18卷4期

• Link 公衛論壇 Public Health Forum
• 從戴奥辛毒性談台灣醫療事業廢棄物焚化處理從戴奥辛毒性談台灣醫療事業廢棄物焚化處理
• 李俊賢、詹長權、王榮德
  Jyuhn-Hsiarn Lee, Chang-Chuan Chan, Jung-Der Wang
• 無
  none
• 無
  none
• 237 - 240
• 10.6288/CJPH1999-18-04-01

• Link 綜論 Review Article
• 綜論吸菸與戒菸對糖尿病患者發生心臟血管疾病的影響The Impact of Cigarette Smoking and Smoking Cessation on Cardiovascular Disease in Diabetic Patients
• 曾慶孝
  Chin-Hsiao Tseng
• 吸菸 ； 戒菸 ； 心臟血管疾病 ； 糖尿病 ； 預防醫學
  ?cigarette smoking?;?smoking cessation?;?cardiovascular disease?;?mellitus?;?preventive medicine
• 糖尿病是台灣地區的第五大死因，估計糖尿病病人的死亡有75%以上與動脈粥狀硬化有關，而吸菸又是心臟血管疾病的主要危險因子。估計美國每年所有冠狀動脈心臟病的死亡中，有30%可歸因於吸菸，而糖尿病病人的心臟血管疾病死亡中有65%可歸因於糖尿病與吸菸之交互作用。吸菸的糖尿病病人比未吸菸的糖尿病病人有較高的心臟血管疾病發生率、再發率、及死亡率，而戒菸可以很快地改善這些現象。有研究指出，發生心肌梗塞的病人戒菸一年後，可使心臟血管疾病的發生降低50%；在戒菸二年後羅志心臟血管疾病之危險性則與無吸菸者相當。美國Multiple Risk Factor Intervention Trial (MRFIT)的研究指出，在比較給予抗高血壓治療、降低膽固醇、給予阿斯匹靈、及實施戒菸等方式的介入時，戒菸的成效是最好的，而且糖尿病病人比無糖尿病者可由預防介入得到更大的效益。
  Diabetes mellitus is the fifth leading cause of death in Taiwan. More than 75% of causes of death in diabetic patients can be ascribed to atherosclerosis. Cigarette smoking has long been identified as an independent risk factor of cardiovascular disease. I n the USA, about 30% of cardiovascular mortality each year can be ascribed to cigarette smoking, and about 65% of cardiovascular mortality in diabetic patients can be ascribed to an interaction between diabetes mellitus and cigarette smoking. The incidence, recurrence rate, and mortality of cardiovascular disease in diabetic patients are all higher in smokers than in non-smokers. Smoking cessation can improve these phenomena. Patients alter myocardial infarction experienced a 50% reduction in cardiovascular events alter quitting smoking for 1 year. The risk was further reduced alter quitting for 2 two years to ale comparable to patients who did not smoke. Analysis of the theoretical benefits of four different approaches to reducing cardiovascular risk in diabetic and non-diabetic populations in the Multiple Risk Factor Intervention Trial (MRFIT) concluded that smoking cessation is the most effective intervention when compared to antihypertensive treatment, aspirin, and cholesterol lowering. Diabetic patients are prone to gain more beneficial effects than are non-diabetics from preventive interventions.
• 241 - 246
• 10.6288/CJPH1999-18-04-02

• Link 原著 Original Article
• 護理指導對高血壓員工自我照護之影響The Influence of Nursing Intervention on Hypertensive Employees' self-care
• 張媚、陳滋茨、徐幸妙、林豔君
  Mei-Chang Yeh, Zei-Tei Chen, Hsing-Miao Hsu, Yen-Chun Lin
• 高血壓 ； 自我照護 ； 護理措施 ； 工作場所
  hypertension ; self-care ; nursing intervention ; workplace
• 無
  Objectives: The purpose of the study was to evaluate the effectiveness of worksite nursing intervention via individual health teaching and regular follow-ups for hypertensive employs. Methods: A pre-experimental design was chosen for the study. It was conducted in 6 large or medium manufacturing companies. The subjects were 408 employed adults with elevated blood pressure (?140/90 mmHg). The experimental nursing interventions were provided by trained occupational health nurses. The interventions included regular blood pressure readings and individual nursing counseling on subject's self-care. Data were collected at baseline, 4-and 16-month intervals from subject's blood pressure records and If-completed questionnaires. Results: Significant improvements were shown in subject's knowledge and self-care behavior, such as exercise frequency, healthy diet consumption, and weight control. Meanwhile, significant reductions (P<0.001) were observed in subjects blood pressure. Average decreases were 11.31 mmHg for systolic and 7.07 mmHg for diastolic blood pressure alter 4-month nursing intervention. At the end of 16 months of intervention, the effects mentioned above were maintained or further improved. Conclusions: Worksite nursing intervention via individual health teaching and regular follow-ups can effectively improve hypertensive employs self-care.
• 247 - 254
• 10.6288/CJPH1999-18-04-03

• Link 原著 Original Article
• 職業別譯碼之一致性分析Inter-rater Agreement on the Classification of Job Titles
• 李中一、張恭賀、馮兆康、吳淑瓊
  Chung-Yi Li, Kung-Ho Chang, Chao-Kang Feng, Shwu Chong Wu
• 職業分類 ； 一致性 ； 信度
  agreement ; job classification ; reliability
• 目標：本研究的主要目的在於評估兩位研究人員將問卷所蒐集工作內容資料歸類譯碼結果之一致性。方法：兩位研究人員根據我國「職業標準分類系統」之職業分類原則，針對145份社區老人（≧65歲）以問卷所蒐集之職業史資料，分別進行職業別歸類譯碼之工作，並以Kappa統計值評估一致性之程度。結果：在145筆有效資料中，兩位研究者大分類譯碼一致者共110筆（75.8%；Kappa=0.70，95%信賴區間(CI)=0.62-0.78），大、中分類譯碼一致者106筆(73.4%；Kappa=0.69，95% CI=0.61-0.77)，大、中、小分類譯碼一致者101筆(70.0%；Kappa=0.66，95% CI=0.58-074)，而大、中、小細分類譯碼均一致者共有98筆(686%；Kappa=0.64，95% CI=0.56-072)。進一步探討歸類不一致的原因，發現，原始問卷對所從事職業工作內容之描述不夠詳盡，是造成不一致歸類之主要原因。其次要原因分別為譯碼者之人為錯誤，以及原分類系統將同性質工作給予兩個不同的譯碼。結論：我國職業標準分類系統之信度仍佳，若能蒐集更詳盡之工作內容資料並加強譯碼者之訓練及標準化等工作，其信度必能更進一步提升。
  Objectives: To assess the inter-rater reliability for the Standard Occupational Classification System (SOCS) of the Republic of China. Methods: Information on the life-time longest- held occupation for a total of 145 adults 65 years and over was obtained from a longitudinal study using questionnaires to interview nearly 1600 community elderly on their work histories. Two investigators independently reviewed participants work histories and categorized each participant's longest-held occupation into a job title designated by a four-digit number. Briefly, the SOCS is based on a 4-digit system. The first digit in the series represents the broadest job category while the subsequent digits are indicative of more specific details. The chance- adjusted agreement between the two raters was assessed by Kappa (K) and its 95% confidence interval (CI). Results: Among the 145 records studied, these two raters agreed on the first digit in the categorization for 110 (75.8%) records (K=0.69, 95% CI=0.62-0.78). They also agreed on the first two digits for 106 (73.4%) records (K=0.70, 95% CI=0.61-0.77), the first three digits for 101 (70.0%) records (K=0.66, 95% CI=0.58-0.74), and all of the four digits for 98 (68.6%) records (K=0.64, 95% CI=0.56-0.72). Causes of disagreements included insufficient job information in the questionnaire, rater's mistakes, and two different SOCS classification codes for similar types of jobs. Conclusions: This study suggests that the reliability of the SOCS was substantial. Further improvement in the reliability can be achieved by training raters with standardized rating procedures and by providing sufficient information on work history to the raters.
• 255 - 261
• 10.6288/CJPH1999-18-04-04

• Link 原著 Original Article
• 台灣版世界衛生組織生活品質問卷量尺語詞的選擇Scale Descriptor Selection for Taiwan-version of Questionnaire of World Health Organization Quality of Life
• 林茂榮、姚開屏、黃景祥、王榮德
  Mau-Roung Lin, Kai-Ping Grace Yao, Jing-Shiang Hwang, Jung-Der Wang
• 生活品質；量尺語詞；世界衛生組織
  quality of life ; scale descriptor ; World Health Organization
• 目標：本研究經由一群醫療衛生相關專家的討論，以及156位志願受訪者的問卷訪談結果，來選取台灣版世界衛生組織生活品質問卷中所需用的20個量尺語詞。方法：世界衛生組織生活品質問卷的量尺語詞的種類包括能力、頻率、強度以及評估四類，每類須含有五個序位量尺語詞。選擇語詞的項序是先由專家討論決定序位量尺語詞的二個端點的用詞，再由問卷訪談選取中間三個序位量尺語詞。問卷中每個候選量尺語詞的二個端點之間有一條10公分線段，讓選自台灣地區10家大型醫院的156位受訪者標示每個候選量尺語詞相對於二個端點用詞的語氣程度。結果：選出的能力量尺語詞為「完全不能」、「少許能」、「中等程度能」、「很能」及「完全能」；頻率量尺語詞為「從來沒有」、「不常有」、「一半有一半沒有」、「很常有」及「一直都有」；強度量尺語詞為「完全沒有」、「有一點有」、「中等程度有」、「很有」及「極有」；評估量尺語詞為「極不滿意」、「不滿意」、「中等程度滿意」、「滿意」及「極滿意」。被選出之量尺語詞前後創的信度普通，語詞之間`有些差異；而前後創平均值並無統計上的明顯差異。結論：本研究選出的序位量尺語詞應可符合台灣版世界衛生組織生活品質問卷及其他類似問卷之需要。
  Objectives: This study is to select appropriate descriptors for Taiwan-version of World Health Organization quality of life questionnaire (WHOQOL). Methods: WHOQOL consists of four kinds of response scales: capacity, frequency, intensity, and evaluation. Each response scale has five ordinal descriptors including two anchors at extreme levels and three intermediates. We invited experts to decide the two anchors for extreme levels, and then selected 156 outpatients and healthy persons from 10 hospitals in Taiwan to place each descriptor on a 10 centimeter line according to where they think each descriptor lies in relation to the two anchors. Results: Five most appropriate Chinese descriptors were ”Completely not” (????), ”A little” (???), ”Moderately” (?????), ”Very” (??) and ”Completely” (???) for capacity ”Never” (????), ”Seldom” (???), ”Half” (???????), ”Very often” (???) and ”Always” (????) for frequency ”Completely not”(????), ”Slightly” (????), ”Moderately” (?????), ”Very much” (??) and ”Extremely” (??) for intensity and ”Extremely dissatisfied” (????), ”Dissatisfied ”(???), ”Moderately satisfied” (??????), ”Satisfied” (??) and ”Extremely satisfied” (???) for evaluation. Test-retest reliability was moderate on the average but varied among descriptors. However, there were no differences between their mean values of test and retest. Conclusions: These selected descriptors are suitable for Taiwan-version of WHOQOL and other use of health profile assessment of quality of life.
• 262 - 270
• 10.6288/CJPH1999-18-04-05

• Link 原著 Original Article
• 藥物濫用住院戒治病人之間接成本推估及其影響因子分析Estimation of Indirect Costs and Analysis of Associated Factors for Hospitalized Drug Addicts
• 黃一展、李志恆、楊銘欽
  I-Chan Huang, Jih-Heng Li, Ming-Chin Yang
• 藥物濫用 ； 間接成本 ； 生產力損失
  drug abuse ; indirect costs ; productivity loss
• 目標：本研究採用人力資本法分析藥物濫用所導致的間接成本，用以呈現藥物濫用對社會的衝擊，做為政府擬訂施政計畫優先順序的參考依據。方法：對82名曾於民國86年間尋求住院戒治之病人進行問卷訪視。結果：分析後發現，民國86年之總間接成本為76，904，128元，平均每人每年為937，855元。總間接成本中以毒品交易費用55，793，400元最高，約佔72.55%，其次為生產力損失20，449，272元，約佔26.59%，再者為交通費用492，696元，約佔0.64%，最低為其他相關費用168，760元，約佔0.22%。平均每人總間接成本若依工作性質變更情形區分，以民國86年以前即無工作者為最高，其次為民國86年間變更工作性質者，最低為一直未變更工作性質者。結論：經過單因子變異數檢定及複迥歸分析後發現，「工作性質變更情形」為總間接成本、總生產力損失、戒治者就醫生產力損失及戒治者變更工作性質生產力損失的重要影響因子。
  Objectives: To understand the impact of drug abuse on our society and for setting policy priorities, we applied the human capital approach to estimate indirect costs of drug abuse. Methods: Eighty-two drug addicts who sought hospitalization treatments in 1997 were sampled and interviewed with a questionnaire. Results: The preliminary results are shown as follows. In 1997, the total indirect costs of 82 addicts were 76, 904, 128 NT dollars; the average costs per person per year were 937, 855 NT dollars. In terms of the types of costs in 1997, the cost of seeking drugs was the highest (55, 793, 400 NT dollars, or 72.55%); the next was productivity loss (20, 449, 272 NT dollars, or 26.59%); the third was transportation fee (492, 696 NT dollars, or 0.64%); and the lowest was other related costs including facilities and special nurses costs (168, 760 NT dollars, or 0.22%). In terms of the employment status in 1997, the cost of unemployed addicts per person per year due to drug abuse before 1997 was the highest; the next was unemployed addicts since 1997; the lowest was persons who never changed employment status. Conclusions: Through ANOVA and multiple regression a1ysis, we found that a change of employment status manifested as the significant factor on total indirect costs, total productivity loss, productivity loss due to eking a drug-free program, and productivity loss due to changing employment status.
• 271 - 282
• 10.6288/CJPH1999-18-04-06

• Link 原著 Original Article
• 全民健康保險重大傷病患者住院醫療資源使用Inpatient Care Use by Patients with Catastrophic Illness under National Health Insurance in Taiwan
• 盧瑞芬、李佳琳、莊逸洲
  Jui-Fen Rachel Lu, Chia-Lin Li, Yi-Chou Chuang
• 部份負擔 ； 重大傷病 ； 醫療資源使用 ； 全民健保
  copayment ; catastrophic illness ; health care utilization pattern ; National Health Insurance
• 目標：分析全民健保所定義重大傷病患者的住院醫療資源使用情形，及初步評估全民健保對重大傷病族群的影響。方法：本研究主要分析比較全國各類重大傷病患者在1996年全年的住院醫療費用分佈情形，同時以林口長庚醫學中心為例，比較各類重大傷病患者在健保前後的住院醫療資源使用情形。結果：本研究有三點主要發現：?全國性全民健保重大傷病資料顯示，第1類癌症的人數最多，而住院費用分佈有偏右趨勢（平均值大於中位數）。?以林口長庚醫學中心為例，健保後的各類重大傷病患者，其平均住院日數及平均住院費用大都較健保前高，平均年齡則較低。?部分重大傷病持卡人的入院診斷，完全不符合中央健保局現定的重大傷病範圍。結論：重大傷病的認定標準，宜採用ICD-9-CM編碼；且重大傷病應持續多年期研究。
  Objectives: This study is designed to evaluate inpatient care utilization patterns of patients with catastrophic illness as defined by the Bureau of National Health Insurance (BNHI), Taiwan. In addition, the impact of National Health Insurance (NHI) on inpatient care utilization for this specific group is assessed. Methods: The distribution of inpatient health expenditures is analyzed using the BNHI national database for 1996. In addition, comparisons in inpatient uses between pre-NHI and post-NHI periods are male using data from Linkou Chang Gung Memorial Hospital (CGMH). Results: Our study has three major findings: (1) The NHI national databases on catastrophic illness demonstrate that the first category, malignant neoplasm, has the largest number of patients. The distribution of inpatient medical expenditure is skewed to the right (mean value is greater than the median). (2) As evidenced by the Linkou CGMH database, most of the catastrophically ill patients have demonstrated higher average annual hospital days and hospital expenses, but lower average age in the post-NHI period than in the pre-NHI period. (3) Some catastrophic illness certificate holders have indicated no NHI-defined catastrophic illness related to admitting diagnoses. Conclusions: Catastrophic illness certificates should be granted based on ICD-9-CM codes. Moreover, research on catastrophic illness should be performed on a long-term basis.
• 283 - 292
• 10.6288/CJPH1999-18-04-07

• Link 實務 Public Health Practice
• 實驗室進排氣口配置不當所引起之甲硫醇中毒事件An Outbreak of Methyl Mercaptan Intoxication Caused by an Inappropriate Arrangement of Exhaust Ventilation System in a Laboratory
• 蘇大成、王榮德
  Ta-Chen Su, Jung-Der Wang
• 甲硫醇中毒 ； 局部排氣
  Methyl mercaptan intoxication ; local exhaust ventilation
• 目標及研究之背景：此研究欲決定一群辦公室行政人員在一次暴發流行全身倦怠、疲勞，頭暈及胸悶的發生原因及致病因子。台北某研究所位於五樓的實驗室，於1998年7月8日（星期三）早上，使用甲硫醇(methyl mercaptan)做分子作用的實驗，位於同樓一樓辦公室的行政人員，則於下午同時聞到劇臭的腐屍味，聞後即感到喉嚨及鼻粘膜強烈不適，大部分人覺得全身倦怠、疲勞，頭暈，胸問及呼吸困難。7月12日晚該實驗室又重覆一次實驗，隔天早上，該所辦公室人員一上班就又聞到與前相同的惡臭味道，身體不適症狀即刻又發生。臨床檢查及現場訪視：該所十三位受害者，均被邀來院接受問卷調查、體檢、及實驗室檢查，項目包括胸部X光檢查、血液學檢查、尿液分析及生化學檢查，並檢測變性血紅素百分比及血紅素結合素。經過三個月的臨床追蹤與檢查，該所受影響之行政人員皆已完全康復，其檢查結果皆正常。經現場勘查，證實應是局部排氣口正對著管道間通風口，導致實驗室所用之甲硫醇經此排氣口，進入管道間而隨重力況下一樓滲入辦公室肇禍，而造成此一事件的排氣管設置不當亦已改善。結論：此次暴發是由於實驗室局部排氣口與辦公室進氣口配置不當，所引起之甲硫醇中毒事件。本文在此提出說明，並呼籲有此類似潛在危險的實驗室皆應設法改善。
  Objectives and Backgrounds: This study is to determine the cause and etiological agent of an outbreak of chest tightness, upper respiratory symptoms and dizziness among a group of office workers. The incident occurred on the morning of July 8th, 1998, when a total of 13 office workers smelt a foul odor and developed symptoms of throat irritation (77%), chest tightness (62%), nose irritation (46%), fatigue, dizziness and drowsiness (69%). Some of them suffered from diarrhea (46%), nausea (31%), muscle weakness (38%) and a staggering gait (15%). The odor stayed in the office for about 2 days before it faded. Clinical Examination and Field Investigation: We followed up these workers for three months with detailed clinical examinations and laboratory tests. No significant clinical sequelae or laboratory abnormalities were found. A field investigation found that this outbreak correlated well with an experiment, which discharged methyl mercaptan on the 5th floor of the same building. The outlet of the laboratory discharge directly faced (less than 1 meter away) the inlet for the general ventilation pipelines for the building. As the density of methyl mercaptan is heavier than that of air, it sank to the first floor and the incident occurred. After the duct and outlet for the laboratory exhaust were extended to the roof of the building, the outbreak stopped. Conclusions: The outbreak was due to methyl mercaptan and the poor design of the local exhaust ventilation system.
• 293 - 298
• 10.6288/CJPH1999-18-04-08