How to improve the population health?

醫療體系綜論報告醫療體系綜論報告 Effectiveness (2):Effectiveness (2):How to improve the population How to improve the population health?health?

Policy Strategies, Evidence, and Policy Strategies, Evidence, and CriteriaCriteria

第二組魏文一第二組魏文一April 11, 2009April 11, 2009

Effectiveness

本章重點本章重點 Health policy strategies ( 健康政策策略 )

1. 從人口觀點看，要由環境、行為、人類生物學及醫療這幾個方面來促進健康

2. 從臨床觀點看 ( 醫療結構、過程、產出 ) ，要能促進病患、醫院、體系這三層級的績效

Evidence (of effectiveness) 1. 長期以來，增加醫療投資以改善民眾健康為策略之一，但效果因

醫院而異2. 提升一般民眾及特定高危險族群健康的最可能有效方法，反而是

要將資源投資在非醫療健康相關因子上 ( 如生活及工作的生理、社會、經濟環境 )

1. Criteria (of assessing health policies in terms of effectiveness)

1. 從臨床觀點看，為評估及管理醫療結果，發展臨床治療指引以提高醫療準確性，發展績效監測系統以改善特定醫療的過程與結果

2. 從人口觀點看，健康政策必須立基於社區健康需求評量的結果與發展醫療服務連續性

Effectiveness

大綱大綱1. Policy strategies relating to effectiveness - population perspective - clinical perspective2. Evidence relating to effectiveness - population perspective - clinical perspective3. Criteria for assessing policy alternatives

in terms of effectiveness - population perspective - clinical perspective

Effectiveness

Factors Contributing to Population Factors Contributing to Population HealthHealth

SystemInstitution Patient

Structure

Process

Outcome

Population perspective

Clinical perspective

Environment

Human biology

Behavior

Medical care

Levels of medical Levels of medical carecare

Effectiveness

Contributing factor Policy strategyPopulation 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

Effectiveness

民眾健康資訊系統民眾健康資訊系統 In CanadaIn Canada

以健康為主題而非討單獨討論疾病本身 Lalonde report (1975, Canada): 為增進大眾的健康，

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 - 依卑詩省的民眾健康資料系統 (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

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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

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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

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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，對所服務的民眾健康狀態結果承擔責任

- 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 Neighborhood Health Centers

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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

院層級專業標準審查組織 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, 醫療研究暨品質管理局 ): 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 )

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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)

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•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

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, 醫療保險計劃僱主資料及資訊集 ) ，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 Monitoring Performance Monitoring SystemsSystems

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From an effectiveness viewpoints, what From an effectiveness viewpoints, what policy strategies contribute most to policy strategies contribute most to improving the health of the improving the health of the population?population?

Effectiveness

Evidence Relating to Evidence Relating to EffectivenessEffectiveness

Effectiveness

Population Health Population Health IndicatorsIndicators 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.

Effectiveness

Major Determinants of HealthMajor Determinants of Health Medical Non-medical

Environment1. 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 problems3. Acute poisoning, birth defects

Social environment1. Social class, status hierarchies, income, social ties

(disruptions due to death, divorce, or immigration), and culture change 民眾健康、死亡率有關

Effectiveness

Evidence about the various Evidence about the various policy strategiespolicy strategies

Health Protection1. 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 Access to medical care

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Health Promotion and Preventive Services1. Mixed effectiveness2. 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 retinopathy5. Bunker et al. (1994)

Preventive services for hypertension, cervical cancer screening, childhood immunizations increased life expectancy over this century in the United States


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長期以來，增加醫療投資以改善民眾健康為策略之一，但效果因醫院而異StructureBiomedical 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。

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Investment in resources1. 增加醫院及醫師之數量對民眾健康的影響 ? 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，許多醫師治療不夠積極

Health planning and regionalization of services1. 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.

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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)

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Evidence about the various Evidence about the various policy strategies policy strategies

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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)


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The Rand Health Insurance The Rand Health Insurance Experiment (Brook et al. 1983)Experiment (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，演變為住院醫療 ,間接浪費醫療資源。

Effectiveness

Regulation of professional performance

專業標準審查組織 (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。


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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(outcome) 上的衝擊。

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Evidence about the various Evidence about the various policy strategies policy strategies

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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。


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Summary of EvidenceSummary of Evidence

從族群觀點來說 , 人種及其他之特性在群體健康造成之差異性 , 與地理區隔造成醫療照護資源及過程上之差異性 , 兩者無顯著關連。

時間證明 , 改善窮人醫療資源及其可近性無法消除不同社會階層間健康程度之差異。

此原因是複雜的 , 體認群體的健康不僅僅是醫療照護而已 , 也許能消除一些因素。

Effectiveness

Summary of EvidenceSummary of Evidence

增加醫療資源的量 , 改善它們的分佈及可近性並不能根本改善群體罹病率及死亡率 , 亦無法消弭社會不平等造成群體健康之差異。

總結來說 , 也許投資在醫療照護上並不能增進群體健康 ,但對弱勢族群 ( 窮人、老人 ) 卻非如此 , 如果想提升整體醫療 , 最好從一些非醫療因素著手 , 以公共衛生導向之健康保護及健康提升策略為主。

從臨床觀點 , 很遺憾的 , 縱使大量及昂貴的心力投注在專業表現規範及醫療結果評估及管理以增進醫療效果 , 到今天仍無具體成果。

Effectiveness

CriteriaCriteria

Effectiveness

Population effectiveness Population effectiveness criteriacriteria 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

Effectiveness

Continuum of Healthcare ServiceContinuum of Healthcare Service

Preventive services

Treatment services

Long-term care

CommunityMedical care

SystemCommunity

Home and communityBased care

Public Health System

Ambulatorycare

Acute institutionalcare

Long-term institutional care

Communityresources

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Clinical effectiveness Clinical effectiveness criteriacriteria 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

Effectiveness

Clinical effectiveness Clinical effectiveness criteriacriteria 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

Effectiveness

Table 3-2 Criteria for assessing health policies in terms of Table 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

Comprehensiveness

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

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.

Health & Medicine

How to improve the population health?