臺灣博碩士論文加值系統

背景：嚴重急性呼吸道症候群Severe Acute Respiratory Syndrome （簡稱SARS），造成醫療系統極大影響，也相對造成民眾醫療服務利用改變。由於牙科醫師服務需近距離與病患接觸，且飛沫傳染為SARS重要危險因子；本研究遂做進一步相關之探討。
研究目的：一、分析SARS疫情對牙科申報之醫療費用、醫療利用率之影響，及對各地區間、醫療服務層級間因疫情嚴重度不同的差異情形。二、瞭解牙科服務項目是否因醫療急迫性之不同而有所差異。
研究方法：利用2001至2003年間全民健康保險之牙科申報醫療點數、件數資料庫，以描述性分析、雙樣本t檢定分析、配對t檢定分析、變異數分析、複迴歸，來檢定前SARS期、SARS流行期、後SARS期及與前一年同期間之影響。
結果：1.One-way anova分析SARS流行期牙科整體醫療點數、件數週平均值均顯著減少，各層級都達顯著差異，且醫院影響普遍大於診所；對各分局間檢定分析則大部分都有顯著減少，再比較大小順序，大多是後SARS期大於前SARS期，而SARS發生期最小；由雙樣本t檢定分析，醫學中心、區域醫院、地區醫院醫療點數、件數降低20至30%，達顯著差異，而基層診所降幅較小。2.在五類醫令中雙樣本t檢定分析，除根管治療類小幅增加外，其餘都減少，且銀粉充填類降低16.38%，洗牙類降低7.45%，達顯著差異。特定醫令分類占率，以銀粉充填類下降1.72%最多，洗牙類下降0.34%次之。3.歸納牙科特定醫令類別緊急程度比較：根管治療類＞樹脂充填類＞拔牙類＞洗牙類＞銀粉充填類。
結論：由本研究證實，SARS對全民健康保險牙科醫療費用、醫療利用率、牙科服務項目間確實產生影響，而對於特定醫令類別緊急程度比較的結果，更可提供予相關單位於特殊疫情再度發生時，作為總額支付制度分配及支付標準調整之參考。

Background：The endemic of Severe Acute Respiratory Syndrome （SARS） had a great impact on the health care delivery system of Taiwan in the year 2003, and also affected the health care utilization of the beneficiaries of the National Health Insurance. Dentists must be in close contract with patients, and could be exposed to the risk factor of breathing the air of a SARS patient. This study was to explore the changes of utilization of the items of specific dental care and the number of visit in the endemic period of SARS.

Study objective：The purpose of this study involved two tasks:
1. The difference in the utilization of dental care and the claims of dental care fees among various districts and health care providers in the endemic period of SARS
2. The study examined whether the items of specific dental care were influenced by the categories of dental care urgency.

Method：The utilization of dental care and the number of visits were collected from the claims of dental care fees from the Bureau of Health Insurance in the years of 2001,2002 and 2003. Descriptive statistics ,two sample t-test, analysis of variance and multiple regression were used to investigate the relationship among the variables in the nineteen weeks of the pre-SARS period 、SARS endemic period and post- SARS period ,
the same period between SARS endemic period in 2003 and non- SARS endemic period in 2002.

Result：1.We found that the number of visits and the dental claim fee per week decreased in the SARS endemic period. Moreover the differences were observed in all levels of dental care institutions and the NHI districts. The degree of decrease in the utilization was that the post- SARS period was greater than the pre-SARS period ,and the least in the SARS endemic period. The two sample t-test in contracted category, academic medical centers, metropolitan hospitals and local community hospitals reduced by 20 to 30%, dental clinics only a small decrease. 2.The two sample t-test in five items of specific dental care shoned a small increase in endodontic treatment, and reduction amalgam restoration 16.38%, scaling 7.45%. 3.The dental care urgent degrees were in the decreasing order of : endodontics ＞teeth composite resin restoration＞extraction＞scaling＞amalgam restoration.
Conclusion：Our results showed obvious differences during the endemic period of SARS in the utilization of dental care 、the claim of dental care fees and the items of specific dental care. These results could serve as the base for a review of the global budget of dental care and fee schedule of dental care in the period of a speacific endemic disease.

目錄
致謝
中文摘要
英文摘要
第一章 緒論……………………………………………….……….……1
第一節 研究背景…………………………………...….………1
第二節 研究目的………………………………………………2
第二章 文獻探討…………………………………………………..……4
第一節 SARS的定義………………………………………… 4
第二節 相關法令……………………………….………….… 12
第三節 各界對於SARS因應之道…………………………...15
第四節 SARS疫情對全民健康保險醫療利用影響初探. .… 21
第三章 研究設計與方法……………………………….…….…….…..27
第一節 研究材料…………………………….………………..27
第二節 比對期程與研究架構……………………………..….. 28
第三節 研究資料處理與統計分析………………………..….. 30
第四章 研究結果………………………………………………………..31
第一節 全民健康保險牙科醫療費用敘述性分析………...…. 31
第二節 SARS對全民健康保險牙科醫療利用影響分析 …...33
第三節 SARS對全民健康保險牙科特定醫令利用影響分析..40
第五章 討論……………………………………………………. …….…51
第一節 SARS對全民健康保險醫療利用影響探討…………….51
第二節 SARS對牙科整體醫療利用影響比較………………..52
第三節 SARS對牙科特定醫令類別急迫程度比..……….… . 57
第六章 結論與建議……………………………………….…..……..….60
第一節 結論……………….…………….………….……….…60
第二節 建議…………………………..…………….……….…61
參考文獻…………………………………………………………………64
表（中文、英文）………………………………………………………69
圖目錄（中文、英文）…………………………………………………114
附錄……………………………………………………………………...119

一、中文文獻
1.中央健康保險局。中華民國九十一年全民健康保險統計。2003年8月編印。
2.工業研究技術院。嚴重急性呼吸道症候群(Severe Acute Respiratory Syndrome, SARS)百科集。九十二年五月十三日編印。
3. 行政院衛生署疾病管制局。台灣嚴重急性呼吸道症候群防疫專刊。台北：2003年8月15日編著。
4.鄭信忠。牙醫師對「嚴重呼吸道症候群」(SARS) 應有之認識與防治之道。台北：台灣牙醫界雜誌2003；4月號。
5.中華民國牙醫師公會全國聯合會。中華民國牙醫師公會全國聯合會對抗SARS防疫之因應措施報告。2003年6月6日編印。
6.曾七賢。牙醫師因應總額支付制度之調適策略探討-以南區健保局之特約診所牙醫師為例[碩士論文]。台南市：成功大學企業管理研究所；2002。
7.謝慧貞。總額預算支付制度對牙醫師醫療行為影響之研究[碩士論文]。台南市：成功大學企業管理研究所；2003。


二、英文文獻
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3. Peiris J, Lai S, Poon L, Guan Y, Yam L, Lim W , Nicholls J et al. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet 2003 Apr 19;361(9366):1319-1325.
4. Can Commun. Epidemiology, clinical presentation and laboratory investigation of severe acute respiratory syndrome (SARS) in Canada, March 2003. Can Commun Dis Rep 2003 Apr 15;29(8):71-5.
5. Drosten C, Gunther S, Preiser W, Van Der Werf S, Brodt HR, Becker S,et al. Identification of a Novel coronavirus in patients with severe acute respiratory syndrome. N Engl J Med 2003 Apr 10. Available at URL: http://sars.nhri.org.tw/ .
6. Ksiazek TG, Erdman D, Goldsmith CS, Zaki SR, Peret T, Emery S,et al. A Novel Coronavirus associated with severe acute respiratory syndrome. N Engl J Med 2003 Apr 30. Available at URL: http://sars.nhri.org.tw/.
7. Rota PA, Oberste MS, Monroe SS. Characterization of a Novel coronavirus associated with severe acute respiratory syndrome. Science 2003 May 1. Available at URL: http://sars.nhri.org.tw/.
8. Marra MA, Jones SJ, Astell CR, Holt RA, Brooks-Wilson A, Butterfield YS,et al. The genome sequence of the SARS-Associated Coronavirus. Science 2003 May 1. Available at URL: http://sars.nhri.org.tw/.
9.Yeh SH, Wang HY, Tsai CY, and National Taiwan University SARS Research Team. Characterization of severe acute respiratory syndrome coronavirus genomes in Taiwan: molecular epidemiology and genome evolution. Proc Natl Acad Sci U S A. 2004 Feb 24;101(8):2542-7.
10. Seto WH, Tsang D, Yung R, Ching TY, Ng TK, Ho M, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003 May 3: 361(9368): 1519-1520.
11. Wu EB, Sung JJ. Haemorrhagic-fever-like changes and normal chest radiograph in a doctor with SARS. Lancet 2003 May 3: 361(9368): 1520-1.
12. Wong KT, Antonio GE, Hui DS. Thin-Section CT of severe acute respiratory syndrome: Evaluation of 74 patients exposed to or with the disease. Radiology 2003 May 8. Available at URL: http://sars.nhri.org.tw/.
13. Mount Sinai Hospital. Interdepartmental division of critical care. ICU management of severe acute respiratory syndrome. Intensive Care Med 2003 May 9. Available at URL: http://sars.nhri.org.tw/.
14. Tsang KW, Ho PL, Ooi GC. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003 Apr 11. Available at URL: http://sars.nhri.org.tw/.
15. Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003 Apr 14. Available at URL: http://sars.nhri.org.tw/.
16. Chang HJ, Huang N, Lee CH, Hsu YJ, Chou YJ. The Impact of the SARS Epidemic on the Utilization of Medical Services: SARS and the Fear of SARS. American Journal of Public Health. Washington: Apr 2004. Vol. 94, Iss. 4; pg. 562-4.
17. Tsai MC, Arnold JL, Chuang CC, Chi CH, Liu CC, Yang YJ. Impact of an outbreak of severe acute respiratory syndrome on a hospital in Taiwan, ROC. Emerg Med J. 2004 May;21(3):311-6.
18. Man CY, Yeung RS, Chung JY, Cameron PA. Impact of SARS on an emergency department in Hong Kong. Emerg Med (Fremantle). 2003 Oct-Dec;15(5-6):418-22.
19. Vlantis AC, Tsang RK, Wong DK, Woo JK, van Hasselt CA. The impact of severe acute respiratory syndrome on otorhinolaryngological services at the Prince of Wales Hospital in Hong Kong. Laryngoscope. 2004 Jan;114(1):171-4.
20. Smales FC, Samaranyake LP. Maintaining dental education and specialist dental care during an outbreak of a new coronavirus infection. Part 1: a deadly viral epidemic begins. Br Dent J. 2003 Nov 22;195(10):557-61.
21. Person B, Sy F, Holton K, Govert B, Liang A. Fear and stigma: the epidemic within the SARS outbreak. Emerg Infect Dis. 2004 Feb;10(2):358-63.

三、網站
1.美國疾病管制局網站資料。Available at：http://www.cdc.gov.tw/sars/default.asp.Accessed February 26,2004.
2.世界衛生組織網站資料。Available at：http://www.who.int/csr/sars/country/table2003_09_23/en/. Accessed February 26,2004.
3. 美國疾病管制局中文網站資料。Available at：http://www.cdc.gov/ncidod/sars/pdf/sars-faq-chinesetrad pdf。美國疾病管制局中文網站資料。Accessed February 26,2004.
4. 台大醫學系SARS工作小組網站。Available at：http://sars.webmd.idv.tw/。Accessed October 18,2003.
5. 衛生署疾病管制局網站資料。Available at：http://203.65.72.52/sarsdoc/01疾病定義/A1-1SARS通報病例定義.doc .Accessed October 19,2003.
6. 世界衛生組織網站資料。Available at：http://www.who.int/csr/sars/country/2003_08_15/en/ Accessed October 19,2003.
7. 國家衛生研究院SARS疫情網站資料。http://sars.nhri.org.tw/. February 26,2004.。
8. World Health Organization. Alert, verification and public health management of SARS in the post-outbreak period. Available at：http://www.who.int/csr/sars/postoutbreak/en/, accessed February 26,2004.
9. World Health Organization. Revision of the international health regulations. World Health Assembly resolution WHA56.28; Available at：http: //www.who.int/gb/EB_WHA/PDF/WHA56/ea56r28.pdf, accessed February 26,2004.
10. World Health Organization. Severe acute respiratory syndrome (SARS). World Health Assembly resolution. WHA56.29; Available at： http:// www.who.int/gb/EB_WHA/PDF/WHA56/ea56r29.pdf, accessed February 26,2004.
11. 國家衛生研究院。台北地區 SARS 病毒之基因體分析。國家衛生研究院電子報，第 36 期，2004-03-11。Available at：http://sars.nhri.org.tw/enews/enews_list_new2.php?volume_indx=36&showx=showarticle&article_indx=866&enews_dt=2004-03-10.Accessed May 2 2004.
12. 中央健康保險局網站資料。Available at：http://www.nhi.gov.tw/cdc/index_cdc05_detail.asp?Kind_No=2&Sars_ID=72. Accessed February 26,2004.
13. 行政院衛生署網站資料。Available at：http://www.doh.gov.tw/ufile/doc/1203_031208.xls. Accessed February 26,2004。
14. 衛生署疾病管制局網站公告。Available at： http://www.cdc.gov.tw/sars/default.asp. Accessed February 26,2004.
15. 中華民國醫師公會全國聯合會在公會網站資料：「SARS處置要點專區」。Available at：http://www.med-assn.org.tw/SARS/sars.htm. Accessed October 18,2003。
16. 中央健康保險局南區分局網站資料：「中醫藥防治SARS的策略」。Available at：http://www.nhisb.gov.tw/. Accessed October 18,2003。