10卷1期

• Link 綜論 Review Article
• 勞工健康檢查之品質保證與管制Quality Assurance and Control of Medical Examinations in the Workplace
• 陳保中、王榮德、張蓓貞
  Pau-Chung Chen, Jung-Der Wang, Pei-Jen Chang
• 無
  Occupational Medicine ; W?rkers' Health Screening
• 高品質之勞工健康檢查計劃是早期發現職業衛生的手段之一，而健康檢查品質保證與管制則是勞工健康檢查計劃成功的基礎。本文是以健康管理的過程，來探討全面性勞工健康檢查品質保證的實際，以做為企業選擇健康檢查醫療院所的依循，同時作為健康檢查醫療院所自我要求的標準。其主要內容包括：（一）勞工健康檢查項目及檢查週期的合適性。（二）勞工健康檢查醫療院所的品質保證與管制。（三）醫師對勞工健康檢查資料的封殺與應用。（四）勞工健康檢查資料管理與保存。唯有在政府、企業、勞工、以及勞工健檢醫療院所之努力配合之下，共同提升勞工健康檢查品質，方可達到勞工健康的最終目的。
  A high quality medical surveillance program is one of the basic tools for early recognition of occupational hazards. The quality assurance and control (QN/QC) of medical examinations in the workplace is the basis for a successful surveillance program. We propose comprehensive guidelines of QA/QC for a variety of medical examinations in the workplace, in order to provide employers with selection criteria adequate for hospitals/clinics and to promote quality of medical service. In addition to QN/QC for history taking, physical examinations, urinalysis, blood chemistry, complete blood counts, pulmonary function tests, chest roentgenograms, and audiometry, selection of examination items and intervals, interpretation and assessment of examination data, and data management as well as record keeping are also discussed. Good cooperation and total quality control among the regulatory agency, companies, workers, and hospitals/clinics is the only way to ehsure that a high quality medical surveillance program is provided.
• 1-10
• 10.6288/JNPHARC1990-10-01-01

• Link 原著 Original Article
• 某醫學中心門診持續性照顧之研究Continuity of Care in a University-Based Outpatients Department
• 宋元宏、賴美淑、張智仁、 謝維銓
  Yuan-Hung Sung, Mei-Shu Lai, Chih-Jen Chang, Wei-Chuan Hseih
• 無
  Continuity of Care ; Delivery of Health Care ; Family Practice
• 本研究以民國77年6月1日至6月7日，某醫學中心家庭醫學斜門診病人年滿15歲以上的391個門診次為樣本，採用以門診就診為基礎的測量方法（包括曾有相同醫師持續性指標、接連相同醫師持續性指標、修正後比例式持續性指標），評估其持續性照顧型態，並就各指標間的相互差異，探討其所代表的意義。 研究結果顯示，曾有相同醫師持續性指標值、接連相同醫師持續性指標值、修正後比例式持續性指標值分別為0.6803、0.5678、0.5127。在各年齡層間，中年年齡層的持續性照顧最佳；保險制才方式的不同、預約的有無、門診就診間隔日數的長短、及醫師資歷的深淺均會影響持續性照顧。 本研究的疾病診斷以國際疾病分類第九版加以編碼，其中，高血壓、糖尿病等慢性疾病的持續性照顧最好。而肌肉骨骼疾患組的曾有相同醫師持續性指標值與糖尿病組相近，但其另外二種指標值卻較糖尿病組及高血壓組為差。這些指標之間的相互差異，可據以推測病人的就醫狀態。 綜而言之，本研究採用的三種測量指標，得以方使他將持續性照顧的品質加以量化，以評估門診的持續性照顧型態。
  This study was carried out between the 1st and 7th of June 1989. Selection criteria required patients to be 15 years old or over. The study included 391 cases from the Outpatient Department, Family Medicine Division, National Taiwan University Hospital. The research methodology utilized visitbased measurements (including known-provider continuity, sequential continuity, and discounted fraction of care continuity) to evaluate the continuity of care situation. In addition, the implications and significance of the different values arising from the above measurements were investigated. Our research produced the following values: 1) known-provider continuity, 0.6803; 2) sequential continuity, 0.5678; 3) discounted fraction of care continuity, 0.5127. Reviewing all age groups, the middle-aged group received the best continuity of care. The following factors were key determinants of good continuity of care: 1. benefits provided by medical insurance; 2. prior appointment with consulting physician; 3. length of time between patient visits; and 4. experience of consulting physician. We concluded from our research that, the continuity of care for diabetes, hypertension and other chronic diseases was superior to that for all other diseases. However, the values for known-provider continutiy for musculo-skeletal disorders were similar to-those for diabetes, but were lower than those for both diabetes and hypertension for the other two values. These variants may be used to predict patient attitudes with respect to outpatient care. In conclusion, by using the above three mentioned measurements, we can quantify the quality of continuity of care and thereby evaluate the continuity of care in outpatient departments.
• 11-18
• 10.6288/JNPHARC1990-10-01-02

• Link 原著 Original Article
• 環保人員及鉛相關工廠員工之鉛暴露Lead Exposure of Personnel of Environmental Protection and Workers of Lead-Related Factories in Taipei City
• 吳振龍、簫東銘、魏美珠、林宜長
  Chen-Long Wu, Ton-Ming Shinu, Mei-Chu Wei, Yi-Chiang Lin
• 無
  Lead ; Zinc Protoporphyrin ; Occupational Exposure
• 從台北市政府環保局環保人員，台北市鉛工廠作業人員及年齡、性別頻率配對之對照組三組樣本分別抽樣：210人，53人及50人，測其血中鉛濃度與游離型鋅原紫質濃度。發現上述三組人員其血中鉛濃度之平均數值為：10.2ug/dl，16.7ug/dl，與1l.3ug/dl；而血中游離型鋅厚紫質濃度為：469ug/l，677ug/l與388ug/l。雖然其平均值均尚未超過正常值，然暴露組之部分人員仍有高出警戒值者(8%)，值得繼續追蹤體例檢查。茲促其改善工作環境，另外，並就其員工之基本資料、工作情形、職業史、住家生活環境，疾病史及生活衛生習慣等資料加以分析探討，以了解血中如鉛濃度及游離型鋅原紫質濃度是否與具有所相關性，作為日後防禦措施之參考。
  Blood lead concentration (PbB) and free zinc protoporphyrin (PEP) were measured in personnel from the Department of Environmental Protection (210 subjects), workers of lead-related industries (53 subjects) and a control group in Taipei city (50 subjects). The mean PbB levels were 10.2, 16.7 and 11.3 ug/dl, respectively, and the mean FEP levels were 469.1, 677.3 and 387.6 ug/l, respectively. Although the mean PbB and FEP levels for all three groups were within normal limits, a few values were beyond the critical level and need for further investigation. In addition, the relations between personal characteristics, working conditions, occupational history, living environment, past history of illness, health status, and PbB and FEP levels in each study group are examined. Some suggestions for prevention of excess exposure are made.
• 19 - 29
• 10.6288/JNPHARC1990-10-01-03

• Link 原著 Original Article
• 美國芝加哥區養老院病人急症住院之原因及其危險因子Hospitalization of Nursing Home Patients in Chicago, U. S. A.
• 許清曉、許玉麗、 David Edelberg 、 M. Todd Grendon
  Clement C.S. Hsu, Yu-Li Hsu, David Edelberg, M. Todd Grendon
• 無
  Nursing home ; Hospitalization ; Risk Factors for Hospitalization ; Immobility ; Foreign Bodies
• 吾等在美國芝加哥之一社區教學醫院做前瞻性的臨床研究，調查養老院病人急症住院診治之原因及其危險因子。受調查之住院個案包括243位病人之326次住院。感染為住院之最常見原因(51.2%)。而皮膚及鄰近組織感染(17.5%)，肺淡(13.8%)，尿道感染(12.6%)及敗血症(6.7%)為其主要類別。感染為總共59.5%住院病人之入院主因或次要診斷。 以132人次無感染症之養老院病人住院為控制組，吾等以Stepwise logistic regression analysis評估每一類別感染症之獨立危險因子。體內異物之存在，尤其是留置導尿管，為每一感染類別之危險因子。不動性亦為和肺炎除外之三額感染症相關的因子。此外，糖尿病和皮膚及鄰近組織感染有關聯；而高年齡則和肺炎之發生有關。這些因子之致病機轉需更進一步之探討，以便給予比類病人適當的醫護。
  A ten month prospective clinical survey was conducted at a teaching community hospital on 326 admissions of 243 patients from 32 nursing homes in the Chicago area. Infection was found to be the most frequent cause of admission (51.2%). Skin and adjacent tissue infection (17.5%), pneumonia (13.8%), urinary tract infection (12.6%), and septicemia (6.7%) were the major categories of infection. A total of 59.5% of the patients had infection as a primary and/or secondary diagnosis. Using 132 nursing home patients without either primary or secondary diagnosis of infection as the control group, independent risk factors of devlopment of all types of infection were assessed by employing a stepwise logistic regression analysis. The presence of foreign body, especially the indwelling urinary catheter, was the risk factor for every category of infection. Immobility was also a variable associated with all infections, except pneumonia. In addition, diabetes mellitus was a risk factor for skin and adjacent tissue infection, and advanced age for pneumonia. Mechanisms underlying these risk factors need further research.
• 30 - 38
• 10.6288/JNPHARC1990-10-01-04

• Link 原著 Original Article
• 基層護理人員時間分配之探討模式－以宜蘭縣之星鄕為例Time Allocations for Primary Health Care Nursing Personnel-An Example from Rural Township of San-Shing, Ilan County
• 季瑋珠、張淑芬、張美惠、簡大任、周金章
  Wei-Chu Chie, Shu-Fen Chang, Mei-Huyei Chang, Ta-Ren Chien, Chin-Chang Chou
• 無
  Delivery of Health Care ; Time Allocation ; Nursing Program Evaluation
• 宜蘭縣三星鄉衛生所同時擁有兩項基層醫療保健的新嘗試：群體醫療執業中心與綜合地段健康管理，醫療與保健的相互配合因而成為其首要工作。本研究挑選1987年7月，每個工作日諳六位地段護士作以分鐘為單位之「自我實地觀察記錄」將工作分為六類，再由研究人員統計每人從事各類工作時間之百分比，及六位地段護士之平均值。結果六位地段護士平均之「家訪」佔全部工作時間的30.08%，「門診」佔全部工作時間的35.82%，「資料處理及抄寫」佔全部工作時間的20.29%，「衛教」佔全部工作時間的0.41%，「預防注射」佔全部工作時間的4.56%，「其他」則佔9.00%。此結果若與省公共衛生研究所綜合地段健康管理的標準相比較，則可發現基層護理人員花在「門診」及「資料處理及抄寫」的時間百分比偏高，花在「家訪」等保健工作上的時間則相對減少。因此本文建議減少報表，實施保健工作電腦化，並加強門診醫療中的保健工作，鼓勵醫師參與社區衛教等保健業務，以使醫療與保健相輔相成。
  The San-shing Health Station of Ilan County was chosen to conduct two newly innovated primary health care trials-the group practice center and the comprehensive district health care projects. Therefore, maximizing limited resources and providing medical care and public health services of good quality became important issues. In July 1987, a self-recording method was used by six district nurses and their head nurse to record in six major categories each nurse's time allocation in minutes. After one month of data collection, the percentages by category for each nurse and the averages (means) of the six district nurses were calculated. For the six nurses, the time allocation percentages were as follows: 1) home visits, 30.80%; 2) outpatient department (OPD), 35.85%; 3) data processing and paperwork, 20.29%; 4) health education, 0.41%; 5) vaccinations, 4.56%; and 6) other, 9.00%. In comparison with the criteria set forth by the Provincial Institute of Public Health, the district nurses took more time on OPD and data processing and paperwork, and less time on public health activeities such as home visits. Based on these results, the authors suggest reducing the paperwork load of district nurses, computerizing health care activities and records, increasing public health activities in OPD, and encouraging physicians to join in public health work in the commumity.
• 39 - 43
• 10.6288/JNPHARC1990-10-01-05

• Link 原著 Original Article
• 社區高血壓控制實驗－先驅研究An Intervention Trial on Hypertension Control in Communities: A Pilot Study
• 李蘭、季瑋珠、施金水、潘怜燕、呂槃、 江永盛、 楊志良
  Lee-Lan Yen, Wei-Chu Chie, Chin-Shui Shih, Ling-Yen Pan, Laura P. Lu, Yung-Sheng Chung, Chih-Liang Yaung
• 無
  Hypertension ; Intervention Trial ; Biofeedback
• 為探討社區健康介入活動影響成人高血壓控制之情形，根據臺灣北部地區成人健康行為研究所完成的血壓篩檢資料，退出590位血壓偏高考（血壓?140/90mmHg），分別、編入「身心鬆池」、「血壓測量」、「函授自學」和「對照」等四個實驗組中。本研究以「村里」為實施分組的分派單位，以「家戶」為實施介入活動的教育單位，於民國七十八年一月至六月期間，分別完成前後測資料之收集與介入活動。實驗結束後，僅299人參與全程計劃。比較四組的資料發現：(1)身心鬆池、測量血壓和函授自學三種方法均有助於個案收縮壓之降低；其中身心鬆弛法還能有效地降低舒張壓，而且具能降低收縮壓的效果優於函授自學法；(2)個案前往測站量血壓的情形並不踴躍；(3)函授自學組個案寄回答案紙的比率雖不高，但它能顯著地延長個索之睡眠時數。這些結果除了提供國內社區衛生教育之實證資料外，並對衛生教育實務，尤其是健康促進工作之推展極具參考價值。
  A health survey was conducted in northern Taiwan from July 1987 to June 1988. In order to investigate the effect of health intervention on high blood pressure control in adults, 590 cases from the survey with blood pressure levels of 140/90 mmHg and higher were selected for inclusion in this study. These cases were randomly assigned to one of four groups: the relaxation, the BP measurement, the self-learning, or the control group. The family was used as the educational unit Pretest and post-test, as well as intervention activities were given during January and June of 1989. After intervention, only 299 cases attended the post-test session. Findings from the comparison of the four treatment groups showed that: (1) the three interventions including relaxation, BP measurement, and self-learning helped decrease individual SBP, meanwhile, relaxation training helped decrease individual DBP and demonstrated better effects in decreasing SBP, than the self-leaning process; (2) cases in the BP measurement group showed poor compliance in measuring blood pressure at the stations; (3) cases in the selflearning group showed poor compliance in mailing test sheets back to researchers. However, they did mention more longer sleeping hours than before. These finding not only provide experimental evidence for the value of community health education, but also are a useful reference in the area of health education practices, especially in the health promotion efforts.
• 44 - 52
• 10.6288/JNPHARC1990-10-01-06

• Link 原著 Original Article
• 宜蘭縣三星鄕綜合地段健康管理成果評估Evaluation of Integrated Health Care in the Rural Township of San-Shing, Ilan County
• 季瑋珠、張淑芬、張美惠、簡大任、周金章
  Wei-Chu Chie, Shu-Fen Chang, Mei-Huei Chang, Ta-Ren Chien, Chin-Chang Chou
• 無
  Delivery of Health Care ; Maternal and Child Health ; Chronic Disease
• 為了在偏遠地區藉由基層醫療保健達成「公元2000年全民健康」的理想，宜蘭縣三星鄉衛生所根據試辦有成之「基層保健服務中心」模式，在全鄉推行「綜合地段健康管理」。自1987年3月至次年2月，為期一年。主要的結果為：人口外流嚴重，但扣除空戶後，孕產婦、嬰幼兒，和慢性病防治三項服務的篩檢涵蓋率各占目標人口的89.9%，100%與46.6%，三項服務的收案率，則分別為孕產婦70.6%，嬰幼兒55.9%，慢性病51.8%。在對孕產婦及慢性病的個案健康管理方面，分別以McNemar氏卡方檢定，比較各項管理項目在管理前後的差異，一般而言，大部分的健康管理都有顯著效果，而孕產婦健康管理對個案學得新知及採取新行為的效果較佳。孕產婦及慢性為個案均有一些項目，如「擬餵母奶」、「生產地點選擇」、「少菸酒實行」等大部分個案在管理前已有正確的認知及行為，亦有一些項目，如「按時就診」、「接待服藥」等，有較多個案管理前從均沒有得到正確的認知及行為，本研究肯定了此一模式對社區及高危險群的貢獻，也提供了日後修訂個案健康管理內容之建議。本文亦討論了研究的限制和政策上的涵義。
  In order to achieve the goal of ”health for all by the year 2000”, in the area of primary health care, the Health Station of San-Shing Rural Township, Ban County, carried out a comprehensive district health care project based on the ”primary health care center model”. After a previously successful trial, the project was carried out, using public health nurses to provide high risk screening and personal health care services from March 1987 to February 1988. After adjusting for Ban County's serious emigration problem, the main achievements were a coverage rate for high risk screening of maternal health, infant health, and chronic disease control of 89.9%, 100% and 46.6%, respectively. The follow-up rates for eligible high risk cases of these three services were 70.6%, 55.9% and 51.85%, respectively. McNemar's Chi-square test was used to determine whether or not the personal health care of high risk cases had improved after educational efforts by health care providers. In general, most of the educational items demonstrated significant improvement, with those items dealing with maternal health care showing even better results. For some of the maternal health care items, such as ”planning to breast feed”, ”choice of place of delivery”, and ”reduced smoking and alcohol consumption”, many of the subjects had acquired correct information and were following it even before receiving educational and personal health care services. However, for other items, such as compliance in chronic disease patients, many of the cases did not have correct information, nor were complying with it either before or after educational efforts and personal health care services. This study further supports the effectiveness and contribution of the ”primary health care center model”, and provides suggestions on the content of personal health care for high risk cases.
• 53 - 65
• 10.6288/JNPHARC1990-10-01-07

• Link 實務 Public Health Practice
• IBMS中文生物檢體電腦化管理系統IBMMS Computerized Biospecimen Management System
• 張衍心、陳建仁、游山林、孫建安、潘文涵、吳成文
  Ah-Seng Chang, Chien-Jen Chen, San-Lin You, Chien-An Sun, Wen-Harn Pan, Cheng-Wen Wu
• 無
  Biospecimen ; Medical Informatics Computing
• 本文的目的在於介紹中央研究院生物醫學研究所(IBMS)最近完成設計的中文生物檢體電腦化管控系統。此系統適用於管理像血清庫之類的大量檢體，尤其是長期追蹤研究蒐集之系列檢體。此系統是以dBASE Ⅲ PLUS套裝軟體計編寫而成，它既可以迅速地接個索的結義或姓名，進行車檢體存放位置，殘餘存量、和使用用途的檢索查詢和更新增?；而且可以正確地列印各項表格，瞭解現檢體之貯存狀況及解凍次數。本系統有下列特色：(1)全螢幕畫面操作，使用方使；(2)對答式運作，簡單易學：(3)檢索迅速，增刪便捷。對大規模世代研究之生物檢體管理而言，本系統可提供相當便捷的協助。
  In order to improve the management of biospecimen Collection, storage and laboratory examination, a Chinese edition of computerized biospecimen management system has been developed by the Institute of Biomedical Sciences, Academia Sinica. Using dBASE III PLUS Software and Clipper Software, the system was designed for a fast search of the current status of stored biospecimens by their identification number. The information of storage location, residual quantity, thawing frequency and examination frequency can be input, revised, updated and retrieved easily, quickly and accurately. This management system is suitable for the biospecimen management in large-scaled epidemiological studies and for the administrative use of serum bank and blood bank.
• 66 - 76
• 10.6288/JNPHARC1990-10-01-08