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.tw 2009/11/11

1. 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.tw2009/11/11

2. Health services research is inquiryto produce knowledge (evidence) about the structure, process or effects of personal health services (Institute of Medicine, IOM, 1979)

3. 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

4. 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

5. 研究主題激發: Topics Attract YOU • My curiosity (好奇) • My specialty • My interest • My boss want me to do!!

6. Topics selection • Added-value • Work • Publications • Or both of above • Time to finish (2010/7/31 or 2010/12/31) • Budget ($$$)

7. Health Policy Characteristics of Delivery System －Availability －Organization －Financing Characteristics of Population at Risk －Predisposing －Enabling －Need Delivery of Medical Care Equity Efficiency Effectiveness Well-Being （Quality of Life） Framework for Classifying Topics and Issues in Health Services Research(2) Structure Process Outcome（intermediate 3E） Outcome（ultimate）

8. 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)

9. Effectiveness: Concept、Methods and Topics

10. 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

11. Effectiveness: Conceptual framework OUTCOMES STRUCTURE PROCESS • Variations in Use • Quantity • Quality • - Appropriateness Quantity Efficacy • Effectiveness • Mortality • Clinical outcomes • Functional

12. 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

13. Key Methods of Assessing Medical Care effectiveness • Measurement variables: health status • Individual measures • Population-based measures • Risk adjustment • Study design • Data sources

14. Structure: Quantity • Nurse per bed (ICU/CCU/general) • one nurse care 8 beds (or 1: 2) • Certification • PCI certification • % of Specialist to all physicians

15. 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

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

17. 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

18. Process: Appropriateness • Overuse, under-use or right use? • Number? • Who provided? • Who received? • Medication, antibiotics • Percentage/number follow the guidelines

19. 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

20. 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

21. OUTCOMES STRUCTURE PROCESS Example: OA patients 關節內注射 • 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 關節內注射劑使用 Yes/no 量

22. 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

23. Efficiency: Concept、Methods and Topics

24. 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

25. OECD國家和台灣醫療保健支出

26. Efficiency: Conceptual framework OUTCOMES STRUCTURE PROCESS • Variations • from SOP • in time, • In utilization Quantity Quality SOP • Efficiency • Money saving • Profit gain • Time saving • Errors

27. Efficiency: Example OUTCOMES STRUCTURE PROCESS • VariationsIn • deviation from….. -專業人力 -人力素質 -SOP/PDCA -IT程度 -設備及設施 -總額分配設定 • Efficiency • Less cost • Less Time • Less errors • High satisfaction

28. 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

29. 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

30. Equity Concept、Methods and Topics

31. 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

32. Well-Being (Health)Concept、Methods and Topics

33. 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

34. Characteristics of Delivery system:Independent variables Organization Availability Financing

35. 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

36. 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

37. 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

38. 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)

39. 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

40. 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)

41. 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

42. Characteristics of Population at risk Predisposing Enabling Need

43. 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

44. All things consider • Cost Effectiveness Analysis (CEA) • Cost-benefit analysis (CBA) • Cost Utility Analysis (CUA)

45. 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

49. 台灣下背痛患者其健康生活品質及中西醫醫療資源使用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

50. 不同程度下背痛的人口學特質