健康照護相關研究論文方向和主題

美和技術學院健管所邱亨嘉 chiu@kmu.edu.tw

2009/11/11

Health services research is inquiryto produce knowledge (evidence)

about the structure, process or effects of personal health services

(Institute of Medicine, IOM, 1979)

Key roles: Who are they? Health research is inherently interdisciplinary

in focus: Require professionals and theories to work

together 主角 : Health care clinicians and practitioners 配角 : Sociologist epidemiologist,

demographist, economist 裁判者 / 觀察者 : Policy makers

寫作研究論文 Motivation 畢業 發表科學文章 To build up knowledge “economic power”

improve efficiency/reduce cost/save time To construct “evidence-based medicine

Safety/complications/mortality/quality of life To marketing

Patient satisfaction/Equity of care

研究主題激發 : Topics Attract YOU

My curiosity ( 好奇 ) My specialty My interest My boss want me to do!!

Topics selection Added-value

Work Publications Or both of above

Time to finish (2010/7/31 or 2010/12/31) Budget ($$$)

Framework for Classifying Topics and Issues in Health Services Research(2)

Health Policy

Characteristics ofDelivery System－ Availability

－ Organization － Financing

Characteristics ofPopulation at Risk － Predisposing

－ Enabling － Need

Delivery of Medical Care

Equity

Efficiency Effectiveness

Well-Being（ Quality of Lif

e ）

Structure

Process

Outcome（ intermediate 3E）

Outcome（ ultimate）

Health Care System Performance Evaluation

Factors on better or worse outcomes Organizations and patients

Macro and Micro Macro Perspective (population/community) Micro Perspective (system, institution, patient)

Component Effectiveness, Efficiency, Equity of Access

Levels Structure, Process, Outcome (intermediate and

ultimate)

Effectiveness: Concept、Methods and Topics

Definition of Effectiveness Population perspective: Macro-level view

of medical care system Epidemiology of Health

Clinical Perspective: (Micro-level view of medical care Clinical evaluation science (Donabedian,

Wennberg) Epidemiology of medical care

Effectiveness: Conceptual framework

Quantity

Efficacy

Variations in Use

- Quantity

- Quality

- Appropriateness

Effectiveness

- Mortality

- Clinical outcomes

- Functional

STRUCTURE PROCESS OUTCOMES

假說 : Important to scientific Inquiry Relationship between structure and outcome

Research Question 1 (efficacy) Research Question 2 (Quantity)

Relationship between process and outcomes Question 1(use of medical care) Question 2 (quantity of medical care procedures) Question 3 (Quality of medical care)

Relationship between structure and process Question 1: volume and process Question 2: Certification and process

Key Methods of Assessing Medical Care effectiveness Measurement variables: health status

Individual measures Population-based measures

Risk adjustment Study design Data sources

Structure: Quantity Nurse per bed (ICU/CCU/general)

one nurse care 8 beds (or 1: 2) Certification

PCI certification % of Specialist to all physicians

Structure: Efficacy (benefit of (not harm) individual or society)

Golden standard Antibiotic use for Clean wound or infected

wound Supplier for age and disease patterns

Practice Indications for surgical procedures Indications of ESRD Indications of implant/transplant Transfusion appropriateness

Process: Variation in Utilization Admission number Admission day Number of outpatient visits Drug item Charges of outpatient and outpatient

Variation in Utilization

Population and Health Care Minority, women, elderly, disparity

Disease and health care utilization ESRD, AMI, DM, Asthma

Area health care utilization and health Urban, population density, remote islands

Process: Appropriateness

Overuse, under-use or right use? Number? Who provided? Who received?

Medication, antibiotics Percentage/number follow the guidelines

Process: Appropriateness

Treatment or not treatment The thresholds Vs gold standard CS VS NSD

Expensive or inexpensive treatment Transplantation or “tomy” 體外碎石機 Vs. medication Vs. water or

BEER… PTCA, PTCA with stent, drug eluting stent. Cancer patient and treatments

Effectiveness: examples Clinical End Point

Mortality, complications and May be discharged (MBD) Predictors of better outcomes (volume)

Functional Status Impairment and Disability

Health-related Quality of life Generic measure (SF-36), disease specific measure (Harris Score)

Quality of Care Quality indicators (from medication to plant safety) Providers profiling, Report cards (THIS, TQIP)

Satisfaction of care Art of care, from physician to housekeeper

Example: OA patients 關節內注射

關節內注射劑使用

Yes/no

量

Variations in Use

- 不同劑型療程- 施打醫院層級別- 施打科別

- 是否遵照健保局規定流程施打 ( 打完一個療程後半年內不可施打 )

Effectiveness

- 緩解疼痛- 延緩執行 TKR

- 提升健康相關生活品質

STRUCTURE PROCESS OUTCOMES

假說 : Example Relationship between structure and outcome

施打關節內注射劑之 OA 病患，施打三劑與施打五劑者其療效相同

施打關節內注射劑型是否延緩人工膝關節之置換 完整性療程和未完整性療程 關節內注射劑治療較傳統口服止痛藥治療具成本效果

Relationship between process and outcomes 不同科別 ( 骨科 / 復健科 ) 施打關節內注射劑療效是否

相同 少或多

Efficiency: Concept、Methods and Topics

Efficiency: the Concepts Allocation efficiency

Attainment of “right” or most value or mixed of outputs

Production efficiency Produce a given level of output at minimum cost

Dynamic efficiency technological and organizational advances

• Economic efficiency• cost per service (per admission)

• Response efficiency• manpower and hardware

OECD 國家和台灣醫療保健支出Macro-Performance

HCE as a % of GDP (1991)

HCE per capita (1991) (US dollar)

HCE as a % of GDP (2001)

HCE per capita (2001) (US dollar)

HCE as a % of GDP(2003)

HCE per capita (2003)(US dollar)

Taiwan 4.6 404 6.0 780 6.2 824

Japan 6.0 1,668 7.8 2,558 7.9* 2,450*

Canada 9.7 2,033 9.4 2,130 9.9 2,670

United States 12.6 2,957 13.8 4,888 15.0 5,635

New Zealand 7.4 892 7.9 1,056 8.1 1,611

German - - 10.8 2,425 11.1 3,204

Italy 8.2 1,678 8.2 1,574 8.4 2,139

France 8.8 1,882 9.4 2,102 10.1 2,967

United Kingdom 6.5 1,148 7.5 1,837 7.7* 2,031*

Netherlands 8.2 1,641 8.7 2,067 9.8 3,088

Spain 6.9 976 7.5 1,083 7.7 1,535

Sweden 8.2 2,402 8.8 2,172 9.2* 2,494*

Efficiency: Conceptual framework

Quantity

Quality

SOP

Variations

- from SOP

- in time,

-In utilization

Efficiency

-Money saving

-Profit gain

-Time saving

-Errors

STRUCTURE PROCESS OUTCOMES

Efficiency: Example

- 專業人力

- 人力素質

-SOP/PDCA

-IT 程度

- 設備及設施

- 總額分配設定

Variations In

- deviation from…..

Efficiency

- Less cost

-Less Time

-Less errors

-High satisfaction

STRUCTURE PROCESS OUTCOMES

Methods to Assess Efficiency of Medical Care -Macro Level Based on International comparison of

health care systems performance Spending (GNP or GDP) Among spent on hospitals and physicians Aggregate measure of inputs:

doctors, nurses, hospital beds, and others

Intermediate outputs: Hospital admission, physician visit

Efficiency :Outcome measure Hospital Efficiency Comparison

Between hospital and ownership Operating costs (department)

Personnel costs, materials Products

Total hip replacement, CABG, PTCA service line costs

Operating room cost, laboratory cost Errors (repeated errors) Time

Equity Concept、Methods and Topics

Access to Care and utilization Supply and Demand

New providers, closure of hospitals Healthcare Disparity Financial issue

Household Income, dollars and health (poor Vs. wealth)

Usual source of care Hospital (large Vs. Small scale) Hospital Vs. doctor office

Rural and remote area Difference in source or care Variations in area

Well-Being (Health)Concept、Methods and Topics

Ultimate outcomes Cause and effect

Effectiveness lead to Quality of Life Efficiency lead to Satisfaction,

effectiveness and quality of life Equity lead to effectiveness and

satisfaction

Characteristics of Delivery system:Independent variables

Organization

Availability

Financing

Organization (1/3)

組織策略相關研究

Laws and regulations impact on hospital management JCI, 評鑑等級 Residency training certificate (Hospital level and specialty)

Core ( 核心 ) service line and market performance Oncology, LTC, Outsourcing

Chain/Vertical and horizontal integration 併購、委托經營、組織再照

Strategic Alliance In service line In purchasing In personnel

Organization (2/3)

組織行為相關研究 Work stress and performance

By professions, work design, work hours.. Job Satisfaction, 士氣 and performance

Leadership Burn out and 離職率

Motivation and performance Money VS 非財務報酬 Incentive program and performance Decentralization VS centralization

In personnel, materials

組織文化 正向 VS 負向文化 Patient safety, learning, participation cuture

Organization (3/3)

管理方法相關研究 Balance-score card (BSC) Process management

PDCA, flowcharts Clinical pathway/clinical guidelines Survey ( 病人 , 員工 and others)

IT as management methods EIS, HIS…

Quality methods to achieve efficiency THIS/TQIP

流程管理 Medication management and use Lab and examination process Infection control process Fire ( 內部 ) or disaster ( 外部 ) Medical information 醫療儀器維護流程 設施和設備維護流程 食物準備及遞送之流程 Outpatient process Admission process 人員進用和訓練 / 教育 Communication ( 會議前 /後 )

建保給付相關研究 (1/3)總額

Effect on providers Hospitals: quota and limited services hours Medical doctors

Effect on accessibility of care beds

Effect on quality of Care Delay in care, mortality..

Effect on technology and 藥品 Effect on medical education and selection of

specialty

建保給付相關研究 (2/3)

Co-payment Medication Level of hospitals, Procedures

Payment items and services lines ICU to RCW

Technology (PET) Procedures Case management (DM, CKD)

建保給付相關研究 (3/3)DRG

Restructure the service line DRG and Non-DRG service line Win/loss at each individual DRG

Quantity and efficiency Who is qualified for performing which DRG

Quantity and quality Quality as methods to achieve efficiency

Characteristics of Population at risk

Predisposing

Enabling

Need

Patient Characteristics Predisposing :

Age, sex, Health Behavior

Adverse 健康行為 ( 抽菸、嚼槟榔、喝酒 )

正向健康行為 ( 交通安全、運動、體重控制、飲食型態、潔牙

社經地位 Income, Education, position

All things consider

Cost Effectiveness Analysis (CEA) Cost-benefit analysis (CBA) Cost Utility Analysis (CUA)

研究可行性 Time Money Knowledge Independent or in group and Materials

46

使用原始或次級資料 原始資料 (primary data)

研究者為特殊目的而收集的資料 直接獲得的第一手情報資料，例如經由問

卷與訪問所蒐集的資料…等 次級資料 (secondary data)

他人所蒐集並經過整理的資料，例如健保資料庫、戶口調查、國民健康訪問調查 等

47

次級資料的來源 政府機構

Health survey Mortality Cancer registry

半官方機構 Claim data 醫院所有之資料

定期 醫院、部門、和個人層次

台灣下背痛患者其健康生活品質及中西醫醫療資源使用

國民健康訪問調查資料庫 + 健保資料

不同程度下背痛的人口學特質

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

過輕 正常 過重 肥胖 18-39歲 40-64歲 65歲以上 男性 女性 不識字 基礎教育 高中 大學以上

BMI 年齡 性別 教育程度

無任何疼痛 偶爾下背痛 常常下背痛

不同程度下背痛的健康相關生活品質【 SF-36八大構面】

0

50

100

Mean無任何疼痛 94.60 88.54 87.54 74.28 71.33 88.50 83.47 74.71

Mean偶爾下背痛 88.59 76.60 72.61 62.91 62.94 83.40 72.83 70.04

Mean常常下背痛 74.74 52.64 55.58 47.65 51.07 74.50 60.65 62.24

身體功能因身體功能問題而角色受限

身體疼痛 一般健康狀況 活力狀況 社會功能因情緒問題而角色受限

心理健康

全國施行冠狀動脈繞道術及冠狀動脈介入性治療之醫療品質與資源利用探討

健保資料庫 - 相同疾病探討不同處置

排除個案 (3.80%)1.性別不明 25人次2.非心臟科或外科及醫師資料遺 漏 161人次3.每年醫師數小於 1 例 531人次4. 每年醫院數小於 10例 270人次

排除個案 (1.99%)1.性別不明 162人次2.非心臟科或內科及醫師資料遺漏976 人次3.每年醫師數小於 1 例 1,321人次4. 每年醫院數小於 5 例 21人次

施行 CABG病患共 25,572人次(98.6 %)

施行 PCI病患共 124,125人次(99.7 %)

資料整理後 150,382人次

CABG病患共 25,942人次

PCI病患 ( 包含當次住院併行 CABG)共 124,440人次

排除個案 (1.4%)1.CABG無法分類處置條數之診斷碼(36.10,36.17,36.19),共 370人次

排除個案 (0.25%)1.PCI包含當次住院併行 CABG,故 CABG無法分類處置條數之診斷碼也排除 (36.10,36.17,36.19)共 315人次

CABG醫療品質分析9 年共 24,585人次(94.77 %)

分析 CABG資源利用9 年共 22,509人次(86.77 %)

排除個案 (8.0%)9 年死亡 2,076人次

PCI醫療品質分析9 年共 121,645人次(97.76%)

排除個案 (2.29%)9 年死亡 2,854人次

分析 PCI資源利用 9 年共 118,791人次(95.47 %)

DD檔(1996-2004年) 選取CABG及PCI病患 共152, 295筆資料資料處理

與樣本篩選

（切帳資料處理：同一位病患在同 一次住院中只會留有一筆資料， 並校正住院天數。 ）

全國施行 CABG之趨勢變化

15012001 2080

24332862

32033514 3374

3617

2.412.252.342.13

1.911.621.39

11.33

0500

1000150020002500300035004000

1996 1997 1998 1999 2000 2001 2002 2003 2004年份

手術次數

0.0

0.5

1.0

1.5

2.0

2.5

3.0

成長倍數

CABG手術人次 ( 1996 )成長倍數 與 年比

圖 4-1 全國施行 CABG 之逐年概況及成長率 (N=25,572)

全國施行 PCI之趨勢變化

45337032

928411831

1357215780

18170 18637

22806

1 1.55 2.052.61

2.993.48

4.01 4.115.03

0

5000

10000

15000

20000

25000

1996 1997 1998 1999 2000 2001 2002 2003 2004年份

手術次數

0.0

1.0

2.0

3.0

4.0

5.0

6.0

成長倍數

PCI手術人次 ( 1996 )成長倍數 與 年比

圖 4-2 全國施行 PCI 之逐年概況及成長率 (N=124,125)

2006 年 OECD 會員國與我國平均每人 NHE 與平均每人 GDP 比較

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

5,500

6,000

6,500

7,000

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000

平均每人NHE(美元 )

平均每人GDP(美元 )

Taiwan

Norway

Japan2005

Iceland

Denmark

SwedenIreland

Finland

United Kingdom

AustriaCanada

Belgium

Australia2005Italy

Greece

France

New Zealand

Spain

Korea

Czech Republic

Hungary

Slovak Republic2005

Portugal

Turkey2005

Poland

Germany

Mexico

Netherlands

出處 :衛生署統計室資料來源： OECD Health Data 2008附註： 1. 刪除美國 United States 、瑞士 Switzerland 、盧森堡 Luxembourg 3 個國家，其 NHE/GDP 分別為 15.3% 、 11.3% 、 7.3% ，平均每人 GDP 分別為 43,864 美元、 51,970 美元及 67,795 美元。 2. 估計迴歸模式為：平均每人 NHE = 0.0942×平均每人 GDP – 157.8, R2 = 0.953

Hope the lecture inspire your research interest and

bring potential research topics?

Thanks