29卷3期

• Link 原著 Original Article
• 探討共病測量方法於健保次級資料之應用Assessing Measures of Comorbidity Using National Health Insurance Databases
• 朱育增、吳肖琪、李玉春、賴美淑、譚醒朝
  Yu-Tseng Chu, Shiao-Chi Wu, Yu-Chun Lee, Mei-Shu Lai, Sing-Chew Tam
• 共病 ； CCI ； 次級資料 ； 行政申報資料
  comorbidity ; CCI Charlson Comorbidity Index ; administrative data ; claim data
• 目標：全民健保次級資料已成為醫療服務研究重要之資料來源，如何適當測量病人共病（合併症；comorbidity）情形，為一重要議題，然國內尚未有研究針對不同學者發展之共病測量方法及其適用情況進行實證探討。方法：採回溯性世代研究，選取5種共病方法進行比較，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。以2002年因慢性腎臟疾病、肺炎住院之病人為對象，比較不同方法預測院內及住院一年內死亡情形之差異。共病採用「類別」及「權重」二種分析方式。判斷共病之資料期間或來源，包括「當次住院」、「當次併前一年住院」、「當次併前一年住院及門診」三種。以邏輯斯迴歸之c統計量比較各方法之相對表現。結果：類別模式下，以D-M's CCI及Elixhauser方法表現較佳。權重模式時，以D-M's CCI表現較佳。對CCI方法，以當次併前一年住院資料表現最佳。以類別模式之Elixhauser預測院內死亡情形，僅以當次住院資料表現最佳。增加住院前門診就醫資料則無法改進預測力。結論：三種版本之CCI方法中，以D-M's CCI表現較佳，建議未來研究者可選用此方法，並使用「當次併前一年住院」資料。當研究樣本數夠大，可採類別變項之D-M's CCI或Elixhauser方法。使用Elixhauser預測院內死亡情形時，建議可僅使用「當次住院」資料。當研究樣本數小採計算權重分數時，建議使用D-M's CCI。
  Objectives: National Health Insurance databases have become an important resource for studies in health services research. It is important to measure comorbidity; however, there has been no study to investigate the performance of the various available claims-based measures of comorbidity in Taiwan. Methods: Five different measures of comorbidity including Deyo's Charlson Comorbidity Index (CCI), D-M's CCI, D'Hoore's CCI, Elixhauser and Chronic Disease Score (CDS), were chosen for investigation in this retrospective cohort study. We compared the performance of the five measures of comorbidity in predicting in-hospital and one-year mortality among patients with chronic renal disease and pneumonia. The measures of comorbidity were implemented as individual components (the presence or absence of the comorbid condition), and also as an index (weighted sum of comorbidity indicators). The measures of comorbidity were created based on 3 sources of data: the index hospitalization, the index and prior hospitalizations, and the index and prior hospitalizations as well as outpatient visits. The c-statistics of logistic regression were used to compare performance. Results: Better discrimination was achieved with the D-M's CCI or the Elixhauser method when using individual components. When measures of comorbidity were used as indices, better discrimination was achieved with the D-M's CCI. For CCI methods, patient information available from both the index and prior hospitalizations yielded the best results. For the Elixhauser method, patient information available from the index hospitalization yielded the best results when predicting in-hospital death. Adding prior outpatient data did not improve the performance of the measures. Conclusions: D-M's CCI performed best, and future investigators might consider this method. When the sample size is large enough, D-M's CCI or the Elixhauser method could be implemented as the individual components. If the sample size is small, then D-M's CCI used as an index and information from the index and prior hospitalizations would be more appropriate.
• 191 - 200
• 10.6288/TJPH2010-29-03-01

• Link 原著 Original Article
• 台灣地區自殺身亡率及其相關因素之研究：1997-2003A Study of Taiwan's Suicide Mortality Rate and Related Factors: 1973-2003
• 陳楚杰、葉瑞垣、李中一、 陳靖宜、洪湘雯
  Chu-Chieh Chen, Jui-Yuan Yeh, Chung-Yi Li, Chin-Yi Chen, Hsaing-Wen Hung
• 台灣地區 ； 自殺身亡率 ； 流行病學
  Taiwan ; suicide mortality rate ; epidemiology
• 目標：自殺是全球所共同關心的重要議題，亦是台灣地區的十大死因之一，因此，本研究擬以死因登記檔，探討台灣地區自殺身亡率及其相關因素。方法：本研究利用衛生署「死因登記檔」，選取1997年至2003年死亡原因為國際疾病分類第九版臨床修正版(ICD-9-CM)代碼E950至E959者（自殺身亡），計18，130人為個案組，其次，隨機選取非自殺身亡者（排除死亡原因為精神疾患者）72，209人為對照組，故本研究之研究對象為90，339人。結果：在自殺身亡率概況方面，台灣地區1997年至2003年每十萬人口自殺身亡人數及自殺身亡率有隨年代增加而增加的線性趨勢。在與自殺身亡相關因素方面，於控制其他變項後，發現年齡、性別、婚姻狀況別、季節、假日別、地區別、都市化層級別與研究對象是否自殺身亡有統計上的顯著相關。結論：台灣地區自殺身亡率有隨年代增加而增加的線性趨勢，自殺防治工作不容延怠。
  Objectives: Suicide is one of the world's most important concerns and one of the ten leading causes of death in Taiwan. This study investigated the suicide mortality rate and related factors in Taiwan through the datasets of the death registration. Methods: In this study, the datasets of the death registration of the Department of Health, Executive Yuan, R.O.C. (Taiwan) were utilized. First, codes E-950-E959 (death from suicide) of the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9CM) from 1997 to 2003, identified a total of 18, 130 people. Then, 72, 520 people who died from other causes were randomly selected as the control group. After eliminating 311 people from the control group whose cause of death was listed as mental illnesses (290-319) but may have been suicides, the study subjects totaled 90, 339. Results: With regard to the profile of suicide mortality, the suicide deaths per hundred thousand people and the suicide mortality rates showed a positive linear trend over the 30-year study period. Among the related factors, age, gender, marital status, season, holidays, region, and level of urbanization were significantly correlated with deaths by suicide. Conclusions: In Taiwan, the suicide mortality rates have shown an upward linear trend and work in suicide prevention has become a critical need.
• 201 - 215
• 10.6288/TJPH2010-29-03-02

• Link 原著 Original Article
• 評論：台灣地區自殺身亡率及其相關因素之研究：1997-2003Commentary: A Study of Taiwan's Suicide Mortality Rate and Related Factors: 1973-2003
• 蕭朱杏、江宜珍
  Kate Chu-Hsing Hsiao, Yi-Chen Chiang
• 無
  none
• 無
  none
• 216 - 217
• 10.6288/TJPH2010-29-03-03

• Link 原著 Original Article
• 作者回覆：台灣地區自殺身亡率及其相關因素之研究：1997-2003 Response: A Study of Taiwan's Suicide Mortality Rate and Related Factors: 1973-2003
• 陳楚杰、葉瑞垣、李中一、 陳靖宜、洪湘雯
  Chu-Chieh Chen, Jui-Yuan Yeh, Chung-Yi Li, Chin-Yi Chen, Hsaing-Wen Hung
• 無
  none
• 無
  none
• 217 - 217
• 10.6288/TJPH2010-29-03-04

• Link 原著 Original Article
• 加倍自然產支付能否降低部腹產比例？Can Doubling the Payment for Vaginal Delivery Lower the Cesarean Section Rate in Taiwan?
• 韓幸紋、連賢明
  Hsing-Wen Han, Hsien-Ming Lien
• 剖腹產 ； 支付標準 ； 誘發性需求
  cesarean section ; medical payment ; induced demand
• 目標：塞於台灣居高不下的剖腹產率，健保局於2005年5月將自然產支付點數加倍和剖腹產點數一致，期望藉由加倍自然產給付來降低剖腹產率。本研究分析該給付調整是否達成其政策目的。方法：本文利用2003至2007年健保資料庫頭胎生產案件，估計上使用邏輯機率模型(logistic model)、固定效果(fixed-effect)和多層次(multi-level model)模型來分析給付調整對降低剖腹產利用的影響，並觀察長(2003-4 v. s 2006-7)、短(2004 v. s 2006)期有無不同效果。此外，本文將剖腹產進一步依原因區分為一般性剖腹(scheduled cesarean sections)及緊急剖腹(emergency cesarean sections)兩種，觀察政策效果是否依剖腹緊急程度而有不同。結果：在控制產婦年紀、醫師接生時點，和醫師特性的考量等因素下，各種模型均顯示提高自然產給付對頭胎樣本不論是短期或長期時，一般性和緊急剖腹產率上皆無顯著變化。結論：這結果隱含醫師接生所得可能不是決定生產方式的主要因素，健保局需考慮其他方法來降低剖腹產。
  Objectives: In light of the high cesarean section (c-section) rate in Taiwan, in May 2005 the Bureau of National Health Insurance (BNHI) doubled the payment for vaginal delivery to the same amount it paid for delivery by c-section. This study investigated whether this payment change effectively reduced the c-section rate in Taiwan. Methods: We obtained information about all obstetric cases between 2003 and 2007 from National Health Insurance data. Logistic, fixed-effect, and multilevel models were utilized to determine if the payment increase lowered the short term (2004 vs. 2006), or long term (2003-4 vs. 2006-7) c-section rates for first-borns. Additionally, we separated c-sections into two groups based on their causes, scheduled or emergency, to examine if the payment increase produced different effects on these two groups. Results: After controlling for the women age at delivery, birth order of the child, provider characteristics, and time of delivery, results of all models indicated that the payment change produced almost no effect on the reduction in scheduled or emergency c-section rates for first-borns, in either the short or long term. Conclusions: Our findings indicated that the reimbursement scheme for deliveries might not be the key factor for obstetricians in determining the use of c-section. BNHI might consider other policy instruments in seeking to lower the c-section rate.
• 218 - 227
• 10.6288/TJPH2010-29-03-05

• Link 原著 Original Article
• 社區民眾回診行為及影響因素探討Factors Influencing the return-visit Rate for Referred Patients in a Community to Their Primary Care Clinics
• 林佩君、劉英琪
  Pei-Jun Lin, Ying-Chi Liu
• 回診 ； 基層診 ； 基層醫師 ； 受轉醫師 ； 轉診回診率
  return visit ; primary care clinics ; primary care physicians ; referral physicians ; return-visit rate
• 目標：建構良好的分級轉診制度，有助於醫療資源作有效率配置。本研究旨在探討某社區基層診所轉診病患回診之影響因素，以提供雙向轉診制度政策之參考。方法：本研究針對台灣地區台中市之33個基層診所之轉診病患501名，訪員透過電話進行問春訪查，共回收有效樣本403份（有效回收率80.4%)，以sPssl40統計軟體進行邏輯斯迴歸分析。結果：研究結果發現雙向轉診制度實施後，基層診所轉診回診率為28.3%仍偏低，邏輯斯迴歸分析結果顯示病患以診所為習慣說醫地、病患之轉診目的為檢查或診斷、診所醫師囑咐回診以及受轉醫師囑咐回診，均有顯著較高之回診率。結論：由研究結果顯示，轉診病患回診的影響因素，除了轉診目的外，未來衛生政策規劃，若能積極推動家庭醫師制度，教育民眾以基層診所為習慣說醫地，且基層家庭醫師及受轉醫師均記得囑咐轉診病患回診，則可提高社區民眾之轉診回診率。
  Objectives: A well-constructed hierarchical medical care system makes effective use of medical facilities and resources. This study explores the factors influencing the return of a select group of referral patients to their primary care clinics in order to give the government constructive feedback for implementing an effective bi-directional referral system. Methods: The sample included five hundred and one referral patients chosen from thirty-three primary care clinics in Taichung, Taiwan. Data was collected by telephone interviews with 403 responders (a return rate of 80.4%). Logistic regression was used to determine the factors associated with return. Windows SPSS 14.0 was employed for analysis. Results: In the government's existing bi-directional referral system there was a relatively low return rate of 28.3% for referred patients. Results from logistic regression showed four primary reasons for returning: 1) patients opted for their original primary care physician out of habit; 2) the purpose of the referral was for testing or diagnosis; 3) these were the specific instructions of the referring physicians; 4) these were the specific instructions of the referred physicians. Of these, referral for testing or diagnosis was mentioned most often. Conclusions: In the future, public health policy could improve referred-patient return rates through patient and physician education. This should stress the value of using primary care and family clinic physicians and remind general practice clinic and hospital physicians to encourage referred patients to return to those primary care clinics.
• 228 - 237
• 10.6288/TJPH2010-29-03-06

• Link 原著 Original Article
• 女性海洛因注射者之愛滋感染情形與保險套使用行為意向階段之調查研究A Survey of HIV sero-prevalence and Condom Use among Women Who Injected Heroin
• 李思賢
  Tony Szu-Hsien Lee
• 保險套使用 ； 海洛因注射者 ； 愛滋病毒 ； 跨理論行為模式 ； 女性
  Condom Use ; Heroin Injection User ; HIV ; The Transtheoretical Model ; Women
• 目標：本文目的是探討女性海洛因注射者感染愛滋情形與使用保險套來防治愛滋感染之意向。方法：本研究有301位自陳入戒治所前半年有海洛因注射經驗、年齡超過18歲、並且識字的女性戒治犯志順填寫問卷、問卷調查包括基本資料、愛滋感染與否、愛滋傳染相關知識、以及性行為與保險套使用意向。結果：研究對象愛滋盛行率為34%；除了一位以外，其他女性都知道未使用保險套性交行為與針具共用會有可能傳染愛滋。最後一次性交時，有19.73%有使用保險套；受訪女性的性伴侶有52.67%是藥物注射者；在保險套使用行為階段，有54.4%目前是在行動期、11.3%在準備期、19%在沈思期、以及15.3%在沈思前期。經過卡方檢定發現，愛滋感染情形、年齡、伴侶是否為藥物注射者、以及最後一次性交時是否使用保險套與本研究受訪者在保險套使用行為階段達到統計上顯著差異。結論：本研究結果發現已知自己感染的女性比起尚未感染者有顯著較高的保險套使用動機與意向。
  Objectives: The purpose of this article was to investigate the prevalence of HIV and intent to use condoms among women who injected heroin. Methods: A total of 301 incarcerated women with a history of heroin injection during the last six months before incarceration participated. All were at least 18 years of age and literate. They completed a survey that consisted of background information, HIV status, knowledge of the routes of HIV transmission, sexual behaviors, and the stage of intention to use condoms. Results: The prevalence of HIV was 34% and all but one participant knew that unprotected sex and sharing injecting equipment can transmit HIV. Results showed that 19.73% used condoms during the last intercourse and 52.67% of respondents' partners were injection drug users (IDUs). Most participants (54.4%) were currently in the action stage of condom use, while 11.3% were in the preparation stage, 19% were in the contemplation stage, and 15.3% were in the pre-contemplation stage. Results from chi-square tests indicated that HIV serostatus, age, an IDU partner, and condom use during the last sexual encounter were significantly different across the stages of condom use. Conclusions: The findings indicate that knowing positive status can help increase the motivation and intention to use condoms.
• 238 - 246
• 10.6288/TJPH2010-29-03-07

• Link 原著 Original Article
• 健康促進學校推動團隊領導方式、集體效能與團體效果之現況及關係模式驗證－以台灣小學為例The Relationship between Leadership Style and Collective Efficacy on the Effectiveness of Health Promotion Work Teams in Taiwanese Elementary Schools
• 牛玉珍、劉潔心、邱詩揚、晏涵文
  Yu-Zhen Niu, Chieh-Hsing Liu, Shy-Yang Chiou, Han-Wen Yen
• 健康促進學校 ； 集體效能 ； 團體效果
  Health Promoting School ; Collective Efficacy ; Group Effectiveness
• 無
  Objectives: The aim of this study was to examine the relationship between the leadership style and collective efficacy on the effectiveness of health promotion work teams in Taiwanese elementary schools. Methods: The study design was cross-sectional. According to the size of the districts and individual schools, a stratified random sample was used to select subjects from 518 health promotion work teams approved by the Ministry of Education in 2007. Four hundred and ninety-seven subjects were recruited and the response rate was 86.32% (n=429). Structured questionnaires including demographics, leadership style, collective efficacy and group effectiveness were used to collect data. The data were analyzed using descriptive statistics, regression and SEM. p<.05 was considered as statistically significant. Results: The leadership style had. 49 direct effect and. 32 indirect effect on Group Effectiveness through collective efficacy. The total effect of leadership style on Group Effectiveness was .81. Leadership style and collective efficacy were the major predictors as they accounted for 53.9% of the total variance for Group Effectiveness. Conclusions: Better leadership style will have direct and indirect effects on group effectiveness.
• 247 - 260
• 10.6288/TJPH2010-29-03-08

• Link 原著 Original Article
• 機動車事故與台灣城鄉平均餘命差距之相關分析Analysis of the Association of Urban/Rural Gap between Motor Vehicle Accidents and Life Expectancy in Taiwan
• 鍾文慎、蔡善璞、蔡旻光、溫啟邦
  Wen-Shen Isabella Chung, Shan-Pou Tsai, Ming-Kwang Tsai, Chi-Pang Wen
• 機動車事故死亡率 ； 平均餘命
  motor vehicle accident ; life expectancy
• 無
  Objectives: To explore the differential impact of urban and rural areas on motor vehicle accidents (MVA) and life expectancy in Taiwan. Methods: Data for population, death registration, income, and motor vehicle registration were acquired from the government. Life expectancy (LX) and its gains after MVA deaths were eliminated were calculated for Taiwan as a whole and for each city and county. Stepwise Regression Models were used to examine the association of MVA with the gap in LX. Results: Residents in most of the rural areas had a shorter LX, ranging from 71.6 to 77.6 years, than did urban residents whose LX ranged from 76.9 to 80.8 years. MVA mortality contributed 4.0% to 16.2% of the gaps in LX between Taipei City and each of the counties or cities. The impact of MVA on LX ranged from 0.6 to 1.1 years in rural areas and from 0.2 to 0.5 years in urban areas. MVA mortality was significantly negatively correlated with life expectancy (r=-0.87, p<0.01) and influenced the gaps in LX (Partial R^2=0.75, p<0.0001). Urbanization was the most important factor in reducing MVA mortality (Partial R^2=0.66, p<0.0001) and heavy motorcycle was the only significantly influential motor vehicle on MVA mortality (Partial R^2=0.03, p<0.0001). Conclusions: Motor vehicle accidents were responsible for the worsening health disparity between urban and rural areas in Taiwan. The rural suffered a higher impact from motor vehicle density and its associated accidents on life expectancy than their urban counterparts. Reducing motor vehicle accidents would most benefit the life expectancy of populations in rural areas.
• 261 - 272
• 10.6288/TJPH2010-29-03-09

• Link 原著 Original Article
• 台北市長期照護機構空氣中細菌之分佈與特性Distribution and Characteristics of Airborne Bacteria in long-term Care Facilities in Taipei, Taiwan
• 方盈禎、趙馨、吳欣橋、陳叡瑜、莊瑛智、張振平、張大邦
  Ying-Chen Fang, Hsing Jasmine Chao, Hsin-Chiao Wu, Ruey-Yu Chen, Ying-Chih Chuang, Cheng-Ping Chang, Ta-Pang Chang
• 長期照護機構 ； 職業衛生 ； 可培養性細菌
  long-term care facilities ; occupational health ; culturable bacteria
• 目標：瞭解我國長期照護機構空氣中細菌菌落濃度的分佈特性，以及影響細菌暴露的環境因子。方法：針對台北市五家長期照護機構進行密集的環境採樣，測量空氣中可培養性細菌菌落濃度及室內空氣品質因子，並利用統計模式評估影響室內細菌濃度的環境因子。結果：五家機構室內總菌落濃度平均值為282-812 CFU/立方公尺，部分機構的平均濃度已超過環保署空氣品質建議值500 CFU/立方公尺。最常出現的細菌類型為球菌及桿菌；革蘭氏陰性菌的濃度皆高於陽性菌。部分機構空調及通風系統出風口菌落濃度高於室內濃度，顯示空調及通風系統為微生物污染的可能來源之一。根據多變項迴歸分析結果，採樣日期（平日、假日）、採樣時段（上、下午）、機構別、有無使用空氣清淨機、二氧化碳濃度、採樣點人數等因素和菌落濃度有顯著相關。結論：各機構由於建築特性、通風量、機構內人數、清潔方式與頻率有所差異，室內微生物濃度的分佈亦不同。若機構能有效控管環境品質，應能大幅降低疾病的發生與傳播
  This study investigated the characteristics and determinants of airborne bacteria in long-term care facilities in Taiwan. Methods: We did intensive environmental samplings, including airborne culturable bacteria and major indoor air quality factors, in five long-term care facilities in Taipei. We used statistical models to evaluate the environmental determinants of the levels of indoor bacterial colonies. Results: The average total bacterial colony concentrations in the study facilities ranged from 282 to 812 CFU/m^3. The mean bacterial colony concentrations in several facilities exceeded 500 CFU/m^3, the maximum level recommended by the Taiwan Environmental Protection Administration. Bacilli and cocci were the dominant bacteria in the study facilities. The concentrations of Gram-negative bacterial colonies were higher than those of Gram-positive bacteria. In some study facilities, the bacterial colony levels near the diffusers of AC (air conditioner) or HVAC (heating, ventilating and air conditioning) systems were higher than indoor concentrations in general, indicating that AC and HVAC systems might be potential sources of microorganisms. According to the results of multiple regression models, sampling time, different facilities, using an air cleaner or not, carbon dioxide levels, and number of people were significantly associated with indoor bacterial concentrations. Conclusions: Building characteristics, ventilation rate, number of people, and cleaning method and frequency were essential factors influencing indoor microbial distributions in long-term care facilities. Effective environmental control can reduce disease transmission and protect the health and safety of residents and staff in long-term care facilities.
• 273 - 282
• 10.6288/TJPH2010-29-03-10