：懷孕週數24週以上、出生體重大於500公克、單胞胎且第一胎。資料經過整理、核對，最後得研究樣本數共約871人；12-19歲有296人，20-24歲（參考組）有575人。採用的統計方法有：勝算比（調整）的95%信賴區間(CI)及邏輯斯迴歸模式。結果：邏輯斯迴歸分析顯示：(1)低出生體重模式（共變項：教育程度與地區別），12-17、18-19歲孕婦的勝算是20-24歲的2.63倍(95% CI:1.07-6.49)、2.28倍(95% CI: 12-4.34);(2)早產模式（共變項：產檢與性別）12-17、18-19歲孕婦的勝算是20-24歲的1.88倍(95% CI: 0.89-3.95)、2、22倍(95% CI: 1.38~3.56)。結論：適當控制社經變項後，12-17、18-19歲青少女懷孕發生低出生體重與早產的危險性明顯高於20-24歲。因此，年齡是低出生體重與早產發生的重要因素，12-19歲是不適育的人生階段。
  Objectives: Teenage pregnancies have been and continue to be a social problem. From official reports, about 5% of births belong to teenage (<19 years old) mothers. This study compares the pregnancy results for teenage mothers with 20-24 year-old pregnant mothers Methods: ”Computerized Medical Birth Registry, 1993-1995” was the main source of data. Data was gathered from hospitals including Veterans General Hospital, Memorial Hospital and Mackay Memorial Hospital. Meanwhile, the social economic variables were collected from the patients records at these three hospitals. The maternal ages of 12-17, 18-19 and 20-24 years were selected and all subjects met the following criteria: gestational age above 24 weeks, birthweight above 500g, singleton and the first parity. At total 871 birthweight included: 76 birthweight maternal age of 12-17 years, 220 births with maternal age of 18-19 years and 575 births with maternal age of 20-24 years. The statistical methods included 95% C.I. for (adjusted) odds ratio and logistic regression model. Results: When compared with subjects with maternal age of 20-24 years, the logistic regression modelsshowed that: maternal age of 12-17, 18-19 years had odds ratio 2.63 (95% Cl: 1.07-6.49), 2.28 (95% CI: 1.2-4.34) respectively for low birthweight while both education and location covariates included; maternal age of 12-17, 18-19 years had odds ratio 1.88 (95% CI: 0.89-3.95), 2.22 (95% CI: 1.38-3.56) respectively for preterm birth while both prenatal care and gender covariates included. Conclusions: Controlling for social-economic variables, teenage pregnancies had significantly higher risks for low birthweight or preterm births than mother 20-24 years old. Hence, very young age is an important risk factor for low birthweight or preterm birth.
• 228 - 234
• 10.6288/CJPH1999-18-03-07

• Link  
• 全民健保學術資料庫簡介全民健保學術資料庫簡介
• 鄭守夏
  Shou-Hsia Cheng
• 無
  none
• 無
  none
• 235 - 236
• 10.6288/CJPH1999-18-03-08