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 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

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健康為策略之一眾，但效果
因醫院而異
2. 提升一般民及特定高危險族群眾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 perspective
2. Evidence relating to effectiveness
3. Criteria for assessing policy alternatives
in terms of effectiveness

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

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

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

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

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
Structure

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
Process

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

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

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

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?

Effectiveness
Evidence Relating to EffectivenessEvidence Relating to Effectiveness

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.

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

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

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
Healthpromotionandpreventiveservices

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
Structure

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
Structure

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
Process

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)
Enhancedaccess
Medicalcare
Process

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

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。
Regulationofprofessionalperformance
Medicalcare
Outcome

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
Outcome

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。
Performancereportingsystem
Medicalcare
Outcome

Effectiveness
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 , 改善它們的分及可近性並不能根本佈
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 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

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

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

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

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

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.

How to improve the population health?

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