29卷1期

• Link 原著 Original Article
• 他山之石－由美國愛滋病個案管理制度談台灣“愛滋病個案管理師計畫”The "HIV Case Management Program" in Taiwan: A Discussion Based on Experience with HIV Case Management in the United States
• 邱珠敏、黃彥芳、楊靖慧、陳穎慧、 林頂
  Chu-Ming Chiu, Yen-Fang Huang, Chin-Hui Yang, Ying-Hwei Chen, Ting Lin
• 愛滋病 ； 個案管理 ； 高風險行為 ； 社區組織模式
  HIV/AIDS ; case management ; high-risk behavior ; Community-Based Organization model
• 愛滋病防治為目前全球所面臨之重要議題，世界各國積極尋求有效愛滋防治策略及方法，愛滋病個案管理制度即為其中公認有效之方法。美國為世界上最早推行愛滋病個案管理制度的國家，其推展實施愛滋病個案管理約有23年的歷史。台灣自2007年起全面推廣愛滋病個案管理計畫，目前仍屬初期發展階段，與美國之愛滋病個案管理制度相較，二者之間有差異性存在，包括：個管組織結構、個案收案條件、個管單位屬性、個管師資格及條件、個管執行內容以及個管執行場域等層面之差異。作者建議將愛滋高風險行為者納入個管收案對象，進行「預防性個案管理」，以及早導正該類族群之危險行為，另建議扶植國內愛滋防治民間團體，發展社區組織(Community-Based Organization, CBO)個案管理模式，可先透過試辦計畫進行前驅性研究，以尋求建立愛滋病個案管理多元化之照護模式。此外，於個管計畫執行過程中，應重視及落實個管計畫執行結果評值之重要性。
  Countries around the world have been searching for effective strategies to prevent HIV/AIDS. Among all the existing strategies, HIV case management appears to be the most effective. The United States was the first country to implement HIV case management twenty-three years ago. In Taiwan, HIV case management has been carried out since January 2007. When comparing our HIV case management with that of the United States, we discovered differences in organizational structure, client eligibility, apply unit eligibility, case manager qualifications, and the content of and areas for case management. We therefore have the following suggestions: first, to categorize people with high-risk behavior as a 'preventative case management' group for early correction of that behavior; second, to develop a pilot Community-Based Organization (CBO) HIV case management model to provide HIV clients with more choices; third, to emphasize evaluation of case management throughout the process.
• 1-7
• 10.6288/TJPH2010-29-01-01

• Link 原著 Original Article
• 回顧與探討次級資料適用之共病測量方法A Review of claims-based Comorbidity Measures
• 朱育增、 吳肖琪
  Yu-Tseng Chu, Shiao-Chi Wu
• 共病 ； 次級資料 ； 行政申報資料
  comorbidity ; administrative data ; claim data
• 行政申報資料已成為醫療服務研究重要之資料來源，如何適當地應用次級資料測量共病成為一重要議題，本文目的為探討適用於次級資料之共病測量方法及其應用。回顧國外文獻後，選取5種方法，包括Deyo等、Romano等(D-M's)、D'Hoore等三種版本之Charlson Comorbidity Index (CCI)、以次級資料發展之Elixhauser、及以藥物處方情形發展之Chronic Disease Score。分4部分進行論述：不同共病測量方法之差異、不同方法比較之實証研究、測量共病之資料期間或來源、及改進共病測量方法。研究者必須對各方法發展之背景與定義有所瞭解，再就其研究選用相對較適當之測量或分析方法，本文並對後續研究者選擇時應考量之因素，歸納出以下幾點建議：依研究族群共病分佈情形、醫療照護結果，選擇較合適之共病測量方法；考量較合適之資料期間或來源；依研究族群樣本數及研究之需要，選擇較合適之分析方法；並可思考改進共病測量方法。
  Administrative databases are increasingly used in health service research, and one major issue focuses on how to measure comorbidity. The purpose of this article was to review comorbidity measures and their applications for use with administrative data. Five methods of measurement: Deyo's Charlson Comorbidity Index (CCI), D-M's CCI, D'Hoore's CCI, Elixhauser and Chronic Disease Score (CDS) were selected. Reports in the literature were categorized in 4 areas: 1) introduction of comorbidity measures; 2) comparison of the performance of comorbidity measures; 3) comparison of the performance of comorbidity measures using different data periods or sources; 4) improving the performance of comorbidity measures. There are four suggestions for future research: 1) Consider the distribution of comorbid conditions in the source population and healthcare outcomes when selecting different comorbidity measures. 2) Consider how to select the data periods or sources when using comorbidity measures. 3) Consider the size of population when creating the comorbidity variables. 4) Consider how to improve the performance of comorbidity measures.
• 8 - 21
• 10.6288/TJPH2010-29-01-02

• Link 原著 Original Article
• 台灣地區1986-2006年兒童及青少年事故傷害死亡趨勢Trends in Child and Adolescent Injury Mortality in Taiwan, 1986-2006
• 簡戊鑑、白璐、朱基銘、高森永、蔡行瀚
  Wu-Chien Chien, Lu Pai, Chi-Ming Chu, Senyeong Kao, Shin-Han Tsai
• 趨勢 ； 兒童青少年 ； 事故傷害 ； 死亡率
  Trends ; Children ; Injury ; Mortality
• 目標：描述台灣地區1986-2006年0-19歲兒童及青少年事故傷害死亡率的長期趨勢。方法：利用衛生署生命統計資料進行分析。以國際疾病傷害死因分類標準第九版，將事故傷害類型區分為非蓄意性及蓄意性，並以簡單線性迴歸對各類傷害死亡率進行趨勢檢定。結果：自1986-2006年，0-19兒童及青少年非蓄意性傷害死亡率下降63%（由35.3/10萬人，至13.2/10萬人），自殺死亡率下降近五成（由1.9/10萬人，至1.0/10萬人）。0-19歲兒童及青少年整體他殺死亡率雖然下降，但5歲以下幼童他殺死亡率卻上升；而且，除了5歲以下他殺外，其他各年齡層死亡率均呈下降趨勢。15-19歲青少年事故傷害（佔全部傷害死亡的52%）死亡率是各年齡層中最高者。交通事故是最常見的傷害類型（佔全部傷害死亡的50%），其次是溺水(17%)、梗塞窒息(7%)、燒燙傷(4%)、跌倒墜落(4%)及中毒(2%)。一歲以下嬰兒事故傷害死亡者中，有68%是梗塞窒息所致。結論：自1989年後，非蓄意傷害死亡率及自殺死亡率均呈下降趨勢，但幼童他殺死亡率呈上升趨勢。往後應加強家庭暴力防制法規的執行、強化溺水防範措施及納入「兒童及少年安全實施方案」；另外，亦應對15-19歲青少年的交通傷害與自殺、0-19歲兒童及青少年的溺水、5歲以下幼童的他殺及1歲以下嬰兒的梗塞窒息等傷害，擬定有效的防制計畫。
  Objectives: To describe national trends in injury mortality rates for Taiwanese children aged 0-19 from 1986 to 2006. Methods: Data were obtained from the official Vital Statistics System of the Department of Health, Executive Yuan. Injuries were classified by intent and mechanism using ICD-9 criteria. Mortality rates were age-adjusted for each year's standard population. Simple linear regression was used to determine the trends. Results: From 1986 to 2006, the mortality rate per 100,000 for unintentional injuries at ages 0-19 declined by 63% (from 35.3 to 13.2) and the suicide rate declined by almost half (from 1.9 to 1.0). The homicide rate for ages 0-19 combined declined but the homicide rate for children under age 5 increased. Except for homicide in young children, all age groups showed decreasing trends. The 15-19 age group had the highest total death rate due to injury and accounted for 52% of all injury deaths. Motor vehicle injuries (MVI) were the most common cause of death (accounting for 50% of all injury deaths), followed by drowning (17%), suffocation (7%), fire and flames (4%), falls (4%) and poisoning (2%). Suffocation caused 68% of injury deaths in infants. Conclusions: After 1989, the mortality rates for unintentional injuries and suicide declined, but the homicide rate for young children increased. Laws to prevent violence in the home must be enforced, and drowning prevention programs implemented and incorporated into the Children and Adolescent Safety Implementation Program. Preventive efforts should also target MVI and suicide in the15-19 age group, drowning at all ages, and suffocation and homicide for infants and children under 5 years of age.
• 22 - 32
• 10.6288/TJPH2010-29-01-03

• Link 原著 Original Article
• 以加速度計步器解析社區老年人之身體活動An acceleration-pedometer Analysis of Daily Physical Activities of Elders Living in the Community
• 彭雪英
  Hsuen-Ying Peng
• 老年人 ； 身體活動 ； 步數 ； 加速度計
  the elderly ; physical activity ; step ; accelerometer
• 目標：應用加速度計步器來檢測社區老年人之日常身體活動現況，以提供基礎資訊作為未來身體活動促進方案建構之參考。方法：以台北市內湖區51名老年人（身體質量指數(BMI) 25.1±3.6；平均年齡72.7±6.4歲）為對象，分析其平均每日的步數、非步行之靜態行為時間、動態性身體活動（如低及中強度）時間及身體特徵與各身體活動資料之間的相關性。此外，本研究亦檢視每日步數與動態性身體活動時間之間的關連。結果：受試者之平均每日步數為9,127±3,598步，平均每日花費在非步行之靜態行為時間為562.9±124.8分鐘，平均每日花費在低及中強度身體活動時間分別為76.4±28.5分鐘及20.8±16.7分鐘。BMI與各身體活動資料之間無顯著的相關性(p＞0.05)，但年齡與身體活動資料之間有顯著的負相關性(p＜0.05)。另外，平均每日步數大於10,000步之受試者的低及中強度身體活動時間分別約為102.6±30.9分鐘及35.4±19.9分鐘。結論：年齡會影響老年人的身體活動。社區老年人之每日步數若大於10,000步時可符合現今對老年人之低強度（60分鐘）及中強度（20-30分鐘）身體活動時間的建議值。
  Objectives: To use the acceleration-pedometer to investigate the daily physical activities of elders in the community as a data base for future promotion of physical activity. Methods: Fifty-one individuals (body mass index (BMI) 25.1±3.6, mean age 72.7±6.4 yrs) who lived in the Neihu area in Taipei city were recruited for this study. The average number of daily steps, the sedentary time of non-ambulatory behaviors, the time in dynamic physical activities (including low-and moderate-intensity activities) and the relationships between physical characteristics and daily physical activities were investigated. The associations between the number of daily steps and time in dynamic physical activities were also examined. Results: The average number of daily steps, the sedentary time of non-ambulatory behaviors, and the time in low-intensity and moderate-intensity physical activities were 9,127±3,598 steps, 562.9±124.8 min, 76.4±28.5 min and 20.8±16.7 min, respectively. The times in low- and moderate-intensity activity for the subjects who took over 10,000 steps per day were 102.6±30.9 min and 35.4±19.9 min. BMI did not correlate with daily physical activities (p>0.05); however, age was negatively correlated with daily physical activities (p<0.05). Conclusions: Age impacts on daily physical activities in the elderly. Those elders in the community who take over 10,000 steps per day may simultaneously meet the recommendations for daily time in low-intensity (60 min) and moderate-intensity (20-30 min) physical activity.
• 33 - 45
• 10.6288/TJPH2010-29-01-04

• Link 原著 Original Article
• 照護連續性與醫療利用之相關性探討The Association between Continuity of Care and Healthcare Utilization in Taiwan
• 黃郁清、支伯生、鄭守夏
  Yu-Ching Huang, Po-Sheng Chih, Shou-Hsia Cheng
• 照護連續性 ； 醫療利用 ； 急診 ； 住院
  continuity of care ; healthcare utilization ; emergency department visit ; hospital admission
• 目標：瞭解照護連續性在沒有家庭醫師制度的台灣所呈現的狀況，並檢視較佳的照護連續性是否可以減少急診與住院的利用。方法：利用國家衛生研究院全民健康保險學術資料庫，自2006年抽樣歸人檔選取第一至五組總計20萬人資料為研究樣本，共有127,992人納入分析，資料庫中包含樣本的所有門診、急診與住院紀錄。本研究採用Bice與Boxerman所發展的照護連續性指標(Continuity of Care Index)，並利用負二項式迴歸模型檢視其對急診及住院利用的影響。結果：台灣照護連續性指標平均為0.31，利用負二項式迴歸模型，控制其他變項後發現，在照護連續性高中低三組樣本中，照護連續性高者，其急診次數比照護連續性低者少了50.8%，而住院次數少了38.0%，顯示照護連續性與急診及住院利用間呈現負相關。結論：本研究結果與國際文獻相似，在台灣，照護連續性似乎也有助於健康照護結果的改善，如何提高民眾就醫的照護連續性，是值得考慮的健康照護改革方向。
  Objectives: To explore the current status of continuity of care in Taiwan, and to examine the association between continuity of care and emergency visits and hospitalizations. Methods: This study used the 2006 National Health Insurance research dataset obtained from the National Health Research Institutes. A total of 127,992 persons were included in the analysis. The dataset provided information about patients’ physician visits, emergency room visits and hospitalizations. We adopted the continuity of care (COC) index developed by Bice and Boxerman for this study. Negative binominal regression was used to examine the association between COC and emergency room visits and hospital admissions while related variables were controlled for in the models. Results: The average continuity of care score in Taiwan was 0.31. The results from the regression models revealed that, among the 3 COC groups, people with high COC made 50.8% fewer emergency room visits and had 38.0% fewer hospital admissions when compared with those with low COC. Conclusions: As in previous studies, our preliminary findings imply that continuity of care improves healthcare outcome. Improving continuity of care should be an important part of future healthcare reform in Taiwan.
• 46 - 53
• 10.6288/TJPH2010-29-01-05

• Link 原著 Original Article
• 以傾向分數配對法評估糖尿病論質計酬方案之成效An Effectiveness Evaluation of a pay-for-performance Program for Diabetes Based on the Propensity Score Matching Method
• 林文德、謝其政、邱尚志、吳慧俞、黃一展
  Wen-Der Lin, Chi-Jeng Hsieh, Shang-Jyh Chiou, Hui-Yu Wu, I-Chan Huang
• 糖尿病 ； 論質計酬 ； 傾向分數配對法 ； 可避免住院
  diabetes ; pay-for-performance ; propensity score matching ; avoidable hospitalization
• 目標：健保局於2001年11月推行糖尿病論質計酬方案，過去研究雖呈正向的成效，但未考慮加入方案者選擇偏差的問題，因此本研究目的旨在以糖尿病可避免住院為品質結果指標，並以傾向分數法配對產生可比較之配對組，以釐清該方案之成效。方法：擷取2002-2003年承保抽樣歸人檔中因糖尿病至門診就診並申報檢查者前後一年之就醫資料，藉由傾向分數(PS, propensity score)配對法，先依病患各項特性建構加入方案之機率（即PS）模型，再自未加入方案者（即對照組，共6,855人）中，以1:1的方式配對產生與加入方案者（即介入組，共647人）加入機率相當之配對組樣本（647人），之後再以廣義估計方程式比較組間可避免住院勝算之比值。結果：對照組在前一年之病患特性、就醫情形、檢查申報比例及住院等變項上與介入組有顯著差異，但配對組與介入組各變項之差異均不顯著。方案實施後，介入組之各項檢查申報比例均顯著高於對照組與配對組，但其糖尿病相關可避免住院率增加幅度高於對照組（勝算比1.01, 95%信賴區間為0.98-1.04），卻低於配對組（勝算比0.98，95%信賴區間為0.94-1.02），惟均未達顯著意義。結論：參加論質計酬方案者與未參加者之特性及過去檢查申報比例並不相同。經傾向分數配對法產生與介入組條件相當之配對組，並據此評估論質計酬方案之成效，與傳統上以未參加者為對照組的比較方式有不同的結果。以傾向分數法做為政策評估的工具，或可提供健康政策成效評估的另一種觀點。
  Objectives: This study aimed to evaluate the pay-for-performance (P4P) program for diabetes by using the propensity score method to construct a comparable matching group, and by using the frequency of diabetes-related avoidable hospitalizations to assess outcome. Methods: In order to construct the intervention group, we selected diabetic cases (N=647) from the NHI beneficiaries claim data from 2002 to 2003. Using the propensity score, we selected the matched group (N=647) from the control group (N=6,855) by matching their characteristics and covariates relating to the probability of their participation in the program. Subsequently, we took a generalized equation estimate (GEE) approach with logit link to compare the likelihood of avoidable hospitalization among groups. Results: The distributions of predicators such as patient characteristics, prior ambulatory care utilization, and the rates of laboratory tests and hospitalizations were significantly different between the intervention group and the control group while there were no significant differences between the intervention group and the matched group. Although the proportion of laboratory tests was higher in the intervention group, after the P4P program this group had a higher likelihood of avoidable hospitalization than did the control group with an odds ratio (OR) of 1.01 (95% C.I.: 0.98-1.04) while having a lower likelihood than the matched group with an OR of 0.98 (95% C.I.: 0.94-1.02). Neither difference was significant. Conclusions: The characteristics of the diabetics who participated in the P4P were different from those who did not. After using propensity scores to create a matched group with the same probability as those who participated in the P4P, we found that the results were different from comparisons made with traditional methods. The propensity score method may provide another insight into understanding the effectiveness of a particular health policy.
• 54 - 63
• 10.6288/TJPH2010-29-01-06

• Link 原著 Original Article
• 評論：以傾向分數配對法評估糖尿病論質計酬方案之成效Commentary: An Effectiveness Evaluation of a pay-for-performance Program for Diabetes Based on the Propensity Score Matching Method
• 黃光華
  Kuang-Hua Huang
• 無
  none
• 無
  none
• 64 - 64
• 10.6288/TJPH2010-29-01-07

• Link 原著 Original Article
• 急診病人侵入性檢查及治療同意書簽署人之研究Who Gives Informed Consent on Behalf of Emergency Patients?
• 李芳年
  Fang-Niarn Lee
• 告知後同意 ； 同意書 ； 急診
  informed consent ; consent form ; emergency department
• 無
  Objectives: Informed consent is intended to insure that a patient fully understands the procedures, benefits, and risks involved in a procedure or treatment. Informed consent is necessary not only for ethical and legal reasons, but also to help improve the quality of care and prevent errors. Unfortunately, little is known about who gives informed consent on behalf of patients before a procedure or treatment in an emergency department. This study investigated the signing of informed consent forms by patients or their relatives in such a setting. Methods: We conducted a review of medical records from 252 cases (234 patients) from January to February 2008 in a general hospital's emergency department in Northern Taiwan in order to determine who signed the consent forms for patients about to receive invasive examinations or treatment. Data were analyzed using T-test and MANOVA. Results: In only 81 cases (32.14%) was the consent form signed by the patient. All of the cases who were assigned triage category-I had the consent forms signed by their parents or other legal guardians. Patient under age 20 had the consent forms signed by their parents, while patient over 65 had consent by proxy. Male patients frequently signed the consent forms themselves, while female patients had consent by proxy. Before invasive procedures, patients frequently signed the consent forms themselves. Conclusions: Patients have the right to participate fully in decisions regarding their treatment in order to make decisions that correlate with their personal values. Frequently, this does not happen. Physicians should seek informed consent from patients unless they are incompetent or unconscious.
• 65 - 75
• 10.6288/TJPH2010-29-01-08

• Link 原著 Original Article
• 以目標導向觀點探索動機與健康促進生活型態之關聯性An Exploratory Study of the Relationship between Motivation and a health-promoting Lifestyle: A goal-oriented Perspective
• 李文玄、陳怡穆
  Wen-Hsuan Lee, Yi-Mu Chen
• 健康促進生活型態 ； 調節焦點理論 ； 目標導向 ； 集群分析
  Health-promoting lifestyle ; regulatory focus theory ; goal orientation ; cluster analysis
• 目標：本研究透過健康促進生活型態量表與問卷之調查，探索大台北地區350名受測者之健康促進生活型態、目標導向、主要健康消費行為與人口統計變數上之特色。方法：研究首先以健康促進生活型態量表(Health-Promoting Lifestyle Scale; HPLS)衡量受測者的健康相關日常習性，並詢問受測者之主要健康相關消費行為與對個人未來健康之目標導向，最後透過因素(factor analysis)與集群分析(cluster analysis)，歸納出四大健康族群。結果：四大族群分別為「人際關懷積極族」、「謹慎飲食防病族」、「規律生活態度族」與「運動保健求知族」。本研究發現，整體而言，各族群對健康所秉持的目標導向有顯著的差異，並且族群間的健康促進生活型態以及主要的健康相關產品服務之消費方式也不盡相同。結論：研究成果除可讓相關領域研究者藉此得知國人健康相關消費行為外，亦可進一步深入了解健康行為與內心目標之關連性，且藉由集群方法歸納的四大健康族群特色，可做為政府相關機關或健康推行單位在進行健康宣導與相關資源分配時之參考依據。
  Objectives: The aim of this research was to explore the relationships among respondents' health related goal orientation, health promoting lifestyle, and demographic profile. Methods: We administered the Health Promoting Lifestyle Profile (HPLP) and a questionnaire to 350 respondents in order to assess health promoting lifestyle, main methods of pursuing or maintaining personal health, goal orientation for their own health, current personal health, and basic demographics. Factor analysis was utilized to extract six factors from the HPLP and cluster analysis found four different groups. Groups were named by referring to the results of the HPLP, respondents' goal orientations for their health, and their basic profiles. Results: People who belong to the same group not only have their own unique characteristics in daily health habits and health related product and service consumption but also hold a specific goal orientation about their expectations regarding health. Conclusions: With a series of analyses, the results provide insight into what motivates people with regard to personal health and suggest ways for both public and private institutions to promote health-related policies and activities.
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• 10.6288/TJPH2010-29-01-09