16卷2期

• Link 原著 Original Article
• 低濃度多種有機溶劑暴露工人尿中馬尿酸研究The Urinary Hippuric Acid of Workers Exposed to the Low Level and Multiple Organic Solvents
• 陳美蓮、毛義方、羅宜文、翁銘雄
  Mei-Lien Chen, I-Fang Mao, Yi-Wen Lo, Ming-Shung Uang
• 尿中馬尿酸；低濃度及多種溶劑暴露
  ?Urinary hippuric acid?;?Low level and mix organic solvents exposure
• 尿中馬尿酸是工人暴露於甲苯時最常用的生物指標，不過它被建議甲苯之空氣中濃度必須超過50ppm，並且需以集體人員來觀察才較有意義。本研究對某造漆廠員工受利人數96人，暴露組41人、非暴露組55人，觀察在某些有機溶劑在在下，較低暴露量（50ppm以下）之情況下，尿中馬尿酸是否仍有效的加以偵測並當作生物指標；結果顯示，在多種有機溶劑暴露之作業環境下，若甲苯濃度超過1ppm時，尿中馬尿酸即可在暴露組與非暴露組問呈現統計上有意義的差異，建議在此情況下，以下班前尿中馬尿酸之濃度作為暴露甲苯之生物指標時，應以團體為塞礎加以觀察與解譯。同時，當甲苯濃度為10ppm時，美國NIOSH建議的馬尿酸濃度標準為2.5g/g Cr.應同樣適用於國人。
  Urinary hippuric acid is a widely used BEI (Biological Exposure Index) for workers exposed to toluene, and it is recommended to use the marker based on population who expose to toluene concentration over 50ppm. To evaluate the reliability of hippuric acid as a bioindicator for toluene concentration in workplace below 50ppm accompanied with other solvents exposure, 96 subjects, including 41 subjects in exposure group and 55 subjects in non-exposure group, were examined. Results indicate that urinary hippuric acid is significantly different between exposure group and non-exposure group. Under this condition, we recommend that using hippuric acid as a bioindicator for toluene exposure should base on group observation and elucidation. It shows that the U.S. NISOH recommended BET value (2.5g/g Cr.) of hippuric acid for toluene exposure worker also meets the requirement of workers, who expose to 100ppm of toluene, of the Republic of China.
• 109 - 118
• 10.6288/CJPH1997-16-02-01

• Link 原著 Original Article
• 中文版多元功能評估問卷之信度效度考驗An Evaluation of the Reliability and Validity of the Chinese-Version Oars Multidimensional Functional Assessment Questionnaire
• 邱亨嘉、陳怡君、毛莉雯、蕭世槐、劉宏文、黃明賢
  Herng-Chia Chiu, Yi-Chun Chen, Lih-Wen Mau, Shih-Huai Shiao, Wen-Liu Hong, Ming-Shyan Huang
• 多元功能評估問卷；健康狀況；功能評估；信度；效度
  ?MFAQ?;?Elderly Health Status?;?Functional Assessment?;?Reliability?;?Validity
• 僅管多數學者專家同意一項完整的健康評估應同時包括身體、心理健康、及社會支持等多面向之功能狀況，國內有關老人健康功能評估之研究仍多限於單面向評估。有鑑於此，本研究小組於1991年獲得美國杜克大學(Duke University)授權使用其所發展之多元功能評估問卷(Multidimensional Functional Assessment Questionnaire, MFAQ)，依台灣之醫療制度、文化背景及社會習俗等各方面因素，修訂成「中文版多元功能評估問卷」(the Chiness-version MFAQ, CMFAQ)，用以瞭解台灣社區及機構老人之社會資源、經濟資源、精神使康狀況、身體健康狀況、及日常活動能力。本研究之主要目的在評估CMFAQ是否為一信度、效度俱佳的多元功能評估工具。其信度考驗包括重到信度及內部一致性；效度考驗包括內容效度及建構效度。信度考驗結果發現：重測一致性百分比以初步測試量表最高(87.5%)，其次為日常活動能力量表(85.75%)，其餘各面向皆在70%以上；同一訪員評分之重測相關係數以社會資源評分相關最高(0.75)，不同訪員評分之重測相關係數則以日常活動能力評分相關最高(0.61)；各面向之Cronbach's α值皆在0.7標?以上，其中以日常活動能力量表的內部一致性最高，其Cronbach's α值達0.93。就建構效度而言，其因素分析結果顯示CMFAQ之實證建構與理論建構相似，其中日常活動能力、認知功能及經濟資源3因素所組成之變項幾乎與理論建構完全相同。由此可見，中文版多元功能評估問卷不失為一有效可信的功能評估工具，在未來建立全國老人資料庫之際，相關研究者可依不同之研究目的及樣本特質，將多元功能評估問卷修訂為一標準化的老人功能評估工具或簡式多元功能評估問卷。
  The most recent wave of health status assessments have been dominated by multidimensional measures. However, the traditional measures of health status in Taiwan still focus on unidimensional approach, which seems to be insufficient by themselves. With respect to a multidimensional approach, the OARS Multidimensional Functional Assessment Questionnaire (OMFAQ) from Duke University has been used widely in gerontological research with established reliability and validity. In order to establish a profile of multidimensional functional status (i.e. social, economic, mental, physical and ADL) of the Taiwanese elderly, the OMFAQ has been tailored into a Chinese-version MFAQ (CMFAQ) in considering the differences in health care delivery systems, culture, and other pertinent characteristics by the Kaohsiung Medical College gerontological research team. The major purpose of this paper is to present the evidence for reliability and validity of the CMFAQ as used in Taiwan. In examining reliability, test-retest reliability, reliability of the interviewers, and internal consistency were evaluated. In the restretest study, 87% of the responses were identical in cognitive functional scale, followed by 85.7% in activity of daily living (ADL), and more than 70% being identical in the other dimensions. The best rating agreement among intra-raters was found in social resources scale (r=0.75), while the highest rating agreement among inter-raters was found in the ADL scale (r=.61). The internal consistency (inter-item reliability) of the CMFAQ is sufficient; the Cronbach's coefficient for each dimension are all above .70 (except the physical health status), especially the c value for ADL up to 0.93. In examining validity, the content validity of the CMFAQ is sustained by the manner of item selection by the interdisciplinary team. The results of exploratory factor analyses disclosed that six empirical factors were corresponded closely with theoretical constructs, especially the items consisted in the constructs of ADL, cognitive functioning, and economic resources. In conclusion, the CMFAQ can be served as a reliable and cross-culturally valid measurement tool for the elderly. For the future development, the CMFAQ can be refined into an extended version for comprehensive population survey, or be modified into a shorter version for health status assessments in clinical settings.
• 119 - 132
• 10.6288/CJPH1997-16-02-02

• Link 原著 Original Article
• 台灣地區醫療品質指標適用性之探討A Study on the Applicability of Medical Quality Indicators in Taiwan
• 陳佩妮、 鄭守夏、鍾國彪、林王美園
  Pey-Ni Chan, Shou-Hsia Cheng, Kuo-Piao Chung, Mei-Yuan Lin Wang
• 醫療品質；指標；德菲法
  ?Medical quality?;?indicators?;?Delphi technique
• 本研究之目的為瞭解醫療品質指標在國內各級醫院的適用情形，以及目前醫院提報品質資料之可信程度，並利用實證資料探討各品質指標問之關係。經以結構式問卷對國內14位醫療品質專家學者，以德菲法(Delphi technique)進行兩回合的調查研究發現，大部份目前常用的醫療品質指標均被視為重要與適用的，其中以院內感染要生率被公認是「非常重要且適用」的品質指標。但在資料可靠性方面，只有結構面及少數結果面品質指標較為可靠。資料不可靠的理由可歸因於「環境」、「組織」及「資料本身」三大因素。以相關檢定分析實證資料要現，結構面的品質指標，除專科醫師比率外，隨醫院評鑑等級越高，各指標間呈一致而顯著的正相關。而絕大多數的過程與結果面品質指標之問，都沒有顯著相關專在。在醫療結構－過程－結果面品質指標問的相關性，只有各死亡率與結構面品質指標呈現較顯著的正向相關。實證分析的結果與專家們的意見是相符合的，唯目前似乎尚無可靠而適用的過程與結果面指標可茲應用。
  The main purposes of this study are to understand the applicability and reliability of quality indicators in Taiwan's hospitals, and to explore the relationship among quality indicators. A structured questionnaire was designed and distributed to collect experts' opinions via Delphi technique. According to the response of 14 medical care quality experts, almost all currently used indicators are considered important and applicable, while hospital-acquired nosocomial infections is considered the most important quality indicator. However, only structural and a few outcome indicators are reliable. Factors affecting the reliability of quality measures can be classified into three categories-environmental, organizational and data problems. According to the empirical analyses, positive relationship are found among structural indicators except the rate of specialists. No consistent correlation can be found among the process-outcome indicators except several death rates. Empirical findings are consistent with those experts' opinions. However, under current situation, there is no reliable and applicable outcome indicator which can be employed for hospital accreditation.
• 133 - 142
• 10.6288/CJPH1997-16-02-03

• Link 原著 Original Article
• 台灣地區醫療院所首長醫務管理訓練需求及影嚮因素之研究A Demand Study of the Current Management Training of Hospital Chief Executives at Taiwan
• 黃佳經、黃秋宇
  Chia-Ching Huang, Chiu-Tsung Huang
• 醫院首長；醫務管理訓練
  ?hospital chief executive?;?health-care management training
• 本文針對台灣地區57所醫療機構之首長接受醫務管理訓練的現況、訓練需求項目及訓練需求因素做一調查。其中有77.2%的首長為醫師，86%的首長沒有具備醫務管理學位。首長平約每年接受32次的在職訓練，而其中每年平均只有1.6次是屬於醫務管理課程。首長對於醫務管理訓練內容需求以「醫療品質」(96.1%)，「醫院資訊系統」(95.9%)，「策略規劃」(94.1%)，「資訊科技與醫療服務」(93.8%)與「醫院經營管理」(92.6%)為最高。在醫務管理訓練需求因素上以「全民健保」(70.2%)，「個人需要」(61.4%)，「醫院內部需求」(57.9%)，與「醫院問競爭」(54.4%)為最高。
  This study reports the current status of and the demand for on-the-job training in hospital management. Data for the analysis came from 57 hospital chief executives in Taiwan area. Seventy-seven percent of hospital chief executives were physician, while 86% of them do not have a health administration degree. The hospital chief executives attended 32 on-the-job training courses, yet only 1.6 was relevant to hospital management. As far as the training needs, most hospital chief executives were concerned about healthcare quality management (96.1%), hospital information system (95.9%), strategic planning (94.1%), information technology and health care (93.8%), and hospital general management (92.6%). Taiwan's health insurance reform (70.2%), executives' personal needs (61.4%), hospital internal needs (57.9%), and competition among hospitals (54.4%) were the strongest motivation driving these hospital management training needs
• 143 - 148
• 10.6288/CJPH1997-16-02-04

• Link 原著 Original Article
• 論量計酬與論病例計酬之支付制度對費用結構與品質之影響：以長庚醫院之剖腹生產與陰道分娩為例The Impact of Two Different Payment Systems on Coststructure and Quality of Care: A Comparison Study of C/S and VD in the C.G.M.H.
• 莊逸洲、盧成皆、陳理
  Yi-Chou Chuang, Sing-Kai Lo, Lee Chen
• 無none
  P.P.S Prospective Payment System?;?Managerial Model
• 醫療費用的上漲已是全世界實施全民健康保險國家共同的壓力，依政府之規劃全民健康保險長遠目標將採用診斷關係群(DRGs)作為醫院服務項目的支付基準。 在前瞻性付費制度下，許多專家學者提出了控制醫療成本及維護醫療品質的管理方法與對策，長庚醫院將各專家學者研究發現表實際有效之管理方法，深入研究、探討，去蕪存菁、整合串連起來，建立了前瞻性付費制度下之醫療管理模式。 本研究之重點為針對此一管理模式在效率及效益的發揮、醫療服務品質的確保、資訊作業在簡化工作及異常管理之功效等方面做一實證研究，而以長皮紀念醫院台北林口、基隆、高雄三院區79年7月至82年6月之DRC 371及DRG 373之住院病患資料共30.076例作實證研究。本研究以Unpaired t-test，ANOVA，Stepwise Logistic Regression，Cross Validation等研究方法統計分析在住院醫療管理模式運作下之PPS制與FFS制是否在住院日、住院醫療費用及醫療品質等方面有所差異，以實證此管理模式之意義。 研究結果顯示在住院醫療管理模式之運作下，醫療品質並未因給付制度係PPS或FFS而有差異，且在醫療費用上確可發揮控制功能，顯示管理的機能可因嚴謹的制度訂定及整合而發揮至極致，實證住院醫療管理模式確是一可提高效率、有具體效益、能維護醫療品質且可行之管理模式，並且可供全民健康保險逐步實施DRGs制度之政策推動及執行上之參考。
  Huge increase in medical expenses is common among countries with national health insurance. Hence, the National Health Insurance Bureau of Taiwan Has Adopted several polices such as referral, co-payment, case payment and DRGs as the long term payment goal, in order to protect its financial status against abuse of the newly introduced national health insurance system. To face this insurance scheme, new management models have to be developed by hospitals to minimize cost. hut at the same time maintaining the quality of health care Standardization of procedures, concurrent and retrospective review, establishment of physician profiles, reviewing the usage of supporting services, as well as continuing education for physicians have all proven to be effective under the prospective payment system (pps). To suit its organizational structure, Chang Gung Memorial Hospital (CGMH) has implemented an integrated management system, combining all the above mentioned concepts. Theoretical foundations of the model include contingency theory as well as management by participation. In addition, data were all processed by computers for abnormal management and to increase efficiency. The aim of this research therefore was to evaluate empirically the effectiveness of the system. Medical information of 30,076 in-patients admitted to various branches of CGMH from July 1990 to June 1993 are available. Only DRG 371 and DGR 373 were included in the analysis as two payment methods (PPS & FFS) can be found in the same period of time. Statistical techniques such as unpaired t-test, ANOVA, stepwise logistic regression and cross validation were used to test if there were any differences in length of stay (LOS), fees, and quality of care between the two methods. Results indicated that under this integrated management system, PPS was significantly better in cost control, hut there was no difference in LOS or quality of care. This is an implication that our model is both effect and efficient, yet is practical and can easily be implemented. Our experience may therefore serve as a reference for other hospitals when designing their own management models.
• 149 - 159
• 10.6288/CJPH1997-16-02-05

• Link 原著 Original Article
• 吸菸預防教育介入研究Evaluation of the Outcome in the Smoking Prevention Program
• 高雅珠、晏涵文
  Ya-Chu Kao, Han-Wen Yen
• 預防吸菸教育；教學介入；拒絕技術
  ?smoking prevention education?;?intervention?;?refusing skill
• 本研究探討「預防吸菸教育計畫」是否能促使國二學生有正確的菸害知識、不吸菸的－態度、減低吸菸意向及增強拒絕同儕邀約吸菸的自我效能。本研究採「不相等實驗組控制組設計」，以華江中學國二自顯就學班學生為對象，並以大理國中自願就學班為校外對照組以處理校內實驗污染的情形。 實驗組接受五小時的預防吸菸教學活動，在教學介入前，所有學生接受前測以作為評量實驗結果的比較基礎，教學結束復一星期內進行後測以了解教學徒的立即效果；間隔十二週再實施後後到以追蹤教學介入的延方效果。資料以單因子共變數分析進行考驗，所得結果在菸害認知、不吸菸意向及拒絕同儕壓力的自我效能方面均有持續而正向的影響。由學生的回饋得知，學生較喜歡以學生為中心的教學方法，學生較喜歡且認為最有幫助的課程內容是「拒絕技術的演練」、「建立積極的自我對話」及「擁有各種不同調適心情的方法」。
  The main purpose of this study was to explore the effect of a smoking prevention program for the second grade junior high school students. The topic of the research was focused on increasing smoking knowledge, promoting no-smoking attitude, reducing smoking intention and enhancing self-efficacy for refusing smoking pressure from peers. A non-equivalent control group design was employed in this study. Two classes of students in Hua-Chiang Junior High School were given with five sessions of smoking prevention curricula as the treatment group. Students of the four classes in Hua-Chiang and Ta-Li Junior High School were served as the control conditions. The effect of intervention was assessed by questionnaires immediately after five sessions of curricula and in the next three months. The data were analyzed by one-way analysis of covariance. Some interesting results are shown as the following: 1. The program can increase students' smoking knowledge and the intervention effect still retains through the next three months. 2. The program has no significant effect in changing students’ no-smoking attitude. 3. The intervention doesn't affect the no-smoking intention of the treatment group immediately. However, its effectiveness gets higher significance than the control groups in the follow-up period. 4. There is significant effect in improving the self-efficacy of treatment group in refusing peer's pressure. 5. Students participating in the instructional activities of smoking prevention appreciated the student-centered instruction.
• 160 - 169
• 10.6288/CJPH1997-16-02-06

• Link 實務 Public Health Practice
• 由“不活性傷寒疫苗之副作用”談軍中傷寒防治策略Adverse Reactions to Killed Parenteral Typhoid Vaccine (Tab) and Recommendations for Military Typhoid Control
• 陳志成、林錫勳、金傳春
  Chih-Cheng Chen, His-Hsun Lin, Chwan-Chuen King
• 傷寒；預防接種；副作用
  Typhoid fever?;?Immunization?;?Adverse reaction
• 本研究以海軍某艦艇單位施打不活性傷寒疫苗(TAB)來評估疫苗副作用，並針對軍中傷寒防治提出建議。1994年六月，海軍某艦艇男性士官兵共92人，其中有84人(82.4%)接種TAB疫苗，年齡在20到28歲(21.9±0.7)，一般身體狀況良好，無發燒或特殊病史。採皮下注射0.5cc，並發給問卷，記錄接種後48小時內之各項症狀。問春回覆者共73人(86.9%),其中33人(45.2%)記錄至少一種副作用。所記錄的副作用人數和比例為：打針部位疼痛29人(39.7%)；打針的手臂疼痛無力15人(20.6%)；發熱全身倦怠8人(11.0%)；打針部位發紅腫脹6人(8.2%)；頭暈4人(5.5%)：腹瀉3人(4.1%)；頭痛2人(2.7%)；頸部淋巴結腫大1人(1.4%)。這位淋巴結腫大者後來診斷確定是「急性淋巴球白血病」(acute lymphoblastic leukemia)，洽由此次疫苗接種提早發現。本文依據文獻資料比較TAB疫苗與活性。服傷寒疫苗(Ty21a)在疫笛效力、方便性及副作用等的差異，並建議軍中停止每年全面性施打此副作用大但保護效果卻有限的不活性傷寒疫苗(TAB)；若有任務需要可採用免疫效果更好且副作用極少的活性。服傷寒疫苗(Ty21a)。其他相關建議包括：（一）「食勤人員」的體檢項目，應增加糞便之傷寒細菌培養檢查，以發現潛伏的無症狀傷寒帶原者，減少引爆流行之可能：（二）定時做拱水系統的傷寒菌偵測，以確保飲水安全；（三）對醫院檢驗科工作同仁，給予活性口服傷寒疫笛Ty21a，以增加免疫力。
  Two specific aims of this study are :(1) to evaluate the adverse reactions of killed parenteral typhoid vaccine (TAB), and (2) to give recommendations for military typhoid control strategies in Taiwan, R.O.C. Eighty four (82.4%) male soldiers (mean age 21.9±0.7) in one naval ship (total 92 persons, age 20-28y/o) received the TAB vaccine with a dosage of 0.5cc through subcutaneous injection in June, 1994. Seventy three (86.9%) persons answered a structured questionnaire about adverse reactions. Among them, 33 cases (45.2%) had at least one of the following adverse reactions: local tenderness at the injection site, pain and soreness of arm, fever and general malaise, local swelling at injection site, dizziness, diarrhea, and headache. One case with neck lymphadenopathy was finally diagnosed as acute lymphoblastic leukemia which was detected earlier through this immunization. According to adverse reactions and vaccine delivery practices between TAB and Ty21a vaccines, we recommend to stop using TAB vaccine but immunize soldiers with Ty21a vaccine for its better protection and less side effects. Other recommendations include: (1) to screen ”stool culture” of typhoid bacilli routinely among food handlers, (2) to set up a periodic bacterial surveillance of water supply, and (3) to immunize hospital diagnostic laboratory personnel with Ty2la vaccine.
• 170 - 176
• 10.6288/CJPH1997-16-02-07

• Link 實務 Public Health Practice
• 台南地區城市與鄉村救護車緊急救護使用之分析Ambulance Utilization in Tainan: Analysis of Emergency Ambulance Missions in Urban and Rural Areas
• 紀志賢、蔡明哲、嚴元隆、葉又菁、林淑敏、吳明和
  Chih-Hsien Chi, Ming-Che Tsai, Yuan-Long Yen, You-Jing Ye, Shu-Min Lin, Ming-Ho Wu
• 救護車 ； 城市地區；鄉村地區 ； 緊急救護
  ambulance?;?urban area?;?rural area?;?emergency medical service
• 無
  To investigate ambulance utilization in rural and urban districts, a retrospective analysis of total 15,808 emergency ambulance calls within the Tainan City and Tainan County from October 1993 to September 1994 was performed. In both areas, traffic accident was the leading cause of ambulance calls (54.9% in city and 57.9% in county, respectively). The response time in emergency missions indicated that 82.8 % of the calls in the city and 84.8% in the county were within eight minutes; 92.0% calls in the city and 91.4% calls in the county were within ten minutes, respectively. In scene stay time was longer in the urban region than in the rural region (3.93.7 vs. 3.13.6 minutes, p<0.05). Total transport time was shorter in urban region than in rural region (15.57.3 vs. 26.116, 2 minutes, p<0.05). Ambulance utilization was higher in the urban region than in the rural region (0.34 vs. 0.19 transport per 10,000 population per day). Non-transport rate was higher in the urban region than in the rural region (37.8% vs. 23.3%). In the city, 94.7% of the transports were sent to the receiving hospital, however, only 72.4% transports in the county were sent to the receiving hospital. The study indicates that there were differences between urban and rural areas due to resource and geographic factors. Such difference must be considered while planning for regional emergency medical service (EMS). In addition, developing large-scaled and standard EMS data collection system is mandatory for improving the quality EMS in Taiwan.
• 177 - 184
• 10.6288/CJPH1997-16-02-08