中老年婦女醫療利用情形與子宮頸抹片檢查之相關性研究
中老年婦女醫療利用情形與子宮頸抹片檢查之相關性研究
郭德貞
慈濟技術學院醫務管理系助理教授
摘要
台灣地區婦女抹片檢查篩檢率約為42-55%，較世界各國為低；但健保每人每年平均就診人次為15 次，醫療利用率則高達九成，故本研究嘗試探討中老年婦女其醫療利用與子宮頸抹片檢查利用之間的相關情形，檢視二者間是否存在顯著正相關。由於健保開辦已逾15 年，本研究亦分析中老年婦女在子宮項抹片篩檢利用情形是否存在年度、年齡層之差異。
本研究採用變動世代追蹤研究法，利用國家衛生研究院所提供健保抽樣歸人檔資料庫，進行次級資料分析。本研究使用四組健保抽樣歸人檔，以1997~2004 該年度年齡滿40 歲之婦女為樣本，每年人數由32300 人逐年增加為44222 人。研究結果：門診就診率均在85%以上，但有逐年下降之趨勢。急診就診率為12~14%，中醫就診率31~33%，牙醫就診率29~34%，則有上昇趨勢，慢性病門診就診率成長快速，自46%增為53%。洗腎就診利用人數增加二倍以上，但就診率小於1%。居家照護利用就診率亦小於1%，但人數增加五倍。預防保健利用人數是三級跳的成長，從7811 人增為15246 人，就診率從24%增為34.5%。骨密度檢查利用就診率以2003 年最低，1998 及1999 年最多，或許與國民健康局補助進行骨密度檢查的政策實施有關。
乳房攝影檢查利用人數增加近三倍，自健保開辦以來隨著年代而利用增加；子宮頸抹片檢查利用人數增加二倍以上，就診率自13%增為26%，年齡上以40~49 歲利用率為最高。利用門診、牙科門診、中醫門診、預防保健、慢性病就診各項利用次愈高者其子宫頸抺片檢查機會愈高。有利用急診、骨密度檢查、乳房攝影檢查、住診醫療、荷爾蒙替代療法者其子宫頸抺片檢查利用機會較大。但洗腎者及使用居家照護者其子宫頸抺片檢查利用機會較少。
相較於門診、牙醫及中醫的高利用率，子宫頸抺片檢查利用率較低。建議政府可多鼓勵醫療院所推動子宮頸抹片檢查篩檢活動，且要對洗腎病人及居家照護利用病人教育多注意癌症相關篩檢。
關鍵字：子宮頸抹片篩檢、醫療利用、勝算比
-------------------------------------------------------------------------------------
Correlation between Medical Utilization and Pap smear Receipt among Middle-aged and Elderly Women in Taiwan
De-Jhen Kuo
Department of Health Administration, Tzu-Chi College of Technology
Abstract
Women's Pap smear screening in Taiwan was 42-55% and lower than most other countries. But contacted rate for medical services was higher than ninety percent. In 2009, per capita visits to out-patient departments measured 15.0. Objectives: This study examined the correlation between several aspects related to medical utilization and the receipt of a Pap smear exam among middle-aged and elderly women in a national representative dynamic cohort in Taiwan over an eight year period. Subject age and annual odds ratios were also considered. Methods: The study population consists of women aged 40 years and over in Taiwan. Our data, provided by National Health Research Institutes, are the sampled registry information of 44,222 beneficiaries of National Health Insurance from 1997 to 2004. The dependent variable was receipt of a Pap smear exam. The independent variables were specific year, subject age, occurrence of outpatient visits, Chinese medicine practitioner visits, emergency room visits, dental treatment visits, with/without chronic disease, undergoing dialysis treatments, receiving home care services, receiving preventive care, classification as an inpatient, undergoing HRT treatment, receipt of bone density exam, and receipt of mammography exam. We used the generalized estimating equation （GEE） model for repeated measurement analysis. Results: Although the annual contact rate of outpatient visits was more than 85%, a continuously declining trend was indicated. The annual contact rate of emergency department visits was between 12 ~ 14%, with a slight increase over time. The annual contact rate of Chinese medicine visits remained generally stable and between 31 ~ 33%. The annual contact rate of dental treatment visits was between 29 ~ 34%, with an increasing trend. A steadily rising trend was noted in the annual contact rates of chronic diseases out-patient, with rates increasing from 46% to 53% over the period of this study. Although the visiting numbers for dialysis treatments increased two-fold, the annual contact rates remained less than 1%. The visiting numbers of home care services increased more than five-fold, but the rates remained less than 1%. A notable increase was seen in the visiting numbers for preventive care as it increased from 7,811 people to 15,246 people, showing a similar increase in annual rate from 24% to 34.5%. The screening rate of bone density was lowest in 2003 and highest in 1999, this may be attributable to the Taiwan Bureau of Health, Promotion of Health Department implementation of subsides for bone density examination. The number of mammography use nearly tripled, and the annual contact rate more than doubled, yet the rate remained below 1%. Conclusions: The overall number of screenings by Pap smear more than doubled during the study period, and the annual contact rate for Pap smears （PSAR） increased from 13% to a peak of nearly 26% in 2001, followed by a modest decline. The odds ratio for Pap smear（ORPS） for age 40 to 49 year old women was the highest at 2.67. With the notable exceptions of “dialysis treatment” and “home care services” all other aspects of medical utilization in this study presented ORPS greater than 1.0, indicating a positive correlation.
Base on the results, we offer two recommendations. Firstly, the government should encourage hospitals to promote Pap smear screening programs, especially among dialysis patients. Secondly, medical professionals in contact with home care patients should encourage them to undergo cancer screenings.
Keywords：Pap smear, Medical Utilization, Middle-aged and elderly Women.
