ASSESSING THE QUALITY OF PRIMARY HEALTH CARE IN A REMOTE COUNTY OF TAIWAN

The purpose of this study was to evaluate the association between the quality of primary care and patient-reported health status, patient disease-specific clinical outcomes, and patients’ satisfaction with their care experience in a remote county of Taiwan. The two aims of our evaluation of health care quality were as follows: 1. To validate the Primary Care Assessment Tool (PCAT) in Taiwan, and 2. To examine the associations between domains of primary care quality and patient outcomes. This study was a population-based cross-sectional survey performed on offshore islands northwest of Taiwan with 12,700 inhabitants. The reliability of the PCAT-C was assessed by measuring internal consistency reliability. Factor analysis and construct validity were used in confirming the hypothesis supporting the composite score. This study used the Primary Care Assessment Tool - Chinese Edition (PCAT-C), which includes four core domains (first contact, longitudinality, comprehensiveness, and coordination) and three related domains (family centeredness, community orientation, and cultural competence). A visit-based questionnaire was used to gather information. Our validation analysis (Study Aim 1) shows that all the seven domains of primary care captured in PCAT-C are retained and the PCAT is a valid, reliable and responsible tool with psychometric properties in the multidimensional quantification of primary health care, similar to previous PCAT-related validation effort (H1 & H2). Study Aim 2 examines the associations between domains of primary care quality and patient outcomes. The analysis shows that those with chronic illness performed better than those without in all the primary care domains (H3). The analysis also indicates that primary care overcomes the gaps between different education and income level, but good primary care experience hinges on it adequate supply (H4). The analysis further demonstrates significant association between PCAT quality and satisfaction (H5). Finally, on the relationship between primary care quality and disease-specific clinical outcomes (H6), the analysis yields mixed findings. The Primary Care Assessment Tool provides an excellent method for assessing and identifying ways in which primary care systems can be improved; as such, it is important to ensure that the instrument stays updated and malleable to change as the field of health care evolves. Advisor: Leiyu Shi, Dr.P.H., M.B.A., M.P.A

Vitamin D Binding Protein, Total and Free Vitamin D Levels in Different Physiological and Pathophysiological Conditions.

This review focuses on the biologic importance of the vitamin D binding protein (DBP) with emphasis on its regulation of total and free vitamin D metabolite levels in various clinical conditions. Nearly all DBP is produced in the liver, where its regulation is influenced by estrogen, glucocorticoids and inflammatory cytokines but not by vitamin D itself. DBP is the most polymorphic protein known, and different DBP alleles can have substantial impact on its biologic functions. The three most common alleles-Gc1f, Gc1s, Gc2-differ in their affinity with the vitamin D metabolites and have been variably associated with a number of clinical conditions. Although DBP has a number of biologic functions independent of vitamin D, its major biologic function is that of regulating circulating free and total levels of vitamin D metabolites. 25 hydroxyvitamin D (25(OH)D) is the best studied form of vitamin D as it provides the best measure of vitamin D status. In a normal non-pregnant individual, approximately 0.03% of 25(OH)D is free; 85% is bound to DBP, 15% is bound to albumin. The free hormone hypothesis postulates that only free 25(OH)D can enter cells. This hypothesis is supported by the observation that mice lacking DBP, and therefore with essentially undetectable 25(OH)D levels, do not show signs of vitamin D deficiency unless put on a vitamin D deficient diet. Similar observations have recently been described in a family with a DBP mutation. This hypothesis also applies to other protein bound lipophilic hormones including glucocorticoids, sex steroids, and thyroid hormone. However, tissues expressing the megalin/cubilin complex, such as the kidney, have the capability of taking up 25(OH)D still bound to DBP, but most tissues rely on the free level. Attempts to calculate the free level using affinity constants generated in a normal individual along with measurement of DBP and total 25(OH)D have not accurately reflected directly measured free levels in a number of clinical conditions. In this review, we examine the impact of different clinical conditions as well as different DBP alleles on the relationship between total and free 25(OH)D, using only data in which the free 25(OH)D level was directly measured. The major conclusion is that a number of clinical conditions alter this relationship, raising the question whether measuring just total 25(OH)D might be misleading regarding the assessment of vitamin D status, and such assessment might be improved by measuring free 25(OH)D instead of or in addition to total 25(OH)D

Non-invasive and transdermal measurement of blood uric acid level in human by electroporation and reverse iontophoresis

The aim of this study was to find out the optimum combination of electroporation (EP) and reverse iontophoresis (RI) on noninvasive and transdermal determination of blood uric acid level in humans. EP is the use of high-voltage electric pulse to create nano-channels on the stratum corneum, temporarily and reversibly. RI is the use of small current to facilitate both charged and uncharged molecule transportation across the skin. It is believed that the combination of these two techniques has additional benefits on the molecules’ extraction across the human skin. In vitro studies using porcine skin and diffusion cell have indicated that the optimum mode for transdermal uric acid extraction is the combination of RI with symmetrical biphasic direct current (current density = 0.3 mA/cm2; phase duration = 180 s) and EP with 10 pulses per second (voltage = 100 V/cm2; pulse width = 1 ms). This optimum mode was applied to six human subjects. Uric acid was successfully extracted through the subjects’ skin into the collection solution. A good correlation (r2 = 0.88) between the subject’s blood uric acid level and uric acid concentrations in collection solutions was observed. The results suggest that it may be possible to noninvasively and transdermally determine blood uric acid levels

H2B ubiquitylation is part of chromatin architecture that marks exon-intron structure in budding yeast

<p>Abstract</p> <p>Background</p> <p>The packaging of DNA into chromatin regulates transcription from initiation through 3' end processing. One aspect of transcription in which chromatin plays a poorly understood role is the co-transcriptional splicing of pre-mRNA.</p> <p>Results</p> <p>Here we provide evidence that H2B monoubiquitylation (H2BK123ub1) marks introns in <it>Saccharomyces cerevisiae</it>. A genome-wide map of H2BK123ub1 in this organism reveals that this modification is enriched in coding regions and that its levels peak at the transcribed regions of two characteristic subgroups of genes. First, long genes are more likely to have higher levels of H2BK123ub1, correlating with the postulated role of this modification in preventing cryptic transcription initiation in ORFs. Second, genes that are highly transcribed also have high levels of H2BK123ub1, including the ribosomal protein genes, which comprise the majority of intron-containing genes in yeast. H2BK123ub1 is also a feature of introns in the yeast genome, and the disruption of this modification alters the intragenic distribution of H3 trimethylation on lysine 36 (H3K36me3), which functionally correlates with alternative RNA splicing in humans. In addition, the deletion of genes encoding the U2 snRNP subunits, Lea1 or Msl1, in combination with an <it>htb-K123R </it>mutation, leads to synthetic lethality.</p> <p>Conclusion</p> <p>These data suggest that H2BK123ub1 facilitates cross talk between chromatin and pre-mRNA splicing by modulating the distribution of intronic and exonic histone modifications.</p

Guidelines for the use and interpretation of assays for monitoring autophagy (3rd edition)

In 2008 we published the first set of guidelines for standardizing research in autophagy. Since then, research on this topic has continued to accelerate, and many new scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Accordingly, it is important to update these guidelines for monitoring autophagy in different organisms. Various reviews have described the range of assays that have been used for this purpose. Nevertheless, there continues to be confusion regarding acceptable methods to measure autophagy, especially in multicellular eukaryotes. For example, a key point that needs to be emphasized is that there is a difference between measurements that monitor the numbers or volume of autophagic elements (e.g., autophagosomes or autolysosomes) at any stage of the autophagic process versus those that measure fl ux through the autophagy pathway (i.e., the complete process including the amount and rate of cargo sequestered and degraded). In particular, a block in macroautophagy that results in autophagosome accumulation must be differentiated from stimuli that increase autophagic activity, defi ned as increased autophagy induction coupled with increased delivery to, and degradation within, lysosomes (inmost higher eukaryotes and some protists such as Dictyostelium ) or the vacuole (in plants and fungi). In other words, it is especially important that investigators new to the fi eld understand that the appearance of more autophagosomes does not necessarily equate with more autophagy. In fact, in many cases, autophagosomes accumulate because of a block in trafficking to lysosomes without a concomitant change in autophagosome biogenesis, whereas an increase in autolysosomes may reflect a reduction in degradative activity. It is worth emphasizing here that lysosomal digestion is a stage of autophagy and evaluating its competence is a crucial part of the evaluation of autophagic flux, or complete autophagy. Here, we present a set of guidelines for the selection and interpretation of methods for use by investigators who aim to examine macroautophagy and related processes, as well as for reviewers who need to provide realistic and reasonable critiques of papers that are focused on these processes. These guidelines are not meant to be a formulaic set of rules, because the appropriate assays depend in part on the question being asked and the system being used. In addition, we emphasize that no individual assay is guaranteed to be the most appropriate one in every situation, and we strongly recommend the use of multiple assays to monitor autophagy. Along these lines, because of the potential for pleiotropic effects due to blocking autophagy through genetic manipulation it is imperative to delete or knock down more than one autophagy-related gene. In addition, some individual Atg proteins, or groups of proteins, are involved in other cellular pathways so not all Atg proteins can be used as a specific marker for an autophagic process. In these guidelines, we consider these various methods of assessing autophagy and what information can, or cannot, be obtained from them. Finally, by discussing the merits and limits of particular autophagy assays, we hope to encourage technical innovation in the field

An Analysis of Medical Utilization and Expenditure before and after the Intervention of Integrated Delivery System in Matsu

連江縣通稱為馬祖地區。全民健康保險局於民國89年3月1日委由連江縣立醫院辦理馬祖地區醫療給付效益提昇計畫，初期協調台北市醫師公會調派醫師支援馬祖地區專科醫療，但由於專科醫師人數與品質難以掌握，遂連繫台北市衛生局，由所屬各市立醫院於民國89年6月1日起輪流派遣專科醫師支援馬祖地區專科醫療。因此，本研究目的在於探討全民健康保險局實施馬祖地區醫療給付效益提昇計畫對馬祖地區民眾門診、住院與預防保健利用與費用之影響，並了解民眾於縣內與縣外就醫之比率是否有差異。 本研究為一自然實驗，觀察馬祖地區民眾在實施馬祖地區醫療給付效益提昇計畫前後四年之時間，為排除外在環境影響，採用實驗年度與對照年度方式進行研究；將穩定實施馬祖地區醫療給付效益提昇計畫之年度為實驗年度，沒有穩定實施馬祖地區醫療給付效益提昇計畫之年度為對照年度。本研究使用次級資料進行分析，運用全民健康保險局資料庫民國93年1月設籍於馬祖地區(連江縣)之民眾，勾稽其於民國88年至91年之健保就醫申報資料進行探討，以差異中之差異法與Chi-square test進行統計分析。 本研究主要結果如下： 1. 馬祖地區居民縣內外之整體門診利用方面，在醫療給付效益提昇計畫介入前每年平均門診次數為9.5(民88)、10.1(民89)次，介入後為10.7(民90)、10.7(民91)次(表4-6)，有增加的趨勢。 2. 馬祖地區實施醫療給付效益提昇計畫後全縣每人門診醫療費用支出呈成長的趨勢，平均每人費用由介入前6557.4元增加至7055.0元，成長了7.6%。縣內費用由介入前之3007.4元增加至介入後之3345.8元，成長率為11.3%，平均每人次縣內費用成長率為-1.5%。此可能因醫療給付效益提昇計畫後門診量增加，但高費用的醫療處置並未增加之故。 3. 醫療給付效益提昇計畫介入後，全縣住院次數由介入前之670次增加至介入後之766次，成長率為14.3%。其中縣內住院次數比率由介入前之18.4%(民89)增加至介入後之23.2%(民90)(表4-19)，成長率僅4.8%。比例雖有增加，但仍顯示居民對馬祖地區醫院的醫療水準尚未建立足夠的信心。 4. 各類預防保健中，成人健檢的人次最不穩定，同時影響統計分析的結果。由於小於5歲兒童之健兒門診人數與人次不受成人健檢之影響，應可做為很好的指標。由健兒門診人次分析，由民國89年之67人次，增加至民國90年之190人次，增幅達183.6%，且縣內外比率也呈現有意義之增加(表4-28)。 5. 縣外之門診或住院所佔全縣之利用比率，在計劃介入後都呈下降的趨勢，顯示提昇醫療供給資源，可以減少馬祖居民因病需舟車勞頓遠赴台灣本島就醫的比例。 6. 縣內原有醫療機構之服務量在醫療給付效益提昇計畫介入後仍有成長。但至民國91年支援計畫就醫量已呈穩定狀態，此時除非引進新的診療服務項目，才有可能有正向之成長率。 7. 馬祖地區醫療給付效益提昇計劃實施後，雖然可預防性住院部份之全縣住院次數由介入前的68人次(民89)減少到介入後的65人次，減少-4.4%，但長期來看並未減少。 整體而言，本研究發現馬祖地區醫療給付效益提昇計劃實施後，馬祖地區居民縣內外之整體門診利用、住院次數與各類預防保健皆有增加的趨勢。全縣每人門診醫療費用支出呈成長的趨勢，縣內門診每人次費用為負成長。縣外之門診或住院所佔全縣之利用比率，在計劃介入後都已下降；但可預防性住院部份長期來看並未減少。縣內原有醫療機構之服務量在醫療給付效益提昇計畫介入後仍有成長。 因此本研究建議，須持續加強馬祖地區原有醫療機構之醫療人力與設施，已訓練完專科之公費醫師仍為最佳支援醫師人選，應努力爭取；馬祖地區島際交通仍須持續改善；並須加強內科與外科系統醫師之支援，而且計劃支援醫院需考慮其支援持續性。Lien-Chian County was commonly called Matsu Island. Integrated Delivery System (IDS) of Matsu was entrusted to Lien-Chian County Hospital by the Bureau of National Health Insurance on March 1st 2000. Initially we coordinated with Taipei Medical Association to sent medical doctors in support of specialist therapy in Matsu. Because the support was instable, we changed to seek support from Taipei Municipal Hospitals on June 1st 2000. The Purpose of this research was to discuss the effect of IDS on the utilization and expenditure of out- patient, admission and preventive services in Matsu, and to understand the ratio of going to a doctor inside and outside the county. This research was a natural experiment, we observed 4 years of IDS program. In order to excluding the effect of external environment, we used the method of experimental year and control year. Experimental year was defined as the year of carrying out stable IDS, and control year was defined as the year of carrying out unstable IDS. This research used secondary data from the database of the Bureau of National Health Insurance, to analyze the declaration data of the population of family registration in Lien-Chian County from 1999 to 2002. We used difference in difference and Chi-square test to examine the effect of the IDS program.. The major findings of this research are listed as follow: 1. The overall utilization of out-patient-department (OPD) revealed the annual average OPD utilization before the intervention of IDS was 9.5(1999), 10.1(2000), and 10.7(2001), 10.7(2002) after the IDS. There was an increasing tendency. 2. The medical expenditure of OPD of each person also shows an increasing tendency, which was NT$6,557.4 before IDS intervention and 7,055.0 after, the growth rate was 7.6$ 3007.4 to NT$ 3345.8 after, the growth rate was 11.3%. The growth rate of average utilization per person was –1.5%. It is possible because there are no high price of medical procedure and medicines in spite of the increase of OPD volume. 3. After the intervention of IDS, the annual admission utilization increased from 670 to 766, the growth rate was 14.3%. Admission utilization ratio increased from 18.4% (2000) to 23.2% (2001) inside the county. Although the ratio was increased, but it also suggests that the residents did not have confidence toward the medical quality inside the county. 4. Among the preventive services, the volume of the adult health examination was unstable, and it will change the result of the statistics and analysis. Because the volume of the healthy baby clinic was not related directly to the volume of adult health examination, so it was a good indicator. In the analysis of volume of healthy baby clinic, the volume increased from 67 persons (2000) to 190 persons (2001), the growth ratio was 183.6%, and the ratio of the volume of inside county and outside county was increased. 5.The utilization ratio of OPD and admission outside the county decreased after IDS intervention. It revealed that if we increased medical resource supply, the ratio of long way trip due to going to a doctor from Matsu to Taiwan would be decreased. 6. The service volume of the existing medical organization in the county increased after intervention of IDS. Because of the volume of medical service was stable in 2002, except for adding new items of health services, it will not be possible to have positive growth rate. 7. After intervention of IDS, although the volume of avoidable admission of the whole county changed from 68 persons to 65 persons, and the decreased rate was –4.4%, but there was no decreasing tendency. Finally, this research discovered that there were increased tendency of the overall volume of OPD utilization, admission and preventive service after IDS intervention. Overall OPD expenditure of each person had growth tendency, each person’s OPD expenditure in the county had negative growth. The overall OPD or admission utilization outside the county decreased after IDS intervention; but avoidable admission had no decrease for a long time period. The OPD volume of existing medical organizations had positive growth after IDS intervention. This research suggest that we should continue to strengthen the human resources and facility of existing medical organization in the county, well trained public financed doctors are the first choice when recruiting new staff; the transportation among Matsu islands should be improved; the number of internal medicine and surgical doctors should be increase to strengthen the support; and the consistency of support of IDS program must be taken into consideration.致謝……………………………………………………………………Ⅰ 中文摘要………………………………………………………………Ⅲ Abstract………………………………………………………………VI 目錄……………………………………………………………………IX 表目錄………………………………………………………………..XI 圖目錄………………………………………………………………..XV 第一章 緒論…………………………………………………………1 第一節 研究緣起…………………………………………………….1 第二節 研究重要性…………………………………………………1 第三節 研究目的及研究問題……………………………………..2 第四節 名詞解釋……………………………………………………3 第二章 文獻探討…………………………………………………..7 第一節 山地離島地區醫療政策探討與研究地區現況分析………7 第二節 醫療服務利用公平性之研究…………………………….21 第三節 個人醫療照護可近性之概念…………………………….22 第四節 個人醫療照護可近性之實證研究……………………….29 第五節 全民健康保險山地離島地區醫療給付效益提昇計劃之相關研究…………… ………………………………………..35 第三章 研究材料與方法………………………………………….39 第一節 研究架構………………… …………………………….39 第二節 研究假說………………………………………………….40 第三節 研究設計………………………………………………….40 第四節 研究對象與資料來源…………………………………….43 第五節 研究變項與操作型定義………………………………….43 第六節 資料處理與統計分析…………………………………….44 第四章 研究結果………………………………………………….48 第一節 馬祖地區醫療給付效益提昇計劃介入對居民醫療利用之影響……………………………………………… …………......48 第二節 馬祖地區整合醫療服務經營模式實施之效益評估…….59 第五章 討論……………………………………………………….80 第一節 醫療給付效益提昇計劃對醫療利用之影響 ………….80 第二節 影響醫療利用之因素探討……………………………….84 第三節 馬祖地區居民及醫護人員對醫療給付效益提昇計劃之建議…....................................................85 第四節 研究限制………………………………………………….85 第六章 結論與建議……………………………………… …….87 第一節 結論……………………………………………………….87 第二節 建議……………………………………………………….89 參考文獻……………………………………………………… .92 中文文獻………………………………………………………………92 英文文獻……………………………………………………………..95 附件一、山地離島地區醫療服務促進方案……………………… .98 附件二、全民健康保險醫療費用支付標準部分增(修)訂項目….100 附件三、九十年度馬祖地區醫療給付效益提昇計畫…………….101 表目錄 表1-1 可預防性住院疾病的診斷名稱與其ICD-9分類碼……………5 表2-1 馬祖地區戶籍人口性別及年齡分佈表……………………….12 表2-2 連江縣各鄉地理、人文、教育及醫療相關資訊…………….13 表2-3 馬祖地區現有醫療人力……………………………………….14 表2-4 馬祖地區健保醫療資源利用情形…………………………….15 表2-5 馬祖地區醫療院所申報門診費用一覽表(88年1月至6月平均值)…..................................................…15 表2-6 馬祖地區醫療給付效益提昇計畫支援型態與支援醫療機構簡介….....................................................20 表2-7 以群體為基礎所作調查的可近性主題……………………….28 表2-8 與IDS政策實施相關之研究與成果報告………………………37 表3-1 八十八年底至九十三年連江縣(馬祖地區)現住人口數年齡分配……45 表3-2 本研究基準人口數…………………………………………….45 表4-1 馬祖地區醫療給付效益提昇計劃介入前居民縣內外門診醫療利用統計(民88年)…………………………………………………….49 表4-2 馬祖地區醫療給付效益提昇計劃介入前居民縣內外門診醫療利用統計(民89年)…………………………………………………….50 表4-3 馬祖地區醫療給付效益提昇計劃介入後居民縣內外門診醫療利用統計(民90年)…………………………………………………….50 表4-4 馬祖地區醫療給付效益提昇計劃介入後居民縣內外門診醫療利用統計(民91年)………….……………………………………….51 表4-5 馬祖地區醫療給付效益提昇計劃介入前後居民縣內外門診醫療利用四年合計(民88-91年).. …………………………………….51 表4-6 馬祖地區醫療給付效益提昇計劃介入前後居民縣內外門診醫療利用年平均值(民88-91年).. …………………………………….52 表4-7 馬祖地區醫療給付效益提昇計劃介入前居民縣內外住院醫療利用統計(民88年)……………………………… ………………..54 表4-8 馬祖地區醫療給付效益提昇計劃介入前居民縣內外住院醫療利用統計(民89年)…………………………………………………..55 表4-9 馬祖地區醫療給付效益提昇計劃介入後居民縣內外住院醫療利用統計(民90年)…………………………………………………..55 表4-10 馬祖地區醫療給付效益提昇計劃介入後居民縣內外住院醫療利用統計(民91年)……………………………………………… ….56 表4-11 馬祖地區醫療給付效益提昇計劃介入前後居民縣內外住院醫療利用四年合計(民88-91年). ………………………………… …56 表4-12 馬祖地區醫療給付效益提昇計劃介入前後居民縣內外住院醫療利用年平均值(民88-91年).. …………………………………. 57 表4-13 連江縣立醫院民國88年至91年就診人數統計表…………59 表4-14馬祖地區醫療給付效益提昇計劃介入對居民縣內外門診醫療利用之影響……………………………………………………………60 表4-15馬祖地區醫療給付效益提昇計劃介入對不同性別居民縣內外門診醫療利用之影響……………………………………………… .61 表4-16馬祖地區醫療給付效益提昇計劃介入對不同年齡層居民縣內外門診醫療利用之影響………………………………………………62 表4-17馬祖地區醫療給付效益提昇計劃介入對&lt;5歲居民縣內外小兒科門診醫療利用之影響…………………………………………… .64 表4-18馬祖地區醫療給付效益提昇計劃介入對居民縣內外婦科門診醫療利用之影響………………………………………………… ….64 表4-19馬祖地區醫療給付效益提昇計劃介入對居民縣內外住院醫療利用之影響………………………………………………… ……….65 表4-20馬祖地區醫療給付效益提昇計劃介入對不同性別居民縣內外住院醫療利用之影響…………………………………………… ….66 表4-21馬祖地區醫療給付效益提昇計劃介入對不同年齡層居民縣內外住院醫療利用之影響…………………………………………… .67 表4-22馬祖地區醫療給付效益提昇計劃介入對&lt;5歲居民縣內外小兒科住院醫療利用之影響…………………………………………… .68 表4-23馬祖地區醫療給付效益提昇計劃介入對居民縣內外婦科住院醫療利用之影響………………………………………………… ….68 表4-24馬祖地區醫療給付效益提昇計劃介入對居民縣內外可預防性住院醫療利用之影響…………………………………………… ….69 表4-25馬祖地區醫療給付效益提昇計劃介入對居民縣內外預防保健醫療利用之影響………………………………………………… ….70 表4-26馬祖地區醫療給付效益提昇計劃介入對不同性別居民縣內外預防保健醫療利用之影響……………………………………………71 表4-27馬祖地區醫療給付效益提昇計劃介入對不同年齡層居民縣內外預防保健醫療利用之影響.. ………………………………… …72 表4-28馬祖地區醫療給付效益提昇計劃介入對&lt;5歲居民縣內外預防保健醫療利用之影響……………………………………………… .73 表4-29馬祖地區醫療給付效益提昇計劃介入對居民縣內外婦科預防保健醫療利用之影響……………………………………………… .73 表4-30縣內門診利用差異中之差異……………………………… .75 表4-31縣內住院利用差異中之差異……………………………… .77 表4-32縣內預防保健利用差異中之差異………………………… 79 附表 附表一 山地離島地區一覽表………………………………… …..99 附表二 馬祖地區戶籍人口性別及年齡分布表………………… .103 附表三 馬祖地區現有醫療人力……………………………………104 附表四 八十九年度馬祖地區醫療利用情形…………………… .105 附表五 台北市各市立醫院專科醫師支援馬祖地區科別及地點排班表…….................................................107 附表六 馬祖地區醫療給付效益提昇計畫每月分項費用金額及計算基礎…...................................................109 圖目錄 圖1-1 醫療照顧的可近性模式(Model of access to personal health care)……………………………………… ……………….4 圖2-1全民健康保險馬祖地區醫療給付效益提昇計畫運作模式… 17 圖2-2全民健康保險馬祖地區醫療給付效益提昇計畫費用運作與流向圖......................................................19 圖2-3 可近性架構圖……………………………………………… .23 圖2-4健康照護可近性的急診模式(An Emerging Model of Access of Health Care)…………………………………………………….24 圖2-5急診醫療服務的Andersen 修正模式………… …………..26 圖3-1研究架構………………………………………………… ….39 圖3-2 馬祖地區醫療給付效益提昇計劃期別圖……………………42 圖4-1馬祖地區醫療給付效益提昇計劃介入前後居民縣內外門診醫療利用折線圖(民88-91年)…………………………………………… 53 圖4-2馬祖地區醫療給付效益提昇計劃介入前後居民縣內外門診醫療費用折線圖(民88-91年)…………………………………………… 53 圖4-3馬祖地區醫療給付效益提昇計劃介入前後居民縣內外住院次數折線圖(民88-91年)………………………………………………….58 圖4-4馬祖地區醫療給付效益提昇計劃介入前後居民縣內外住院醫療費用折線圖(民88-91年)…………………………………………… 58 圖4-5馬祖地區醫療給付效益提昇計劃介入前後居民縣內外平均住院日折線圖(民88-91年)……………………………………………… 5

Macroinvertebrate assemblage patterns as indicators of water quality in the Xindian watershed, Taiwan

In the present study, we assessed the water quality along a stretch of the watershed with considerable economic importance at the Xindian in Taiwan, using macroinvertebrate assemblages, along with environmental variables. The research was carried out at the seven sampling sites (abbreviated as XD1-XD7) where human impacts varied in intensity from upstream tributaries to the downstream of the Xindian watershed from December 2010 to December 2011. All variables except for the hardness, pH, dissolved oxygen, conductivity, turbidity, phosphate, ammonia, and alkalinity were significantly different (P b 0.05) between the sampling sites. A total of seventy seven taxa belonging to forty five families within eight insect orders, along with three non-insect invertebrate taxa were recorded, with most representative orders being Ephemeroptera and Diptera. Mean values of the density, abundance of macroinvertebrates, Shannon index, Simpson index, and Pielou&apos;s evenness were much higher in the reference sites, XD2, XD3, and XD4 compared with impacted sites, XD5, XD6, and XD7. Most of the benthic metrics were greatest in the reference site compared to the impacted site. Only the composition measures, percentages of Chironomidae and Oligochaeta which are more tolerant to pollution were dominant in the impacted site, XD7. As the results of assessment by different benthic metrics, water quality of Xindian watershed became gradually worse from upstream to downstream. Generally, our results suggest that macroinvertebrate assemblages can be used for assessment of water quality