臺灣博碩士論文加值系統

目的：在台灣，民眾對於中醫醫療的需求具有相當高之比例（根據DOH統計資料，民國93年，每一中醫師服務人數約為4,946人），綜觀過去國內外研究發現在醫護人員相關研究中，多半較著重於西醫師職業群體，而同身為醫師族群之中醫師，卻鮮少被關注。因此本研究目的為：透過健保資料庫之分析，探討中醫師職業世代與一般族群在死亡組與存活組住院及門診疾病型態、住院風險與醫療利用率特性之差異。

方法：由衛生署中醫師證照登記資料庫，建立領有中醫師執照之中醫師世代，排除1985年前，年滿85歲及未滿25歲之族群，進一步串聯其在1998年至2002年之健保資料，並以1：4之性別、年齡配對方式，得到其對照之一般族群之健保資料，最終得到死亡人數1,010人（中醫師202人，一般族群808人），存活人數32,815人（中醫師6,563人，一般族群26,252人），並進一步分析兩組在住院及門診間疾病型態、住院風險與醫療利用率之差異。

結果：由1998至2002年住院資料分析中發現，死亡組中醫師平均每人次住院天數為14.57天顯著高於一般族群12.41天（p＝0.002），住院率（38.71% v.s 37.41%）及平均每人次住院醫療費用（99.67仟元 v.s 67.03仟元）皆高於一般族群，在住院風險與疾病型態分析中，中醫師呈現有較高的腫瘤（OR=1.25, 16.34% v.s 12.00%）、血液及造血器官疾病（OR=5.36, 0.99% v.s 0.25%）與泌尿生殖系統疾病（OR=1.86, 6.44% v.s 4.33%）的住院風險與住院比率；而在門診率分析中，中醫師之平均門診率（90.36% v.s 96.79%, p＜0.001）顯著低於一般族群，在平均每人次門診醫療費用分析，中醫師為4.50仟元顯著高於一般族群的1.53仟元（p＜0.001），門診疾病型態中，中醫師求診於腫瘤（5.45% v.s 2.35%, p＝0.021）與泌尿生殖系統疾病（8.42% v.s 3.59%, p＝0.003）有顯著較高於一般族群的比率。在存活組部份，中醫師平均每人次住院天數為5.56天顯著低於一般族群8.55天（p<0.001），住院率（3.39% v.s 5.40%）亦顯著低於一般族群（p＜0.001），平均每人次住院醫療費用（36.24仟元 v.s 37.25仟元, p＝0.524）則略低於一般族群，且在住院風險與疾病型態分析中，中醫師大多呈現較一般族群為低的疾病風險與比率；在門診率分析部份，中醫師呈現出顯著低於一般族群的情形（53.96% v.s 93.61%, p＜0.001），中醫師平均每人次門診醫療費用為1.09仟元顯著高於一般族群的0.77仟元（p＜0.001）。門診疾病型態分析部份，中醫師明顯在洗腎科利用比率（0.16% v.s 0.05%, p＜0.001）與門診醫療費用（43.41仟元 v.s 49.27仟元, p＜0.001）相較於一般族群有顯著性的差異。

結論：本研究發現，中醫師之住院風險與門診率相較於一般族群有較低之結果，呈現其擁有較為健康的趨勢與現象，且在疾病率探討中發現，存活組中醫師大多呈現皆較低於一般族群的情形，進一步推論可能原因為中醫師擁有豐富之健康專業知識、自我調養行為及對於自身健康狀態較為關切的情形，因此傾向有較健康之狀態，而有較低之住院及門診率，但較低的住院與門診率，是否受中醫師諱疾就醫與自我治療，而產生此一情形，則需進一步深入探討。但不論死亡組或存活組中醫師相較於一般族群皆擁有較高比率的泌尿系統疾病與洗腎科之就醫比率，因此，未來需進一步探討泌尿生殖系統疾病在中醫師職業群體之重要性，亦是醫師之職業衛生中不可忽視之環節。

Objectives: Using Chinese medicine to treat disease is very popular in Taiwan. However, very few studies focused on the investigation of the disease pattern of the related physicians. In this paper, we attempt to use National Health Insurance database to compare the disease patterns, the risk and hospitalization rates between the Chinese medicine physicians and general population.

Method: The data of the Chinese medicine physicians were obtained from the medical personnel register system of Taiwan Department of Health. Physicians under 25 years of age or above 85 years in 1985 were excluded from the study. The membership records were obtained by linking to the 1998 - 2002 National Health Insurance Research database, and general population data was used as reference group for matching age and sex. Finally we obtained 1,010 death people, including 202 Chinese medicine physicians and 808 general population, and 32,815 living people, including 6,563 Chinese medicine physicians and 26,252 general population, to compare the disease patterns and hospitalization rates.

Result: The hospitalization rate and the medical expenses of the death Chinese medicine physicians were significantly higher than general population ( 38.71% vs. 37.41% )( 99.67 thousand dollars v.s 67.03 thousand dollars ). To investigate the risk and disease pattern in hospital, the death Chinese medicine physicians showed significant higher rates in neoplasms(OR =1.25, 16.34% v.s 12.00%), blood and hemutopoiesis organ disease(OR =5.36, 0.99% v.s 0.25%), and the genitourinary system diseases (OR =1.86, 6.44% v.s 4.33%). The outpatient service rate of the death Chinese medicine physicians significantly lower than general population (90.36% v.s 96.79%, p<0.001). To inspect the risk and disease pattern in outpatient, the death Chinese medicine physicians showed significant higher rates in neoplasms(5.45% v.s 2.35%, p=0.021), and the genitourinary system diseases (8.42% v.s 3.59%, p =0.003). In the living Chinese medicine physicians, the hospitalization rate and the medical expenses were lower than general population (3.39% vs. 5.40%)(36.24 thousand dollars v.s 37.25 thousand dollars). To investigate the risk and disease pattern in hospital, the living Chinese medicine physicians showed significant lower rates than general population. The outpatient service rate of the living Chinese medicine physicians revealed significantly lower than general population (53.96% v.s 93.61%, p<0.001). To inspect the risk and disease pattern in outpatient, the living Chinese medicine physicians showed significant higher rates and cost in dialysis (0.16% v.s 0.05%, p＜0.001) (43.41 thousand dollars v.s 49.27 thousand dollars, p<0.001).

Conclusion: The hospitalization rates of the Chinese medicine physicians are substantially lower than those in the general population. One possible reason may be due to the nature of the job. The Chinese medicine physicians tend to be well-educated and have good knowledge in medical care based on Chinese medicine. Their health conditions are in general better than the averaged person in other professions. No matter death or living group, Chinese medicine physicians have higher rates than general population in the genitourinary system diseases, the genitourinary system diseases need tobe concerned in the Chinese medicine physicians.

摘要 I
Abstract III
目錄 V
表目錄 VII
第一章 前言 1
第一節 研究動機 1
第二節 研究目的 2
第三節 研究架構 3
第二章 文獻探討 4
第一節 醫師生活習慣與就醫態度 4
第二節 醫師之醫療利用 6
第三節 另類醫療 8
第四節 中醫師可能的職業暴露風險 10
第三章 材料與方法 13
第一節 研究對象之選取 13
第二節 研究族群的資料來源 13
第三節 資料處理與統計分析 14
第四章 結果 21
第一節 死亡組分析結果 21
第二節 存活組分析結果 30
第五章 討論 40
第一節 中醫師之住院利用率探討 40
第二節 中醫師之門診利用率探討 44
第三節 本研究優點與限制 47
第六章 結論與建議 49
第一節 結論 49
第二節 建議 50
參考文獻 52

1. Torre DM, Wang NY, Meoni LA, et al. Suicide compared to other causes of mortality in physicians. Suicide & life-threatening behavior 2005;35:146-53.
2. Thompson WT, Cupples ME, Sibbett C.H., et al. Challenge of culture, conscience, and contract to general practioners' care of their own health:Qualitative study. British Medical Journal 2001;323.
3. Davidson SK, Schattner P.L. Doctor's health-seeking behaviour:A questionnaire survey The Medical journal of Australia 2003;179:302-5.
4. 張珣. 疾病與文化---台灣民間醫療人類學研究論集. 台北, 2000.
5. Sun WY, Chen L, Wang G.. Difference of lifestyle advice between traditional Chinese medical doctors (TCMDs) and Western-style medical doctor (WSMDs) in People's Republic of China. Patient education and counseling 1995;25:311-6.
6. Oxley JR.. Services for sick doctors in the UK. The Medical journal of Australia 2004;181:388-9.
7. Kay MP, Mitchell G.K, Doctors do not adequately look after their own physician health. The Medical journal of Australia 2004;181:368-70.
8. Kennedy I, Williams S. Occupational exposure to HIV and post-exposure prophylaxis in healthcare workers. Occupational Medicine 2000;50:387-91.
9. Innos K, Rahu K, Baburin A, et al. Cancer incidence and cause-specific mortality in male and female physicians: a cohort study in Estonia. Scandinavian journal of public health 2002;30:133-40.
10. Frank E. Physician health and patient care. Jama 2004;291:637.
11. Martensen RL. On the mortality patterns of physicians. Jama 1996;275:1541.
12. Frank Ebdjm A.H, Simoes E.J, Kahn H.S, et al. Health-related behaviors of women physicians vs other women in the United States. Archives of internal medicine 1998;47:115-31.
13. Foster GM, Anderson B. G.. Medical anthropology., 1978/1992.
14. Stavem K., Hofoss D., Aasland, O. G., et al. The self-perceived health status of Norwegian physicians compared with a reference population and foreign physicians. . Scandinavian journal of public health 2001;29:194-9.
15. 成島香里 Isha Wa Jibun No Byouki Wo Naoseruka-Oishasan 15-Nin No Toubyouki., 2000/2002.【章蓓蕾（譯）15 位醫師抗病記。台北：天下遠見】
16. Rosvold E.O., Bjertness E. Illness behavior among Norwegian physician. Scandinavian journal of public health 2002;30:125-32.
17. Ingstad B, Christie V. M. Encounters with illness: the perspective of the sick doctor. Anthropology & Medicine 2001;8:201-10.
18. McKevitt C., Morgan M.. Anomalous patients: the experiences of doctors with an illness. Sociology of health & illness 1997;19:644-67.
19. Vanden Berg JH. Psychology of the sickbed. 1952/2001.
20. Rosvold E.O., Bjertness E.. Physicians who do not take sick leave: hazardous heroes? Scandinavian journal of public health 2001;29:71-5.
21. Forsythe, M. Calnan, M. Wall, Doctors as patients:postal survey examining consultants and general practitioners adherence to guidelines. British Medical Journal 1999;319:605-8.
22. Wachtel T, Wilcox V., Moulton A., et al.. Physicians' utilization of health care Journal of General Internal Medical 1995;10:261-5.
23. Rennert MH, L. Epstein, L. Shifroni G. The care of family physicians and their families: A study of health and help-seeking behaviour Family practice 1990;7:96-9.
24. Juel KM, J. Hansen E.S.. Mortality and causes of death among Danish medical doctors 1973-1992. International journal of epidemiology 1999;28:456-60.
25. 邱清華. 台灣地區中醫醫療狀況及需求調查研析. 1990.
26. 李金鳳. 中西醫門診病患對傳統醫療認知、情意與行為意向之調查研究. 陽明大學公共衛生研究所碩士論文, 1990.
27. 梁淑勤. 全民健保中醫門診利用之研究. 中國醫藥學院碩士論文, 2003.
28. Ernst E. Prevalence of use of complementary/alternative medicine: a systematic review. Bulletin of the World Health Organization 2000;78:252-7.
29. Kelly JP KD, Kelley K, Rosenberg L, et al.. Recent trends in use of herbal and other natural products. Archives of internal medicine 2005;165:281-6.
30. 行政院衛生署中央健康保險局網頁：http://www.doh.gov.tw/statistic/data/.表52 門診醫療核付狀況--按中、西、牙醫及分局縣市別分
31. Joelle L. Chinese herbs and urothelial carcinoma . New Engl J Med 2000:343.
32. Nortier J., Schmeiser H.H.. Urothelial carcinoma associated with the use of a Chinese herb. New Engl J Med 2000;342:1686-92.
33. Kessler DA. Cancer and Herbs. 2000;342:1742-3.
34. Van Ypersele, Strihou C. Chinese herbs nephropathy or the evils of nature. Am J Kidney Dis 1998:pp 1-ii.
35. 楊垂勳. 中草藥腎病變. 台灣醫學會會訊 2000;19:14-5.
36. But P. Need for correct identification of herbs in herbal poisening. The lancet oncology 1993;341:637-8.
37. Bieler CA SM, Wiessler M. 32P-post-labelling analysis of DNA adducts formed by aristolochic acid in tissues from patients with Chinese herbs nephropathy. Carcinogenesis 1997;18:1063-7.
38. Tanaka A SS, Kasuno K. Chinese herbs nephropathy in the Kansai area: a warning report. Nippon Jinzo Gakkai shi 1997;39:438-40.
39. Vanherweghem JL DM, Tielemans C. Rapidly progressive interstitial renal fibrosis in young women: association with slimming regimen including Chinese herbs. Lancet 1993;341:387-91.
40. 童承福，何玉鈴，煎輝彥，張永勳. 台灣市售易誤用、混用中藥品種之調查. 中國醫藥學院雜誌 1999;8:35-45.
41. 羅財樟. 中藥製造從業人員罹患腎臟疾病死因研究. 疫情組流行病學訓練科論文 行政院衛生署疾病管制局, 2000.
42. Yang CS LC, Chang SH. Rapidly progressive fibrosing interstitial nephritis associated with Chinese herbal drugs. Am J Kidney Dis 2000;35:313-8.
43. 羅財樟. 台灣地區中藥製造從業人員罹患慢性腎臟疾病個案對照研究. 台北: 國立臺灣大學公共衛生學院 職業醫學與工業衛生研究所碩士論文, 2003.
44. 吳朝舜. 中醫師世代之死亡型態分析. 國立陽明大學環境衛生研究所碩士論文, 2006.
45. Gochfeld M. Occupational medicine practice in the United States since the industrial revolution. Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 2005;47:115-31.
46. Lin SH LC, Wang HZ, Tsai RK, et al. Fungal corneal ulcers of onion harvesters in southern Taiwan. Occupational and environmental medicine 1999;56:423-5.
47. Chen JC CW, Chang W, Christiani D. Occupational factors associated with low back pain in urban taxi drivers. Occup Med (Lond) 2005;55:535-40.
48. Sun J KH, Hisanaga N, Shibata E, et al. Mortality among Japanese construction workers in Mie Prefecture. Occupational and environmental medicine 2002;59:512-6.
49. Carpenter LM SA, Fear N.T. Mortality of doctors in different specialties: findings from a cohort of 20000 NHS hospital consultants. . Occupational and environmental medicine 1997;54:388-95.
50. Innos K RK, Baburin A, Rahu M. Cancer incidence and cause-specific mortality in male and female physicians: a cohort study in Estonia. Scandinavian journal of public health 2002;30:133-40.
51. 林姬妙. 台灣地區醫事人員之住院風險分析. 國立台北護理學院醫護管理系碩士論文. 台北, 2005.