上海交通大学医学院2012级研究生课程循证医学社区卫生决策制定09.5课件

1、决策制定与纵向分析Decision making & Vertical Analysis上海交通大学公共卫生学院上海市全科医学教育培训中心施 榕一、纵向分析（VA）的定义Definition of Vertical AnalysisA 纵向分析 vertical analysis, which is an analytical methodology to be applied to a health problem;A 纵向项目 vertical programme, which is a set of activities, preferably useful and necessary,

2、 with the objective to reduce or resolve a given health problem (or a small number of related problems);A 纵向机构 vertical structure, which is a service or a structure that is specialised in the implementation of a (vertical) programme.纵向分析定义横向方面的问题（“horizontal” approach） The concepts of health, health

3、 problem, care, health service and health care delivery structures. 纵向方面的问题（“vertical” approach） methodologies for an adequate approach of health problem. the approach centered on the problems and must answer the question WHAT needs to be done in order to control a specific health problem.纵向分析定义纵向分析

4、是对有关健康问题的识别、描述和系统分析“vertical analysis” is an intellectual exercises in the identification, description and systematic analysis of health problem in its various aspects, in order to make an inventory of all possible solutions or interventions, which is expected to permit us to select those activities

5、 that have to be implemented with some degree of priority in order to solve or reduce the problem.It is highly probable that one comes to identify areas of uncertainty- or gaps in the knowledge that is needed for rational decision making。纵向分析是主要分析方法是流行病学 The analytical model is essentially epidemiol

6、ogical. The main tool that is used is the epidemiological understanding of health problem. Quantification is used as much as necessary.三、纵向分析的基本步骤1. 问题描述 The problem concept2. 流行病学模型 The epidemiological system3. 列出可能的干预措施并选择 Inventory of interventions selection4. 干预机构 Which services?5. 干预人员 Which pe

7、rsonnel?6. 干预措施的操作Operationalisation of selected activities7. 效果评价 Evaluation of activities问题描述问题重要性的分析目的 Analysis of importance serves two main purpose.确定健康问题是否需要优先解决 Deciding whether the health problem can be called a priority or not (not only the importance, but also the vulnerability, the possib

8、ility to do something about it).确定健康问题的重要程度例：结核病的纵向分析结核病的发生和发展结核菌首次侵入人体主要是通过呼吸道进入肺泡并在此繁殖，称为“原发感染”原发感染处形成原发病灶，结核菌从原发病灶中沿淋巴管进入到血流中，叫做“血行播散” 结核菌通过血行播散进入各脏器中，有的立即发病，发生严重的粟粒型结核病和结核性脑膜炎有的结核菌潜伏在各种器官内，待机体免疫力下降时发病，称为继发结核病，也叫内源性发病 结核分枝杆菌1882年Koch首先由肺结核病人痰中发现了结核杆菌，并且证实结核病的病原是结核杆菌。结核菌为细长杆菌，常有分枝倾向，具有抗酸脱色的性质，可在肺结

9、核病人痰中经抗酸染色涂片发现结核杆菌根据致病性分为几型，引起人结核病的主要病原体是人型和牛型结核杆菌。而牛型结核杆菌也能使牛、羊、家兔患结核病，所以，结核病也是一种人畜共患的疾病。描述在世界各个国家和地区观察到的结核病流行趋势上的异常现象TB报告率上升多耐药结核病（MDR-TB）严重爆发HIV感染者中TB爆发，且病死率高初治TB病人中 耐药(23%) 和多耐药(7%) 率高结核病控制的实施效果差： (e.g. 在结核病治疗中失败率可高达89%)2000年接近2百万人口死于结核病每年有8百万以上结核病发病世界三分之一人口感染结核杆菌结核病导致青壮年死亡比其他任何传染病都多每四秒即有一人患结核病每

10、十秒即有一人死于结核病如果不治疗,活动性结核病人每年可感染10-15人结核病流行现状 1980末：WHO仅两位工作人员负责全球的TB控制普遍认为结核病化疗的发展决定了结核病很快就不再是公共卫生的一个重要问题很少有人清醒地认识到在发展中国家的贫困人群中TB仍具有重大公共卫生意义（二）我国结核病的状况我国结核病的流行有以下三点特征：1高感染率2高死亡率3高耐药率 5亿以上的人口感染菌核杆菌 结核病负担位居全球第二 (140万) 每年150,000 TB 死亡 活动性肺结核、涂阳肺结核和菌阳肺结核患病率 分别 为 367/105 , 122/105, and 160/105 肺结核死亡率为 8.8

11、/105 中国结核病现况(WHO, 2000)(全国第四次流调，2000)我国结核病流行现状（1） 高感染率2000年感染率为44.5%全国约有5.5亿人感染结核菌2000年全人群感染状况45%55%感染未感染我国结核病流行现状（2）疫情下降缓慢，传染性病人几乎没有减少涂阳患病率(110万)1990-2000年涂阳肺结核年递降率为3.2%估算涂阳病人数:1990年 151万2000年 150万我国结核病流行现状（3）不同地区疫情差别较大农村疫情高于城镇近一倍19902000年卫V项目地区的涂阳患病率下降了44.4%，而非卫V项目地区患病率只下降了12.3%。我国结核病流行现状（6） 结核病死亡

12、率仍然较高1999年死亡率为9.8/10万，较1989年19.1/10万下降了53.9%，目前每年约有12万人死于结核病。（二）流行病学模型模型的基本要素 Elements of the model:根据疾病自然史，确定疾病发展的相关阶段 In the construction of such a model we make use of elements of the natural history of the disease: the relevant stages in systemic terms and/or in terms of interventions;取得某阶段的静态概率

13、和动态概率 To this are added the “static” probabilities (in terms of prevalence) and the “dynamic” ones (in terms of risks, probabilities to go from one stage or status to another);描述疾病转归的相关因素 describe the elements that are relevant for transmission of the disease, if this is necessary and relevant;描述动态转

14、变的营销因素 describe the factors that can influence the dynamics within the system(co-factors, risk-factors, risk-markers)结核病流行病学模型 Inf. Not res. Ill (1) Inf. Inf. Inf. Not Inf. Not ill Resist Ill (2) Not res. Not ill “Resist” There appear to be 2 different diseases:-type 1 is a typical infectious, trans

15、mittable, mono-factorial;-type 2, though etiologically an infectious disease, has more of the characteristics of a chronic disease, multi-factorial.（二）影响感染的因素1年龄 2性别 3职业 4HIV感染和艾滋病 5其他因素 （三）影响流行的因素1自然因素 2病原生物学因素 3社会因素 （三）列出可能的干预措施并进行选择Inventory of interventions-selection对每项干预措施进行分析1. 干预措施的关联性分析（一般可分

16、解为以下二个问题）: 干预措施的有效性？ Is this intervention desirable? 干预措施的可行性？ Is this intervention feasible?2. 对预措施进行系统分析 技术层面效能 Its technical efficacy 操作层面效能 Its operational efficacy ( or effectiveness) 成本（效率） Its cost (efficiency) 可行性 Its acceptability结核病可能的干预措施检测和治疗肺结核检测好治疗原发或继发感染BCG 接种化学预防提高社会-经济状况隔离病人Isolatin

17、g contagious patients重症患者的康复对动物传染源的措施分析结果选择三项措施检测和治疗肺结核检测好治疗原发或继发感染BCG 接种（四）实施机构Choices to be made here are situated in the following sets of oppositions:中央/集中性或非中心机构 Centralized - decentralized永久性或阶段性机构 Permanent-periodic多功能或专业机构 Multi-functional (versatile, polyvalent)-specialized（五）实施人员 personnel

18、 专业技术人员或社区卫生服务人员 One can, again, use the opposites specialized multi-functional, but also, more specifically, the necessary level of training or qualification.措施1：接种服务类型 centralized/decentralized multipurpose/specialized permanent / periodicBCG 接种结论: 唯一重要特征是强调非中心机构的作用 -在社区卫生服务中心 -通过流动接种队（专业、短期、非中心的机

19、构）BCG 接种工作人员 专业人员或多功能人员 高资质/ 不需高资质评价:从多个方面 技术层面 (生物学效果无必要性） 操作层面(覆盖率?) 效应(是否达到健康目标?)BCG 接种-操作层面评价（覆盖率）: 1)N vaccinated (1 week” 700 44“cough 2 weeks” 350 43Marginal cost or marginal return 350 exams 1 case（1）在一般就诊中发现肺结核可疑患者In conclusion, a decentralized and versatile service is necessary.Permanence

20、will be an asset, but rather a secondary one.Quality (1)在一般就诊中发现肺结核可疑患者In this case, “cough 2 weeks appears to be the most efficient screening sign.Other sign: -weight loss (well-nourished population) -night sweat (2) 痰涂片检查 -technical competence: -training to acquire the necessary skill -sufficient

21、frequency to maintain the skill -some kind of quality control system (supervision, quality testing) -decentralized structure(3) 痰涂片检查阳性者启动抗结核治疗 common situation: patients are diagnosed as PTB in the hospital and that treatment is started in the hospital. After 2 or 3 months these patients are referr

22、ed back to the HC for further continuation of treatment. -the initiation of treatment can best be integrated in the package of activities of the same service (multipurpose and decentralized). （4）持续进行抗结核治疗 -maintaining continuity: accessibility (decentralized service) -other factors (social context a

23、nd individual tendency): sex, age, literacy, degree of schooling. -identifying individual causes with the patients, by asking him why he is irregular. -search for solutions with patients -a capacity to listen and to hear things outside our own professional logic - a capacity to empathize操作性分析 Operat

24、ionalisation of selected activities Answers to the questions: who does what, where, how, when, for whom, what with?操作性分析（OA）(M.Piots Model) 1.定义 通过对卫生服务功能进行综合分析，构造模型识别实施特定健康问题干预时可能存在的问题。以定量分析为主。 2.方法 (1) 选择某一健康问题，如结核病防治 (2) 描述已采用的策略（根据VA分析情况） Results of the V.A.: Strategy of passive detection-treatm

25、ent at FLHS Diagnosis = finding AAFB in sputum Treatment is started as soon as results are know (3) 对各干预环节可能环节进行分析（从起点到终点） A: individual is still free of PTB Z: individual is cured of PTB = Attempt to visualise the patients health seeking and case management course 3. 构造分析模型 3.1 识别干预过程的主要环节（每一环节的概率）

26、 A: population of individuals still free of problem X = population for which the health service takes responsibility (1) PTB发病或患病情况: Incidence or prevalence (2) 对疾病的知晓率（根据症状）: Awareness(3)知晓者接受卫生服务的频率 : Motivation(4) 就诊者中接受痰涂片检查的频率: Examination(5) PTB患者痰涂片检查阳性率: Sensitivity(6) 实验室检测的一致性: Reliability

27、(7) 持续接受规则治疗: Regularity(8) 治疗的有效性: EfficacyZ: Total N of individuals (timely) cured of PTB= N x Incidence (prevalence) x Awareness x Motivation x Examination x Sensitivity x Reading Reliability x Regularity x Efficacy.四方面参数:1.流行病学 Epidemiology: Incidence(prevalence)2.参与性 Participation: Awareness x Motivation These patients want access to service3.诊断 Diagnosis: Examination