臺灣博碩士論文加值系統

研究背景及目的：結核病(Tuberculosis, TB) 是一種由結核分枝桿菌感染所造成的慢性傳染病，目前仍普遍存在於全世界。在台灣每年新增約15,000名結核病患，每年約有1,300人死於結核病，結核病的發生率和死亡率均為台灣法定傳染病的第一位，因此持續推動及落實結核病防治工作一直是我國衛生署疾病管制局非常重視的政策。都治計畫或稱短程直接觀察治療(Directly Observed Treatment, Short-course, DOTS)是世界衛生組織1993年起在各國大力推動的結核病治療計畫，這個策略是希望確保病人服下每劑藥物，如期治癒以提高結核病的治癒率，有效切斷傳染源，保護抗結核藥物的效力。進而預防多重抗藥性細菌的產生。2006年4月1日起衛生署在結核病十年減半的目標及長程計畫下，全面落實推動都治計畫，目前全國肺結核病患痰塗片呈陽性均納入都治計畫其執行率已高於九成。
本研究的個案醫院，國軍高雄總醫院，自2006年起配合行政院衛生署疾病管制局實施結核病都治計劃(DOTS)治療結核病病患，實施已屆滿三年，因而想瞭解擴大實施都治計劃後對結核病的防治是否比未實施前有顯著的改善
研究方法：本研究以個案醫院的次級資料庫分析2006年都治計畫實施前後24個月的資料進行統計分析，探討個案醫院在都治計畫實施後是否明顯的改善結核病病患的治療結果。統計方法主要以卡方交叉分析檢定治療結果是否與都治計畫的實施有相關性。
研究結果：本研究所取出的次級資料庫分析得知，在性別特質方面，男性與女性在是否完成治療是沒有差別的，但男性在X光診斷為空洞明顯較女性為高。在年齡<65歲的個案較易完成治療，當X光診斷無空洞時，塗片結果為陰性的機率較高，當X光診斷有空洞時，個案完成管理比率較高，痰塗片結果與是否完成治療沒有相關性。在實施DOTS前後及接受DOTS與否的分析上，個案醫院實施DOTS前後24個月，治療結果沒有差異；個案醫院實施DOTS後24個月，其中有無參與DOTS並無影響治療結果。
研究結論：若僅看都治計畫實施後（2006年4月之後）對個案醫院的結核病個案管理的完成並沒有顯著的進步，但這並不能否定DOTS的成效。這可能是因為個案醫院是位處都會區，又是屬於台灣結核病的高盛行區；在本區的結核防治網，整體醫療資源的運用相對較全國其他區域充分，因此結核病的管理多年來一直是很嚴謹且完成治療管理比率也高，才會看不出DOTS的成效；但台灣結核病的防治成績雖然有進步，仍要繼續努力，才不會讓肺結核的防治工作功虧一簣。

Background and purpose: Tuberculosis (TB) is one kind of chronic infectious disease which caused by the mycobacterium tuberculosis, and still widely exists in the world. In Taiwan, there are approximately 15,000 new tuberculosis patients and 1,300 died annually. The incidence and mortality rate rank the number one among the legal reported disease in Taiwan. Therefore, how to prevent and control the tuberculosis becomes a crucial policy for Centers for Disease Control (CDC) in Taiwan.
Directly Observed Treatment, Short-course (DOTS) is a TB control program implemented in many countries aggressively by the World Health Organization (WHO) since 1993. The implementation method is that patients are supervised by well-trained health care staff while medication is administered, to assure the clients taking each dose of medicine. This policy is intended to cure the patient in time, cutting off the infectious sources, prevent the efficacy of anti-tuberculosis drugs and cease the emerging of multidrug resistant tuberculosis (MDRTB) . For the long-term planning and the target of “Halve the TB over the next ten years,” the CDC of Taiwan has been enforced the DOTS program since April 1st, 2006. The rate implementing DOTS in smear- positive case has been exceeded 90%. The purpose of this study is to examine the effect of DOTS policy on the outcomes of Tuberculosis before and after the DOTS policy implementation.
Methods: The secondary databases from the study hospital were retrieved. The data included 24 months before and after the DOTS implementing (April 1st, 2006). We investigated if there’s significant improvement in treating tuberculosis after the DOTS. Both descriptive and Chi-square tests were used to depict the study sample and to examine the correlation between treatment outcome and DOTS, respectively.
Results: There is no difference on treatment outcome between male and female. Male had higher cavity formation on the chest x-ray. There’s more easy treatment completion when the clients were younger than 65 years old. No cavity on the chest x-ray was statistically associated with negative acid fast stain. The chest x-ray showed cavity was related to higher completion rate of treatment. There’s no correlation between the acid fast stain and treatment completion. There’s no significant difference on treatment outcome after the DOTS implementing.
Conclusions: There’s no difference in treatment result between the “DOTS” and “without DOTS” group after April 2006. The reason we deliberate that may be the study hospital is located at the urban area, which is high prevalence area in tuberculosis and thus have been under control for years. The completion rate in tuberculosis treatment is already high enough. No wonder there’s no such difference. Anyway, we can not ignore the policy of the DOTS, we must keep cooperation with this policy, make great efforts on tuberculosis prevention and control in Taiwan.

摘 要 i
Abstract iii
誌謝...................................................................................................................................v
目 錄 vi
表 目 錄........................................................................................................................viii
圖 目 錄 ix
第一章 緒論.....................................................................................................................1
第一節 研究背景與動機.........................................................................................1
第二節 研究目的.....................................................................................................1
第三節 個案醫院介紹………………………….....................................................2
第二章 文獻探討...........................................................................................................9
第一節 結核病簡介.................................................................................................9
第二節 台灣結核病流行現況................................................................................14
第三節 台灣結核病防治系統的演進....................................................................17
第四節 結核病十年減半計畫................................................................................21
第五節 都治計畫....................................................................................................21
第三章 研究方法..........................................................................................................32
第一節 研究設計………………………………....................................................32
第二節 個案醫院的次級資料分析…………………............................................36
第四章 結果..................................................................................................................42
第一節 描述性分析結果........................................................................................42
第二節 卡方檢定的結果………………………………………............................42
第五章 討論與建議……………………………………..............................................46
第一節 實施DOTS前後結核病個案的成效……………...................................46
第二節 結論與建議................................................................................................48
參考文獻........................................................................................................................51

一、中文部份
行政院衛生署疾病管制局，2008，「結核病診治指引第三版」。
行政院衛生署疾病管制局，2008，「台灣結核病防治年報 2008」。
江振源，2000，「DOTS -- 結核防治之最佳策略」，胸腔醫學，15期:172-7。
李健明、江國華等，2001，「新診斷結核病患者的追蹤掌握之世代研究」，疫情報導，17卷9期:435-442。
吳思儀，2005，秀林鄉社區肺結核患者疾病觀、服藥行為與在地服藥督促介入探索研究，臺灣大學衛生政策與管理研究所碩士論文。
索任，2008，「台灣防癆工作的今昔」，疫情報導，24卷3期:169-176。
索任，2003，「台灣防癆工作回顧」，感染控制雜誌，13卷3期:173-179。
黃紹宗、黃瑞明 ，2007，「結核病院內感染管制」，疫情報導，23卷3期:129-136。　
莊志杰、許玫玲，2004，「臺灣結核病防治政策與相關議題：組織發展與通報政策變革」，臺灣衛誌， 23卷4期:292-296。
許建邦、羅秀雲，2008，「台灣都治(DOTS)執行經驗及成效初探」，疫情報導， 24卷3期:184-203。
張淑卿，2006，「戰後臺灣的防癆健保員」，近代中國婦女史研究，14期:89-123。
張雅雯 ，2006，「推動結核防治 創造無核家園」，衛生報導，126卷:30-31 。
楊欣田 ，2008，中部四縣市實施都治計畫之成效初探，亞洲大學健康管理研究所碩士論文。
廖惠玲，2008，「肺結核都治關懷員」，防癆雜誌，冬季號。
劉宏泰，2008，針對短期時間結核病控制之最佳資源分配，清華大學工業工程與工程管理學系碩士論文。
謝家如、林麗嬋，2003，「結核病與個案管理模式」，護理雜誌 ，50期:77-81。
蘇秋霞、胡雅容、余明治，2007，「金門縣結核病都治前驅計畫成效分析」，疫情報導，23卷2期:62-72。
鐘威昇，2008，台灣肺結核都治計畫的經濟評估，臺灣大學醫療機構管理研究所 博士論文。
二、英文部份
Helen S Cox, Nathan Ford, John C Reede.2009.Are we really that good at treating tuberculosis?，The Lancet Infectious Diseases.,9， Iss. 3: 138-139
Ganapati M. 2004.Medical charity criticises shortcoming of DOTS in management of tuberculosis, BMJ, 328:784.
Volmink J, Matchaba P, Garner P. 2000.Directly observed therapy and treatment adherence，The Lancet, 355:1345-50.
What is DOTS? A Guide to Understanding the WHO-recommended TB Control Strategy Known as DOTS. In. Geneva,World Health Organization World .1999. 13p
Burman, W. J. & B. L. Stone, et al. 1997. The incidence of false-positive cultures for Mycobacterium tuberculosis. Am J Respir Crit Care Med, 155: 321– 326.
Burman, W. J. Dalton, C. B. Cohn, D. L. et al..1997.A cost-effectiveness analysis ofdirectly observed therapy vs self-administered therapy for treatment oftuberculosis. Chest,112: 63-70.
Crows, S. 1997.DOTS is effective even in nomadic populations. Lancet, 350: 343.
Dholakia, R. 1996.The Potential Economic Benefits of the DOTS Strategy Against TB in India. Ed. J. Almeida. WHO/TB/96.218.The Global Programme of the World Health Organization, Geneva.
G R Davies, S B Squire. 2008. Doubts about DOTS ,British Medical Journal (International edition), 336, Iss. 7642; pg. 457
Donabedian A. 1976.Measuring and evaluating hospital and medical care. Bull N Y Acad Med. Jan; 52(1): 51-9.
Liu, C. E. Chen, C. H. et al..2004.Drug resistance of Mycobacterium tuberculosis complex in central Taiwan. J microlbiol immunol infect, 37：295-300.
Murray, C. J. DeJonghe, E. Chum, H. J. et al.. 1991. Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries. Lancet, 338: 1305-8.
Muhwa, J. C. Lorna, N. et al.2004.DOTS in the African Region:A framework for engaging private health care providers.Regional Tuberculosis Programme World Health Organization.