〔摘要〕
醫療診斷的差異攸關醫療品質的一致性與醫療照護的成本效益，對於目前外籍勞工(人士)體檢X光肺結核檢查的判讀，究該由放射科醫師或胸腔科醫師判讀，還是由健檢直接問診病患的家醫科醫師來判讀，將造成外勞體檢的流暢及整體品質的一致性有所不同。有見國內對於醫師診斷差異的研究闕如，本研究設計為一實證性橫斷研究，針對三個不同專科別醫師對3595位至國軍左營醫院體檢之外籍勞工(人士)體檢X光判讀結果進行研究，評估其判讀結果差異，以作為防疫單位公共衛生政策的制定與健檢醫院醫療作業品質及管理之參考。
研究結果發現醫師個人特質與胸部X光判讀為(疑)肺結核之分析：在科別與醫師所屬醫院層級無統計顯著差異，而十位醫師彼此兩兩間在胸部X光(疑)肺結核的判讀上，關連性、差異變化很大，Kappa值界於-0.005至1.0之間。另外Kappa一致性比較在十位醫師間、四位胸腔科醫師間、三位放射科醫師間及三位家醫科醫師間，Kappa值介於0.035至0.2之間，皆呈現彼此一致性低、關連性與信度不佳、差異大之情形。其中以三位家醫科醫師間Kappa值0.18629最高，而四位胸腔科醫師間Kappa值0.038197最低。另外醫師個人特質與胸部X光判讀為異常之分析：十位醫師彼此兩兩間在胸部X光異常的判讀上，關連性、差異變化很大，Kappa值介於-0.009至0.375之間。而外籍勞工(人士)胸部X光判讀積分與醫師特質之統計分析:十位醫師彼此兩兩間在胸部X光判讀積分上，關連性、差異變化很大，ICC值界於-0.0159至0.5540之間，整體而言並不佳。
本研究即在不涉及醫療保險支付制度的架構下，去探討不同醫師個人特質，在外籍勞工(人士)體檢胸部X光診斷上的差異。若依據疾病管制局的要求，只考量外籍勞工(人士)傳染性疾病肺結核，結果顯示三個科(胸腔科、放射科及家醫科)，在胸部X光肺結核的診斷上並無統計差異，因而若由第一線問診之家醫科醫師也同時擔任判讀胸部X光片的醫師，則不僅加速流程，也同時因為較其他判讀醫師更瞭解受檢外勞的相關病史，而對整個判讀之建立有相輔相成之功效。本研究由國外文獻回顧中，得知醫師彼此間在診斷上，如胸部X光片、病理組織切片、電腦斷層、乳房超音波及急診胸、腹部、骨骼X光片大都存有不少差異，彼此的診斷關連一致性與信度也不佳，進而有些研究提出如何透過不斷的討論、研習，來提高彼此診斷的關連一致性與信度。反觀國內在醫師間差異探討的研究幾乎付之闕如。由本研究結果得知醫師間彼此的診斷關連一致性、差異變化很大，其後續是否會造成醫療行為的影響，如過度使用其他相關的醫療檢查或不必要的藥物等，進而影響病患的安全，實有待進一步探討。

〔Abstract〕
The difference of medical diagnosis and its related effect is important to medical quality consistency and medical care cost-effectiveness. At present, the specialists including radiologists, chest medicine doctors & family medicine doctors able to perform X-ray diagnosis of foreigners’ physical examination would cause the difference of flow fluency & consistency of medical quality in foreigners’ physical examination. Due to the shortage of studies in discussing the difference among doctors’ diagnosis in our country, the study is an experimental cross-section design that focuses on the diagnosis difference of 3595 foreigners’ chest X-ray among 3 different specialists. The result of research may be useful for making policy of public health and be referent to the quality control and management in the hospital.
According to the result, the X-ray diagnosis of lung TB showed no difference between specialists & hospital levels in Chi-square analysis, but the diagnosis consistency of kappa between every 2 doctors was so fluctuant among 10 doctors, the kappa value ranged from –0.005 to 1.0. Besides, the consistency of kappa among either 10 doctors, 4 chest medicine doctors, 3 radiologists or 3 family medicine doctors were poor, and the kappa value ranged from 0.035 to 0.2. The highest kappa was 0.18629 among 3 family medicine doctors, while the lowest kappa was 0.038197 among 4 chest medicine doctors. The other studying result also showed low consistency of kappa among 10 doctors in X-ray diagnosis of lung abnormality, the kappa value ranged from –0.009 to 0.375. Besides, the low consistency of ICC was also noted among 10 doctors in X-ray diagnosis scores of lung abnormality. ICC value ranged from –0.0159 to 0.5540.
The exploration of doctors’ difference in X-ray diagnosis of lung was under no interference of medical payment system. If the X-ray diagnosis followed the standard of CDC, only requiring the abnormal TB, 3 specialists would show no difference in X-ray TB diagnosis. Therefore, the first line family medicine doctors who see the foreigners directly would also fit to make the diagnosis of X-ray lung TB. Moreover, due to the family medicine doctors understand the foreigners’ history than other specialists, if the family medicine doctors make the diagnosis of X-ray lung TB, the overall examination procedure would be fast and better.
From the article review, the consistency was low among doctors in many medical diagnoses, such as chest X-ray, cytology, CT scan, breast sono, emergent chest X-ray, KUB and skeletal X-ray. Due to the low consistency, there were researchers making effort and doing study to suggest that the doctors could elevate the consistency and reliability by continual discussion and learning. However, our country is short of study in discussing the difference among doctors. From the study result, the variation of consistency is huge. Whether it would affect the medical behavior of doctors, such as overusing the related tests or medicine having influence on patients’ health and safety, further studies will be needed.

目 錄

誌謝 i
中文摘要 ii
英文摘要 iv
目 錄 vi
附 錄 viii
表 次 ix
第一章 緒論
第一節 研究背景 1
第二節 研究問題 2
第三節 研究目的 3
第二章 文獻探討
第一節 外籍勞工引進現況及醫療、健康相關議題 4
第二節 結核病的診斷及對公共衛生的衝擊 10
第三節 不同專科別醫療照護差異與醫療品質之相關議題 20
第三章 研究設計與方法
第一節 研究假設 36
第二節 研究架構 36
第三節 資料來源與變項操作型定義 37
第四節 研究樣本 41
第五節 分析方法 42
第四章 研究結果與討論
第一節 描述性統計分析 46
第二節 推論性統計分析 51
第五章 結論與建議
第一節 主要發現 87
第二節 結論 89
第三節 建議 90
第四節 未來研究方向 91
參考文獻 93

附 錄

附錄一 臺閩地區外籍勞工概況按國籍分 1
附錄二 外籍勞工健康證明應檢查項目表 1
附錄三 臺灣地區九十年受聘僱外籍勞工(含家庭幫傭、監護工)健康檢查不合格
統計表 2
附錄四 全球1990-2000年結核病預估發生率 17
附錄五 全球1990-2000年結核病預估死亡數 17

表 次

表1 變項的操作性定義 39
表2樣本代表性之卡方適合度檢定 42
表3樣本基本資料及參與醫師之次數分配表 47
表4情境一(正常(無肺結核)v.s.(疑)肺結核)各醫師判讀之結果 48
表5情境二(正常v.s.異常)各醫師判讀之結果 49
表6 情境三(各種X光胸腔疾病)各醫師判讀之結果 50
表7情境一胸部X光(正常(無肺結核)v.s.(疑)肺結核)與外籍勞工基本
資料及醫師特質之卡方分析 54
表8情境二胸部X光(正常v.s.異常)與外籍勞工基本資料及醫師特質
之卡方分析 57
表9情境四胸部X光判讀結果積分與外籍勞工基本資料之獨立樣本
T檢定 58
表10情境四胸部X光判讀結果積分與醫師特質及外籍勞工基本資料
之變異數分析 61
表11情境四胸部X光判讀結果積分與醫師特質之一般線性模式重
複量測分析 64
表12情境一(正常(無肺結核) v.s. (疑)肺結核)與不同醫師間之Kappa
分析 68
表13情境二(正常v.s.異常)與不同醫師間之Kappa分析 73
表14情境四(胸部X光判讀積分)與不同醫師間之ICC分析 81
表15情境一胸部X光(正常(無肺結核)v.s.(疑)肺結核)與外籍勞工(人
士)基本資料之羅吉斯迴歸分析 85
表16情境二胸部X光(正常v.s.異常)與外籍勞工(人士)基本資料之羅
吉斯迴歸分析 86

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