30卷4期

• Link 綜論 Review Article
• 過勞職災的認定爭議與政策因應：日本經驗對台灣的啟示Disputes and Policy Responses Concerning the Hazards of Overwork and Workers' Compensation: Experiences in Japan and Their Implications for Taiwan
• 鄭雅文、吳宣蓓、翁裕峰
  Ya-Wen Cheng, Shiuan-Be Wu, Yu-Feng Wong
• 工作壓力 ； 職業傷病 ； 職災補償制度 ； 預防 ； 日本 ；
  job stress ; occupational injuries and diseases ; worker's compensation ; prevention ; Japan
• 台灣近年來疑似工作過度而猝死的事件頻傳，政府為因應此職災認定爭議，陸續參考日本規範，頒布修訂相關認定指引。本研究採文獻回顧與政府統計分析，旨在回顧日本過勞職災認定爭議的發展歷程，描述歷年職災認定狀況，最後探討日本對於過勞問題所採的預防策略。我們建議，台灣應參考日本經驗，檢討當前職災認定標準與程序；針對工時規範與工時過長工作者的健康管理，應修改相關法規，使雇主與醫師能落實預防責任；政府並應整理並公布職災認定相關統計資料，以利外部監督。我們亦應留意日本過勞政策之缺失，以期建立更好的規範。
  In Taiwan, cases of sudden death linked to overwork are a growing concern. The government has adopted several Japanese regulations and guidelines which concern the recognition of and compensation for work-related injuries and diseases that are due to overwork. Based on the literature and analyses of official statistics from the worker's compensation system in Japan, we examined the development of policies concerning the recognition and prevention of overwork hazards in Japan. Based on this review, we suggest that Taiwan should reduce the barriers for workers' compensation by revising the criteria for the recognition of work-related diseases. Regulations concerning working hours and the health management of workers with prolonged working hours should also be improved. In addition, statistics and the related content of workers' claims for compensation should be made public. Taiwan should also be aware of and avoid the limitations of the Japanese approach.
• 301 - 315
• 10.6288/TJPH2011-30-04-01

• Link 原著 Original Article
• 台灣阿茲海默症病人確診前的門診醫療利用The Utilization of Ambulatory Care Services before the Diagnosis of Alzheimer's Disease in Taiwan
• 蔡維河、侯素秋、黎家銘、楊清泉
  Wer-Her Tsai, Shu-Chu Hou, Chia-Ming Li, Ching-Chyune Yang
• 阿茲海默症 ； 門診醫療利用 ； 病例對照研究 ； 全民健保研究資料庫
  Alzheimer's disease ; ambulatory care utilization ; case-control study ; National health insurance reseach database
• 目標：本研究旨在探討台灣阿茲海默症病人確診前3年內的門診醫療利用，及與非阿茲海默症病患間是否存在顯著差異。方法：採用1996至2007年國家衛生研究院2005年全民健康保險承保抽樣歸人檔資料，採用隨機對照研究，篩選用藥明細首次出現阿茲海默症用藥（乙醯膽鹼酶抑制劑與NMDA受體拮抗劑）之確診病人共845人為病例組，另經性別、年齡、查爾森共病指數等匹配隨機選取1,677人為對照組，比較確診前三年兩組個案同期門診醫療利用的差異。結果：阿茲海默症病人確診前的門診醫療利用明顯高於對照組。阿茲海默症病人確診前1年的總門診次數及神經精神科門診次數，診察費、藥費、處置費、及總費用等4項費用，均較對照組高，且均達統計顯著差異水準。其中，阿茲海默症病人確診前3年期間的藥費，均顯著較對照組為高。結論：台灣阿茲海默病人確診前門診醫療利用，高於非阿茲海默症個案。
  Objectives: The aim of this study was to assess if the rate of ambulatory care utilization within three years before the diagnosis of Alzheimer's disease was significantly different from that of non-Alzheimer's patients. Methods: The data were drawn from the National Health Insurance Research Database from 1996 to 2007. A case-control design was employed. A total of 845 patients treated with Alzheimer's disease medications (cholinesterase inhibitors and NMDA receptor antagonists) were the case group. Another 1,677 patients who were randomly matched by age, sex, and Charlson index served as the control group. Ambulatory care utilization by the case group within three consecutive years before diagnosis was explored and compared to that of the control group. Results: Alzheimer's disease patients used significantly more ambulatory care services (neurology and psychiatry clinics, diagnostic fees, drug fees, treatment fees) than did the control group within the first year before diagnosis. Drug fees within the three consecutive years before diagnosis were significantly higher than those of the control group. Conclusions: Patients with Alzheimer's disease patients used significantly more ambulatory care services than did non-Alzheimer's patients before that diagnosis was made.
• 316 - 325
• 10.6288/TJPH2011-30-04-02

• Link 原著 Original Article
• 部分負擔調整對醫療利用的衝擊：以2005年政策調整為例How Did the Increase in NHI Copayments in 2005 Affect the Use of Health Care?
• 許績天、韓幸紋、連賢明、羅光達
  Ji-Tian Sheu, Hsing-Wen Han, Hsien-Ming Lien, Kuang-Ta Lo
• 部分負擔 ； 醫療利用 ； 容量限制
  payment ; health care utilization ; capacity constraints
• 目標：本文探討2005年健保局調高部分負擔對民眾醫療利用和就醫選擇影響。方法：本文使用2005年健保百萬歸人檔中的西醫門診資料來分析政策效果。由於2005年部分負擔調高僅侷限於醫院，政策效果理應依民眾所屬鄉鎮使用診所高低而有差別。本文因而將病患經常就醫鄉鎮按平均診所就醫比例區分三組：低於65%（分組Ⅰ），65%-75%（分組Ⅱ），高於75%（分組Ⅲ），採障礙模型(Hurdle model)估計部分負擔調高後對各組就醫機率與次數影響。結果：部分負擔調整顯著減少就醫機率及門診次數。整體而言，調漲後半年門診次數減少0.34次（或6.1%），其中醫院次數為0.07次，高層級醫院為0.01次。更重要的是，各分組間政策效果存在相當差異。處於使用醫院最高比例鄉鎮（分組Ⅰ）民眾，降低醫院（和高層級醫院）利用；相反的，處於使用醫院比例最低鄉鎮（分組Ⅲ）民眾，增加醫院（和高層級醫院）利用。這估計結果即使將樣本時間延長至政策前後一年仍相同。結論：部分負擔調高的確減少就診次數，降低民眾醫療利用。另外，政策效果會依民眾經常就醫地點而有顯著差異。一個可能解釋為醫院服務的容量限制(capacity constraint)。因醫院存在容量限制，使得鄰近醫院的分組Ⅰ民眾較易接受醫院服務，但是當部分負擔調漲使得分組Ⅰ民眾降低醫院就醫，此時就醫距離較遠鄉鎮民眾（分組Ⅲ）填補原先醫院門診空缺，使得分組Ⅲ民眾醫院利用反而在部分負擔調高後有所增加。
  Objectives: The aim of this study was to evaluate the impact of the increase in NHI copayments in 2005 on the choice and use of health care. Methods: We analyzed the outpatient utilization of one million NHI enrollees between 2004 and 2006. Because the policy increased only the copayment for hospital visits, it was plausible to expect that the effect would be smaller for individuals residing or working in towns with a lower propensity for visiting hospitals. Therefore, based on the average percentage of clinical care in the town of residence, the sample was separated into three groups: less than 65% (group ?), between 65 and 75% (group?), and more than 75% (group ?). We then used the Hurdle regression model to examine the effect of the new policy on the probability of health care utilization, and the number of outpatient visits for each group. Results: Our results showed that the increase in copayment significantly reduced the probability and the number of outpatient visits. We estimated that outpatient use six months after the policy change decreased by 0.34 visits (or 6.1%), of which 0.07 were visits to hospitals, and 0.01 were visits to regional hospitals or above. More importantly, the effect differed substantially across groups. Individuals residing or working in towns with a higher propensity to visit hospitals (group ?) reduced their visits to hospitals after the policy change. On the other hand, individuals residing or working in towns with a lower chance of visiting hospitals (group 3) increased their visits. These findings were robust even after extending the sample period from six to 12 months. Conclusions: Our results confirmed that a copayment increase in 2005 reduced the use of outpatient services. Nonetheless, the effect differed substantially across groups with various propensities to make hospital visits. One explanation might be that there is a capacity constraint that limits outpatient services offered by hospitals. While individuals residing or working in towns near hospitals reduced their hospital visits due to the price hike, those residing or working in more distant towns increased their hospital visits.
• 326 - 336
• 10.6288/TJPH2011-30-04-03

• Link 原著 Original Article
• 財務誘因與台灣區域醫院醫師服務績效之跨層次分析A Multievel Analysis of Financial Incentives and Physician Performance in Taiwan's Regional Hospitals
• 汪秀玲、羅永欽、洪純隆
  Hsiu-Ling Wang, Joon-Khim Loh, Shen-Long Howng
• 服務績效 ； 成果基礎誘因 ； 系絡效果 ； 層級線性模式
  service performance ; outcome-based incentive ; contexual effect ; hierarchical linear modeling
• 無
  Objectives: Previous studies of performance have focused on either organizational or individual-level analysis. Multilevel theory has been used to explore the effect of the method of compensation on the quality and quantity of individual physician services after hospital global budgeting (HGB) was implemented in Taiwan. Methods: We used a sample of convenience of 33 regional hospitals that participated in HGB and surveyed managers and physicians with structured questionnaires in 2008. A total of 210 valid questionnaires from 24 hospitals were returned. We conducted hierarchical linear modeling analyses and demonstrated that both individual-level and organizational-level factors were associated with physician performance. Results: The effect of the variable compensation level on quality of physicians' service, productivity in the outpatient department (OPD) and in the inpatient department (IPD) was not significant (0.250, 0.171, 0.253, all p>.05). The ratio of beds to physicians negatively affected individual quality (-0.044, p<.01) while positively influencing productivity in and IPD (0.040, p<.05). The OPD production of physicians in public or non-profit hospitals was higher than those in private ones (43.7%, 79.1%). Physician quality and IPD production in northern hospitals was higher than that in the southern area (18.3%, 45.1%). Tenure was positively related to physicians’ productivity (0.846, p<.001; 0.523, p<.05). The OPD of internists was higher than that of 27.0% of surgeons. Overall, the individual-level factors explained 19.96%, 20.74%, 18.86% of within-hospital variance on performance and hospital-level factors explained 54.13%, 56.93%, 36.26% of between-hospital variance. Conclusions: Variable compensation did not stimulate physicians to reduce quality or productivity. Hospital features and physician performance were co-determinant, thus weakening the contextual effect of financial compensation.
• 337 - 346
• 10.6288/TJPH2011-30-04-04

• Link 原著 Original Article
• 利用地區差異與人口學特徵評估全民健保資料庫人口居住地變項之推估原則Using Regional Differences and Demographic Characteristics to Evaluate the Principles of Estimation of the Residence of the Population in National Health Insurance Research Databases (NHIRD)
• 林民浩、楊安琪、溫在弘
  Min-Hau Lin, Ann-Chi Yang, Tzai-Hung Wen
• 居住地變項 ； 全民健保資料庫 ； 地理資訊系統 ； 人口估計 ； 健康服務研究
  Place-of-Residence ; National Health Insurance Research Databases NHIRD ; Geographic Information Systems GIS ; Population Distribution ; Health Service Research
• 目標：瞭解地理區位差異在公共衛生研究扮演重要的角色，但在全民健保資料庫中，並不包含居住地資訊，侷限探索地理與健康關連的可行性。本研究之目的在於提出估計居住地變項的原則及其適用性。方法：利用2005年承保抽樣歸人檔，依不同被保險人特質及就醫地，建立三種不同的居住地估計方法，並與內政部各鄉鎮市區現住人口數為基準，比較其相關係數，再以肺癌與肝癌就醫人數的鄉鎮分佈進行驗證。結果：以被保險人投保地、呼吸道感染門診就醫地、被保險人身分、投保類別與被保險人年齡相互搭配之居住地估計方法，在不同都市化程度的鄉鎮與不同年齡層都有較佳的表現。僅以投保地為居住地或僅以呼吸道感染就醫地為居住地的估計方法，則僅適用於特定鄉鎮市區與特定年齡層人口。結論：本研究比較不同都市化程度與年齡結構的分層結果，確認居住地估計方法的可行性，並瞭解不同居住地估計方法的適用性。本研究結果可提供研究者選擇適合之居住地估計原則。
  Objectives: Understanding the geographic patterns and regional differences in health status plays an important role in public health research; however, the place-of-residence (township level) of an insured is not available in National Health Insurance Research Databases (NHIRD). The objective of this study was to propose principles for estimating the place-of-residence (township level) in NHIRD. Methods: Based on demographic characteristics, insurance classification, location of hospital visit, and insurance registration of the insured, this study compared three methods of estimating the place-of-residence (township level) from the Longitudinal Health Insurance Database of NHIRD in 2005. Official statistics of the usual resident population in each township from the Department of the Interior were used as reference data for comparisons among the three methods. The study further verified these methods by comparing the estimated numbers and official statistics for the medical treatment of lung and liver cancer patients in 2005. Results: This study found that the method which combined insurance classification, location of hospital visit, and insurance registration provided an optimal estimate of place-of-residence in each area by different levels of urbanization and age-group. Consideration of either location of hospital visit or insurance registration may be appropriate for specific townships and age groups. Conclusions: This study demonstrated the feasibility of estimating place-of-residence in NHIRD and the applicability of these proposed methods.
• 347 - 361
• 10.6288/TJPH2011-30-04-05

• 評論 Commentary
• 評論：利用地區差異與人口學特徵評估全民健保資料庫人口居住地變項之推估原則Commentary:Using Regional Differences and Demographic Characteristics to Evaluate the Principles of Estimation of the Residence of the Population in National Health Insurance Research Databases (NHIRD)
• 呂宗學
  Tsung-Hsueh Lu
• 無
  none
• 無
  none
•  
• 無none

• Link 原著 Original Article
• 血液透析之末期腎病併多重器官衰竭之病人，退出血液透析的影響因素探討－質性比較分析法What Makes Doctors Suggest Withholding Hemodialysis Treatment for Patients with end-stage Renal Disease and Multiple Organ Failure? A Qualitative Comparative Analysis
• 張必正、陳端容、吳寬墩
  Bih-Jeng Chang, Duan-Rung Chen, Kwan-Dun Wu
• QCA研究 ； 質性研究 ； 撤除透析 ； 末期腎病 ； 末期照護
  qualitative comparative analysis ; qualitative research ; withhold hemodialysis ; End-Stage renal disease ; End-of-Life care
• 目標：2003年起，台灣末期腎病的發生率與盛行率皆為世界第一。全民健保施行後，有更多重症病人接受洗腎，即使病情不樂觀，仍不願放棄治療。本研究希望了解醫師建議病人退出透析的原因，及當醫師建議退出透析後，病人／家屬同意與否的因素。方法：8位腎臟科與急重症專科醫師提供末期腎病個案，並接受訪談。共蒐集31例。利用QCA(Qualitative Comparative Analysis)研究法進行質性資料分析。結果：『無法積極治療』是醫師建議退出透析最重要的必要條件。當『家人對治療的信念不一致』，即使醫師建議退出，家屬仍會拒絕。『年齡不大且透析時間長』是另一個意見不同的原因。結論：如果家屬間對治療的信念一致，而且醫師判定為「病患年齡大、情緒不佳、且預後不佳」時，醫師會建議退出透析，家屬多能接受。當家屬間對治療的信念不一致，醫師實需強化醫病溝通，建議退出透析，易引起爭議，不易提升末期照護品質。
  Objectives: The incidence and prevalence of End-Stage Renal Disease (ESRD) in Taiwan have ranked first in the world since 2003. Under National Health Insurance, more ESRD patients with severe multiple organ failure undergo hemodialysis (HD) without regard to the quality of end-of-life. The purposes of this study were: first, to examine the conditions for which doctors would suggest that their patients consider withholding HD; second, to examine the conditions for which doctors had suggested that their patients consider withholding HD but the patients' families declined. Methods: Eight nephrologists and ICU specialists were asked to provide detailed information about their ESRD patients without revealing their names or other identifying data. Thirty-one clinical cases were collected. The Qualitative Comparative Analysis (QCA) method was employed to analyze the qualitative data. Results: The crucial factor associated with a doctor's suggestion to withhold HD was that the treatment would not be effective. When there were family disputes, the families would decline doctors' suggestions to withhold HD. Young age with a long duration of dialysis was another factor in disagreement. Conclusions: When a patient suffered from emotional problems, was in critical condition, was aged and there were no family disputes, then patients and doctors could agree on withholding HD for a better quality end-of-life. Given the same conditions, yet with family disputes, shared decision-making is recommended to reach consensus and preserve a better quality of life.
• 362 - 371
• 10.6288/TJPH2011-30-04-06

• Link 原著 Original Article
• 台灣地區已婚婦女非計畫懷孕情形及其相關因素分析Factors Associated with Unplanned Pregnancy among Married Women in Taiwan
• 張德安、林宇旋、洪百薰、施靜儀、吳秀英、邱淑媞
  Te-An Chang, Yu-Hsuan Lin, Baai-Shyun Hurng, Ching-Yi Shih, Shiow-Ing Wu, Shu-Ti Chiou
• 生育力調查 ； 非計畫懷孕 ； 人工流產 ； 婦女健康
  reproductive survey ; unplanned pregnancy ; induced abortion ; maternal health
• 目標：本文旨在探討台灣育齡已婚人口非計畫懷孕現況、相關因素與婦女懷孕結果。方法：以2008年「第十次家庭與生育力調查」完訪之2,603名20至49歲已婚婦女為對象，比較不同社會人口學背景特徵已婚婦女之非計畫懷孕經驗，探討其與個人生育經驗、知識及對婚姻態度之相關，並分析比較以人工流產終止懷孕之百分比在計畫懷孕與非計畫懷孕婦女之差異。結果：77.2%已婚婦女曾有非計畫懷孕經驗，其中近70.0%曾重複非計畫懷孕。年紀較輕、教育程度越低、自述經濟狀況不佳、或活產數越多之已婚婦女，非計畫懷孕之風險明顯較高。非計畫懷孕婦女以人工流產終止懷孕之百分比，顯著高於計畫懷孕婦女。結論：我國育齡已婚人口非計畫懷孕百分比偏高，且因社會人口學特性不同而呈現明顯差異，為降低非計畫懷孕之不良影響，應針對高風險族群提供相關宣導及介入服務。
  Objectives: The aims of this study were to examine the proportion of unplanned pregnancies among married couples in Taiwan, their association with potential risk factors, and the results of those pregnancies. Methods: Data from the 2008 Women and Fertility Survey of a national representative sample of 2,603 married women aged 20-49 were analyzed. We compared the proportion of unplanned pregnancies among subgroups characterized by socio-demographic factors, experience of child-bearing, and their knowledge about and attitude toward marriage. The difference in induced abortion rates between women with planned and unplanned pregnancies was also examined. Results: A total of 77.2% of the married women had ever had an unplanned pregnancy. Near 70% of those had repeated unplanned pregnancies. Younger age, lower educational attainment, poor self-rated economic status, and more live births were significantly associated with unplanned pregnancies. The induced abortion rates were higher among women with unplanned pregnancies than among women who planned pregnancy. Conclusions: The proportion of unplanned pregnancies among married couples in Taiwan was high. Socio-demographic factors were significant predictors of unplanned pregnancy. The provision of health education and intervention services that focus on high-risk groups is crucial in order to reduce the adverse outcomes of an unplanned pregnancy.
• 372 - 387
• 10.6288/TJPH2011-30-04-07

• Link 原著 Original Article
• 病人安全氣候、文化研究中測量等值性問題的檢視：本質、影響、檢測程序與補救Measurement Equivalence/Invariance in the Climate and Culture of Patient Safety Research: Its Nature, Effects, Test Procedures, and Remedies
• 汪秀玲、關皚麗、洪純隆
  Hsiu-Ling Wang, Aij-Lie Kwan, Shen-Long Howng
• 測量等值 ； 病人安全態度 ； 安全氣候 ； 安全文化
  measurement equivalence/invariance ; patient safety attitude ; safety climate ; safety culture
• 目標：簡述測量等值性(Measurement Equivalence/Invariance; ME/I)的本質、影響及檢測程序，檢視病安態度研究對該議題重視的程度並討論ME/I某些疑慮。方法：搜尋PubMed電子資料庫，2000年1月至2010年4月英文期刊論文，檢索條件以”Patient Safety Attitude” or ”Safety Culture” or ”Safety Climate” in Keyword，同時以”HealthCare” or ”Hospital” in Title/Abstrat，以及”Safety Instrument” in Text，針對問卷調查為主的量性研究分析工具心理計量特徵，分析層次以及如何利用測量作比較。結果：41篇文獻內容分析顯示，效度衡鑑統計技術多以信度估計、相關分析、迴歸分析、因素分析、多特質多方法，以T-test，ANOVA，MANOVA，Chi-square test比較跨群差異，少有以ME/I檢視病安氣候因素結構在跨樣本或跨情境等值程度，僅報導適配度評定假設模型與觀測資料的共變異矩陣之接近程度。本文提出ME/I實作、未能通過ME/I檢定的原因及補救方法。結論：ME/I攸關著病安氣候構念的概化以及預測氣候是否改變，其重要性不容忽視，期以本文與國內學者共同關注這些議題的後續發展。
  Objectives: The aims of this study were to articulate what measurement equivalence/invariance (ME/I) is, determine its impact, describe the procedural techniques in conducting ME/I, review the health-care literature on the climate and culture of patient safety, and discuss questions about ME/I testing. Methods: We looked at English language journal articles published between Jan 2000 and April 2010 by searching PubMed (free Medline) electronic databases using the keywords ”patient safety attitude” or ”safety climate” or ”safety culture”, simultaneously with the terms ”health care” or ”hospital” in title/abstracts, and ”safety instruments” in text. Our focus was on quantitative empirical studies adopting questionnaire-survey methods. A total of 41 articles were reviewed to analyze the psychometric properties of instruments, the level of analysis and the use of this measure for comparisons. Results: We found that most studies demonstrated reliability and validity of the constructs using the statistical methods of reliability estimation, correlation, regression, exploratory factor analysis, confirmatory factor analysis, and multitrait-multimethod matrices, and tested group differences by t-tests, ANOVA or MANOVA. Evaluations of invariant factor structure across populations or contexts by applying ME/I testing were seldom addressed. The majority of these studies did not address the ME/I issue. We suggest that some analytical forms of ME/I testing, the triggers for not supporting ME/I, and the remedies for patient safety require further research. Conclusions: There are some questions about the sensitivity of ME/I analytical procedures and the susceptibility of these procedures to contextual influences.
• 388 - 407
• 10.6288/TJPH2011-30-04-08