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How to improve the population health?
1. 醫療體系綜論報告醫療體系綜論報告
Effectiveness (2):Effectiveness (2):
How to improve the populationHow to improve the population
health?health?
Policy Strategies, Evidence, and CriteriaPolicy Strategies, Evidence, and Criteria
第二組 魏文一第二組 魏文一
April 11, 2009April 11, 2009
3. Effectiveness
大 綱大 綱
1. Policy strategies relating to effectiveness
- population perspective
- clinical perspective
2. Evidence relating to effectiveness
- population perspective
- clinical perspective
3. Criteria for assessing policy alternatives
in terms of effectiveness
- population perspective
- clinical perspective
4. Effectiveness
Factors Contributing to PopulationFactors Contributing to Population
HealthHealth
System
Institution
Patient
Structure
Process
Outcome
Population perspective Clinical perspective
Environment
Human biologyBehavior
Medical care
Levels of medical careLevels of medical care
5. Effectiveness
Contributing factor Policy strategy
Population perspective Population health information system
Environment Health protection
Behavior Health promotion
Human biology Biomedical research
Preventive services
Medical care
Structure
Efficacy Biomedical research
Quantity Investment in resources
Distribution and organization Health planning and regionalization
Process Organized/ integrated delivery systems
Utilization Enhanced access
Clinical perspective
Medical care
Process
Quality Regulation of professional performance
Outcome Outcome assessment and management
Practice guidelines
Performance monitoring systems
6. Effectiveness
民眾健康資訊系統民眾健康資訊系統 InIn
CanadaCanada
以健康為主題而非討單獨討論疾病本身
Lalonde report (1975, Canada): 為增進大 的健康眾
,環境、生活形態、人類生物學,和醫療同樣重要
(health determinants)
加拿大健康政策 :
- equal access to health, as opposed to equal access to healthcare
- 依卑詩省的民 健康資料系統眾 (population health
information system), 發展全面的健康政策
卑詩省的 Population Information System (POPULIS)
- 以國家醫療保險計劃被保人為 database
- 分析 demographic changes, expenditure patterns,
hospital performance, outcome research,
utilization review and health reform
Populationhealthinformationsystem
Populationperspective
7. Effectiveness
民眾健康資訊系統民眾健康資訊系統 In USAIn USA
對健康決定因素瞭解的提升,發展清楚的健康促
進及疾病預防策略
Healthy People Report
- Healthy People 1990 目標 : health promotion, protection,
preventive services ,但未清楚的提出達成策略
- Healthy People 2010: 提出針對不同健康決定因素的達成策
略,包括非醫療方面
*Environment (health protection): ozone exposure, tobacco
smoke
*Behavior (health promotion): sexual behavior, substance
abuse
*Human biology (biomedical research, preventive services):
immunization, obesity
Office of Health Promotion and Disease Prevention
Populationhealthinformationsystem
Populationperspective
8. Effectiveness
Structure
- Efficacy: biomedical research
1930 National Institutes of Health (NIH) ( 前身為海軍醫院衛生實驗室 )
1937 National Cancer Institute 併入 NIH
1948 National Heart Institute 併入 NIH
NIH 的成立是以 population 的觀點出發,卻演變成 Clinical 觀點的力
量
將生醫研究成果傳播到實際醫療運用:繼續醫學教育
1965 Regional Medical Program (A National Program to Cnquer Heart
Disease, Cancer and Stroke):
Mid-1970s Consensus Development Program
Guidelines for medical practitioners: NIH consensus development
conferences
- Quantity: investment in resources (increasing the quantity of medical
care resources)
1946 Hill-Burton legislation 增加醫院的數量及分布密度
1963 Health Professions Educational Assistance Act 增加醫師、護士及
其他醫療專業人士
- Distribution and organization: Health planning and regionalization of
services
1966 Comprehensive Health Planning legislation 提供地區健康規劃補助
1965 Regional Medical Program legislation 發展整合性醫療的基礎技術
,提昇服務的效果及效率
Medicalcare
Populationperspective
Structure
9. Effectiveness
Process of care delivery:
Organized/integrated delivery system
網狀的組織,為某些特定族群安排提供一
個整體連續性的醫療,並在臨床上的及財
務上,對所服務的民 健康狀態結果承擔眾
責任
- Utilization:
Enhanced access 針對特定族群
Maternal and child health programs
State and local health departments
Medicare ( 聯邦醫療保險 ) ,是為 65 歲或以
上
人士、不足 65 歲但患有某種殘障的人士,及
患有永久性腎臟衰竭的任何年齡的人士提供的
健康保險
Medicaid ( 州醫療輔助 ) ,是為收入和資產有
限的某些人士和家庭提供的健康保險
Office of Economic Opportunity
Medicalcare
Populationperspective
Process
10. Effectiveness
Process
Quality: regulation of professional performance 過
程為導向 ( 專業醫療的規範 )
1965 Medicare 實施後 , 一些組織隨之成立以監測醫療品質
1972 Professional Standards Review Organization (PSRO): 醫
院層級專業標準審 組織查
Health Care Financing Administration: 州層級專業標準審查
組織
Outcomes: outcomes assessment and
management 結果為導向 ( 結果評估和管理 )
1989 Agency for Healthcare Research and Quality
(AHRQ, 醫療研究 品質管理局暨 ): outcome research 的
旗鑑單位,也是美國發展指引最具代表性最常被引用的機
構
1997 AHRQ 成立 Evidence-Based Practice Centers: 協助
其他組織發展指引
Practice Guidelines ( 病患層級,臨床治療指引 )
Performance Monitoring Systems ( 醫院、體系層級,
績效監測系統 )
Medicalcare
Clinicalperspective
11. Effectiveness
Practice GuidelinesPractice Guidelines
系統性發展出來的論述,目的是在幫助醫師
及病人對於特定病況,能做正確的臨床選
擇,以期降低不當的醫療,並控制地理上
的差異,增加醫療上的效果。
Practice guidelines by AHRQ (patient 、
provider 、 researcher versions provided)
Medicalcare
Clinicalperspective
Outcome
•Acute pain management
•Urinary incontinence in adults
•Pressure ulcers in adults
•Cataract in adults
•Depression in primary care
•Sickle cell disease
•Early HIV infection
•Benign prostatic hyperplasia
•Management of cancer pain
•Unstable angina
•Heart failure
•Otitis media with effusion
•Quality mammography
•Acute low back problems
•Post-stroke rehabilitation
•Cardiac rehabilitation
•Smoke cessation
12. Effectiveness
提供一套過程和結果評量的相關標準,藉由這些
標準 , 可以針對特定的醫療單位,在內部比較時依
時間的變化,外部比較時依單位的績效做衡量、
監控 。
這個績效監控的系統由各種身份不同的人和單位
共同來贊助的。
National Committee for Quality Assurance (NCQA
全國品質保證委員會 ) 於 1989 年開發 Health Plan
Employer Data and Information Set (HEDIS, 醫療保
險計劃 主資料及資訊集僱 ) ,提供了一系列標準化
評量的的標準,讓消費者或病人有足以信賴的資
訊去比較不同的管理式醫療保險計劃間的差異。
HEDIS 包含 8 個醫療領域 ( 醫療的效果、醫療的
可近性、醫療滿意度、醫療保險計劃的穩定性、
醫療服務的利用、醫療成本、資訊充分的醫療選
擇及醫療計劃說明資訊 ) ,共 68 個評量項目。
Performance MonitoringPerformance Monitoring
SystemsSystems
Medicalcare
Clinicalperspective
Outcome
13. Effectiveness
From an effectiveness viewpoints, what policyFrom an effectiveness viewpoints, what policy
strategies contribute most to improving thestrategies contribute most to improving the
health of the population?health of the population?
15. Effectiveness
Population Health IndicatorsPopulation Health Indicators
U. S. Office of Disease Prevention and
Health Promotion 2003: 22 indicators of
population health status
measures of morbidity, access, health behaviors,
substance use, and childhood outcomes
與多數已開發國家相比美國醫療花費較高
U.S. ranked at the bottom on many of these
indicators, esp. for infant mortality, total
mortality, and worked-related injury deaths
Health disparities between racial and ethnic
population groups
Hispanics appear to be faring better than blacks.
16. Effectiveness
Major Determinants of HealthMajor Determinants of Health
Medical
Non-medical
Environment
1. Cancer mortality: 60-90% of cancers are
environmentally caused, with as much as 1/3 of
cancer deaths being attributed to diet.
diet, tobacco, infection, occupational exposures,
radiation, food contamination, food additives,
water pollution, air pollution, indoor chemicals,
occupational exposure, toxic wastes, carcinogens,
noise, trauma, accidents
2. Nervous-, endocrine-, immune-system problems
3. Acute poisoning, birth defects
Social environment
1. Social class, status hierarchies, income, social
ties (disruptions due to death, divorce, or
immigration), and culture change 民 健康、死眾
亡率有關
17. Effectiveness
Evidence about the various policyEvidence about the various policy
strategiesstrategies
Health Protection
1. Most prominent contributors to
mortality in U.S. in1990: tobacco,
diet and activity patterns, alcohol,
microbial agents, toxic agents,
firearms, sexual behavior, motor
vehicles, and illicit use of drugs
(accounted for more than half of
the deaths)
Socioeconomic status
Healthprotection
Populationperspective
18. Effectiveness
Health Promotion and Preventive Services
1. Mixed effectiveness
2. 2000 年,紐約預防政策 ( 心臟病、愛滋病、藥物濫用、暴力
預防 )15 年回顧 : 計劃有助於不同族群低收入市民的健康,
但因沒有改變潛在社會因素及沒有針對特定次族群介入,所
以效果有限
3. Glanz et al. (2002) reviewed 社區心血管疾病治療降低死亡
率效果不顯著
4. 1994 Thacker et al. Centers for Disease Control and
Prevention: effectiveness of preventive services
95%~98% effectiveness of vaccination in preventing measles
20%~70% effectiveness of mammography in preventing
breast cancer deaths
50% effectiveness of retinal screening and treatment in
preventing blindness with retinopathy
5. Bunker et al. (1994)
Preventive services for hypertension, cervical cancer
screening, childhood immunizations increased life expectancy
over this century in the United States
Evidence about the various policyEvidence about the various policy
strategiesstrategies
Healthpromotionandpreventiveservices
Populationperspective
19. Effectiveness
Biomedicalresearch
長期以來,增加醫療投資以改善民 健康眾
為策略之一,但效果因醫院而異
Structure
Biomedical research:
directed at improving the efficacy of
medical care
1. Randomized clinical trial: determine
the efficacy of medical care
2. Cross-sectional study: assess the
effectiveness of medical care
3. McKinlay et. al. (1989)
研究治療冠心症、癌症、中風對死亡率的
影響。結果顯示醫療可延長平均壽命。
Medicalcare
Populationperspective
Structure
Evidence about the various policyEvidence about the various policy
strategiesstrategies
20. Effectiveness
Healthplanningand
regionalizationofservices
Investment in resources
1. 增加醫院及醫師之數量對民 健康的影響眾 ?
Berlowitz (1998) 研究兩年新英格蘭地區五個榮民事業部的
高血壓榮民,結果發現許多榮民血壓控制不良,許多醫師治
療不 積極夠
Health planning and regionalization of services
1. 醫療的分布 (distribution) 與組織化 (organization)
Lattimore (2003) 社區醫院成立中風治療中心大幅增加缺血
性中風的溶血栓治療
2. Regionalization of surgical services
探討醫院手術案例與手術死亡率關係 ?
Carey (2003) 分析 1997-1999 年,在加州 119 家非聯邦醫院接
受心臟外科手術後出院病歷摘要資料 : 每年 CABG 數小於 200 例
醫院與每年 CABG 數大於 500 例醫院相比,前者手術住院中死亡
率較高。但很多手術量少的醫院手術結果較好。結論雖然較多的
手術與較低之該手術死亡率有關,但病患因素與過程更重要。外
科手術結果是可被改善 . Regionalized surgical services for the
proce-dures that require a high volume to maximize
effectiveness.
Investmentinresources
Medicalcare
Populationperspective
Structure
Evidence about the various policyEvidence about the various policy
strategiesstrategies
21. Effectiveness
Process: integrated health care system
Luft 1981: HMO( 健康維護組織,一種管理式
健康護理計劃,在預付費基礎上為自願加入
的客戶提供或安排全面、協調的醫療服務 )
outcomes were not very different from those
of conventional practice
Miller and Luft 1994,1997, 2002 (update):
the outcomes were in general no better nor
worse on average ( 例外 negative outcomes
for Medicare enrollees with chronic
conditions)
Integratedhealthcaresystem
Medicalcare
Populationperspective
Process
Evidence about the various policyEvidence about the various policy
strategiesstrategies
22. Effectiveness
Process, utilization:
Enhanced access
改善特定族群醫療可近性
證明其效果必須研究以下之間關係 :
process variables of utilization, quantity
of procedures, quality of care, various
outcome, 這些變項以為測量標準
Differences in utilization have a modest
relationship to outcomes.
The Rand Health Insurance Experiment
(Brook et al. 1983)
Evidence about the various policyEvidence about the various policy
strategiesstrategies
Enhancedaccess
Medicalcare
Populationperspective
Process
23. Effectiveness
The Rand Health Insurance ExperimentThe Rand Health Insurance Experiment
(Brook et al. 1983)(Brook et al. 1983)
1. the effects of varying utilization rates on health outcomes
2. what influence various levels of copayment in a national health
insurance scheme might have, primarily on utilization and secondarily
on health status
3. The utilization examined included both outpatient treatment and
hospitalization for both adults and children
4. Clinical outcome assess: blood pressure and vision for adults and
anemia, hay fever, heating, fluid in the middle ear, and vision for
children
5. Utilization: 33 percent greater for adults and 22 percent greater for
children in the free-care versus the 95 percent copayment plan
(Valdez et al. 1985)
6. An important caveat--there is substantial heterogeneity in health
outcomes across different socioeconomic and racial groups as well as
differences by gender and geography
7. 這些限制及管控 ( 部分負擔 ) 並不顯著影響一般人的健康 , 但對貧窮及
老人會產生負面影響。
8. avoidable or preventable hospitalizations: 醫療的可近性可預防疾病惡
化。越是貧窮者 , 越缺乏適當的醫療,原本不必住院醫療,演變為住院
24. Effectiveness
Regulation of professional performance
專業標準審 組織查 (PSRO)
Quality monitoring: an investigation of quality
and variation in hospital mortality rates
Dubois et al. 1987: hospital mortality rates for
three specific conditions-heart attack,
pneumonia, and stroke-and two different
measures of quality of care 較差之醫療品質
與死亡率有關。
Evidence about the various policyEvidence about the various policy
strategiesstrategies
Regulationofprofessionalperformance
Medicalcare
Populationperspective
Outcome
25. Effectiveness
Outcome assessment and management
Practice guidelines and performance monitoring systems
(HEDIS), 可改善醫療結果。
Evidence of clinical practice guidelines developed slowly.
The Consensus Development program—example of
practice guidelines
12 consensus recommendations 臨床醫師知道 , 但沒帶來
什麼衝擊
Physician behavior were changing even before the
consensus statements were disseminated
Lomas et al. (1989) Canadian national guidelines
(cesarean-section rates): actual practice had in fact
changed little
當 focus 在 process of care 時 , 有著清楚的 guidelines 可增
進臨床實作 , 但少於兩成的研究去正視 guidelines 帶來結果
Outcomeassessmentandmanagement
Medicalcare
Populationperspective
Outcome
Evidence about the various policyEvidence about the various policy
strategiesstrategies
26. Effectiveness
Performance reporting systems
目前仍待系統性的研究其有效性。也許現在
尋求一個完美的績效監控系統 (performance
monitoring system) 之評估太早了些 , 但健康
服務的研究仍對未來系統之設計與應用有所
幫助 , 也就因此具備判斷此系統是否真能改
善病人預後之效能。
Evidence about the various policyEvidence about the various policy
strategiesstrategies
Performancereportingsystem
Medicalcare
Populationperspective
Outcome
30. Effectiveness
Population effectiveness criteriaPopulation effectiveness criteria
based on the results of a community health-
needs assessment
A community health-needs assessment from informa-
tion on policy options are derived
A population-based, community level health inform-
ation system should be in place
reflect an appropriate relationship to the
continuum of healthcare services
31. Effectiveness
Continuum of Healthcare ServiceContinuum of Healthcare Service
Preventive
services
Treatment
services
Long-term
care
Community
Medical care
System
Community
Home and
community
Based care
Public
Health
System
Ambulatory
care
Acute
institutionalc
are
Long-term
institutional
care
Community
resources
32. Effectiveness
Clinical effectiveness criteriaClinical effectiveness criteria
Precision of medical care- be fostered by the
specification in advance of guidelines for
clinical performance
Reduce the uncertainty on medical care
improve effectiveness
enhance efficiency
33. Effectiveness
Clinical effectiveness criteriaClinical effectiveness criteria
Performance of medical care- improved through
the monitoring of process and outcomes
indicators for selected clinical conditions
Outcome indicators are:
Preventive services screening rates
Senior’s health status
Satisfaction with care
34. Effectiveness
Table 3-2 Criteria for assessing health policies in terms ofTable 3-2 Criteria for assessing health policies in terms of
effectivenesseffectiveness
Dimensions Criteria Indicators Examples
Populations effectiveness
Need based Community health
needs assessment
Population health
information system
美國與乳癌相關的人口資
料庫: SEER, Medicaid,
Medicare
Comprehensiven
ess
Appropriate relationship
in continuum
Full continuum of
service
乳癌照護不連續常發生在
篩檢、後續追蹤與治療上
Clinical effectiveness
Precision Specified guideline for
structure
Practice guidelines 不同組織機構對乳房攝判
讀影標準不同
Performance Monitor outcomes Performance
monitoring system
績效監控系統常受限於特
定的幾個計畫
35. Effectiveness
ConclusionConclusion
What policy strategies contribute most?
Evidence from population perspective, the point of
diminishing returns from further investment in medical
care may have been reached, a case should be made for
investments in vulnerable populations’ medical care
improvement.
The health of the population in general, is most likely to be
enhanced by focusing more resources on non-medical
determinants.