Transcript Process

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 [email protected]
2009/11/11
Health services research is inquiry
to 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:
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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”

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To construct “evidence-based medicine

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improve efficiency/reduce cost/save time
Safety/complications/mortality/quality of life
To marketing
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Patient satisfaction/Equity of care
研究主題激發:
Topics Attract YOU

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
My curiosity (好奇)
My specialty
My interest
My boss want me to do!!
Topics selection

Added-value

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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
Structure
Characteristics of
Delivery System
－Availability
－Organization
－Financing
Characteristics of
Population at Risk
－Predisposing
－Enabling
－Need
Process
Delivery of
Medical Care
Equity
Outcome
（intermediate 3E）
Efficiency
Effectiveness
Well-Being
（Quality of Life）
Outcome
（ultimate）
Health Care System Performance
Evaluation

Factors on better or worse outcomes

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Macro and Micro

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Macro Perspective (population/community)
Micro Perspective (system, institution, patient)
Component
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Organizations and patients
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

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Epidemiology of Health
Clinical Perspective: (Micro-level view of
medical care

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Clinical evaluation science (Donabedian,
Wennberg)
Epidemiology of medical care
Effectiveness: Conceptual framework
STRUCTURE
PROCESS
OUTCOMES
Quantity
Variations in Use
Effectiveness
Efficacy
- Quantity
- Mortality
- Quality
- Clinical outcomes
- Appropriateness
- Functional
假說: Important to scientific Inquiry

Relationship between structure and outcome
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Relationship between process and outcomes
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Research Question 1 (efficacy)
Research Question 2 (Quantity)
Question 1(use of medical care)
Question 2 (quantity of medical care procedures)
Question 3 (Quality of medical care)
Relationship between structure and process
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Question 1: volume and process
Question 2: Certification and process
Key Methods of Assessing Medical
Care effectiveness
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Measurement variables: health status
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Individual measures
Population-based measures
Risk adjustment
Study design
Data sources
Structure:
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Nurse per bed (ICU/CCU/general)
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one nurse care 8 beds (or 1: 2)
Certification
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Quantity
PCI certification
% of Specialist to all physicians
Structure:
Efficacy
(benefit of (not harm) individual or society)
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Golden standard
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Antibiotic use for Clean wound or infected
wound
Supplier for age and disease patterns
Practice
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Indications for surgical procedures
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Indications of ESRD
Indications of implant/transplant
Transfusion appropriateness
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Process:
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Variation in Utilization
Admission number
Admission day
Number of outpatient visits
Drug item
Charges of outpatient and outpatient
Variation in Utilization
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Population and Health Care
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Disease and health care utilization
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Minority, women, elderly, disparity
ESRD, AMI, DM, Asthma
Area health care utilization and health
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Urban, population density, remote islands
Process: Appropriateness

Overuse, under-use or right use?
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Number?
Who provided?
Who received?
Medication, antibiotics
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Percentage/number follow the guidelines
Process: Appropriateness
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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
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Clinical End Point
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Functional Status
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Generic measure (SF-36), disease specific measure (Harris Score)
Quality of Care
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Impairment and Disability
Health-related Quality of life
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Mortality, complications and May be discharged (MBD)
Predictors of better outcomes (volume)
Quality indicators (from medication to plant safety)
Providers profiling, Report cards (THIS, TQIP)
Satisfaction of care
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Art of care, from physician to housekeeper
Example: OA patients 關節內注射
STRUCTURE
PROCESS
OUTCOMES
Variations in Use
Effectiveness
關節內注射劑
使用
- 不同劑型療程
- 緩解疼痛
- 施打醫院層級別
- 延緩執行TKR
Yes/no
- 施打科別
- 提升健康相關生
活品質
量
- 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)
假說: Example
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Relationship between structure and outcome
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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
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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
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•
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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
-
-
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*
German
Efficiency: Conceptual framework
STRUCTURE
PROCESS
OUTCOMES
Quantity
Variations
Efficiency
Quality
- from SOP
-Money saving
SOP
- in time,
-Profit gain
-In utilization
-Time saving
-Errors
Efficiency: Example
STRUCTURE
PROCESS
OUTCOMES
-專業人力
Variations In
Efficiency
-人力素質
- deviation from…..
- Less cost
-SOP/PDCA
-Less Time
-IT程度
-Less errors
-設備及設施
-High satisfaction
-總額分配設定
Methods to Assess Efficiency of
Medical Care -Macro Level
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Based on International comparison of
health care systems performance
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Spending (GNP or GDP)
Among spent on hospitals and physicians
Aggregate measure of inputs:
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doctors, nurses, hospital beds, and others
Intermediate outputs:
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Hospital admission, physician visit
Efficiency :Outcome measure
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Hospital Efficiency Comparison
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Operating costs (department)
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Total hip replacement, CABG, PTCA
service line costs
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Personnel costs, materials
Products
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Between hospital and ownership
Operating room cost, laboratory cost
Errors (repeated errors)
Time
Equity
Concept、Methods and Topics
Access to Care and utilization
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Supply and Demand
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Healthcare Disparity
Financial issue
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Household Income, dollars and health (poor Vs.
wealth)
Usual source of care
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New providers, closure of hospitals
Hospital (large Vs. Small scale)
Hospital Vs. doctor office
Rural and remote area
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Difference in source or care
Variations in area
Well-Being (Health)
Concept、Methods and Topics
Ultimate outcomes
Cause and effect
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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
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Laws and regulations impact on hospital management
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Core (核心) service line and market performance
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Oncology, LTC, Outsourcing
Chain/Vertical and horizontal integration
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JCI, 評鑑等級
Residency training certificate (Hospital level and specialty)
併購、委托經營、組織再照
Strategic Alliance
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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
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In personnel, materials
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組織文化
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正向 VS負向文化
Patient safety, learning, participation cuture
Organization (3/3)
管理方法相關研究
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Balance-score card (BSC)
Process management
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PDCA, flowcharts
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Clinical pathway/clinical guidelines
Survey (病人, 員工 and others)
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IT as management methods
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EIS, HIS…
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Quality methods to achieve efficiency
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THIS/TQIP
流程管理
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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
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Effect on quality of Care
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beds
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
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ICU to RCW
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Technology (PET)
Procedures
Case management (DM, CKD)
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建保給付相關研究 (3/3)
DRG
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Restructure the service line
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Quantity and efficiency
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DRG and Non-DRG service line
Win/loss at each individual DRG
Who is qualified for performing which DRG
Quantity and quality
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Quality as methods to achieve efficiency
Characteristics of Population at risk
Predisposing
Enabling
Need
Patient Characteristics
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Predisposing :
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Health Behavior
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Age, sex,
Adverse 健康行為
正向健康行為 (交通安全、運動、體重控制、飲食型態、潔牙
(抽菸、嚼槟榔、喝酒)
社經地位

Income, Education, position
All things consider

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Cost Effectiveness Analysis (CEA)
Cost-benefit analysis (CBA)
Cost Utility Analysis (CUA)
研究可行性
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Time
Money
Knowledge
Independent or in group and
Materials
使用原始或次級資料
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原始資料(primary data)
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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
46
次級資料的來源

政府機構
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Health survey
Mortality
Cancer registry

半官方機構
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Claim data
醫院所有之資料
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

定期
醫院、部門、和個人層次
47
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
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
過輕
正常
過重
BMI
肥胖
18-39歲 40-64歲 65歲以上
年齡
無任何疼痛
男性
女性
性別
偶爾下背痛
常常下背痛
不識字 基礎教育
高中
教育程度
大學以上
不同程度下背痛的健康相關生活品質【SF-36八大構面】
100
50
0
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
無任何疼痛 Mean
94.60
88.54
87.54
74.28
71.33
88.50
83.47
74.71
偶爾下背痛 Mean
88.59
76.60
72.61
62.91
62.94
83.40
72.83
70.04
常常下背痛 Mean
74.74
52.64
55.58
47.65
51.07
74.50
60.65
62.24
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
資料處理
與樣本篩選
DD檔(1996-2004年)
選取CABG及PCI病患
共152,295筆資料
（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。 ）
資料整理後150,382人次
CABG病患
共25,942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
PCI病患(包含當次住
院併行CABG)
共124,440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
施行CABG病患
共25,572人次
(98.6 %)
施行PCI病患
共124,125人次
(99.7 %)
排除個案 (3.80%)
排除個案 (1.99%)
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
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
CABG醫療品質分析
9年共24,585人次
(94.77 %)
PCI醫療品質分析
9年共121,645人次
(97.76%)
排除個案 (8.0%)
排除個案 (2.29%)
9年死亡2,854人次
9年死亡2,076人次
分析CABG資源利用
9年共22,509人次
(86.77 %)
分析PCI資源利用
9年共118,791人次
(95.47 %)
全國施行CABG之趨勢變化
手術次數
4000
3500
3000
2500
2000
1500
1000
500
0
成長倍數
2862
2001 2080
1501
1.33
1.39
3203
2433
1.62
1.91
2.13
3514
3374
3617
3.0
2.5
2.34
2.25
2.0
2.41
1.5
1.0
1
0.5
0.0
1996
1997
1998
1999
2000 2001
2002
2003
2004
年份
CABG手術人次
成長倍數(與1996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
手術次數
成長倍數
22806
25000
20000
15000
11831
9284
10000
5000
13572
7032
4533
1
1.55
2.61
2.99
15780
3.48
18170 18637
6.0
5.0
5.03 4.0
4.01
4.11
3.0
2.0
2.05
1.0
0
0.0
1996
1997
1998
1999
PCI手術人次
2000
2001
2002
2003
2004
成長倍數(與1996年比)
圖 4-2全國施行PCI之逐年概況及成長率(N=124,125)
年份
2006年OECD會員國與我國
平均每人NHE與平均每人GDP比較
平 均 每 人 NHE(美 元 )
7,000
6,500
Norway
6,000
5,500
Iceland
5,000
Denmark
Canada Netherlands
Austria
Belgium
Ireland
France
Sweden
Germany
United Kingdom
4,500
4,000
3,500
Finland
3,000
Italy
Japan2005
New Zealand
2,500
Greece
2,000
Australia 2005
Spain
Portugal
1,500
Hungary
1,000
Turkey2005
Korea
Taiwan
Czech Republic
500
Mexico Poland
0
0
10,000
Slovak Republic2005
20,000
30,000
平 均 每 人 GDP(美 元 )
40,000
50,000
60,000
70,000
80,000
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