臨床流行病學(xué)：決策制定與項(xiàng)目縱向分析

決策制定與項(xiàng)目縱向分析Decisionmaking

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VerticalAnalysisDefinitionofVerticalAnalysis

Averticalanalysis,whichisananalyticalmethodologytobeappliedtoahealthproblem;Averticalprogramme,whichisasetofactivities,preferablyusefulandnecessary,withtheobjectivetoreduceorresolveagivenhealthproblem(orasmallnumberofrelatedproblems);Averticalstructure,whichisaserviceorastructurethatisspecialisedintheimplementationofa(vertical)programme.縱向分析定義

橫向方面的問題（“horizontal”approach）

Theconceptsofhealth,healthproblem,care,healthserviceandhealthcaredeliverystructures.縱向方面的問題（“vertical”approach）

methodologiesforanadequateapproachofhealthproblem.theapproachcenteredontheproblemsandmustanswerthequestionWHATneedstobedoneinordertocontrolaspecifichealthproblem.縱向分析定義縱向分析是對(duì)有關(guān)健康問題的識(shí)別、描述和所涉及的相關(guān)方面進(jìn)行系統(tǒng)的分析，列出可能的干預(yù)措施，并對(duì)干預(yù)措施的可行性進(jìn)行分析，提出優(yōu)先實(shí)施的干預(yù)措施?！皏erticalanalysis”isanintellectualexercisesintheidentification,descriptionandsystematicanalysisofhealthprobleminitsvariousaspects,inordertomakeaninventoryofallpossiblesolutionsorinterventions,whichisexpectedtopermitustoselectthoseactivitiesthathavetobeimplementedwithsomedegreeofpriorityinordertosolveorreducetheproblem.通過縱向分析，識(shí)別與特定健康問題相關(guān)知識(shí)的不確定性和缺陷，從而做出合理決策。Itishighlyprobablethatonecomestoidentifyareasofuncertainty-orgapsintheknowledgethatisneededforrationaldecisionmaking。二、縱向分析目的

健康問題的縱向分析主要解決以下問題:Isthereaproblem,andwhatisthisproblem?Whereistheproblem?Whataretheproblem’sdeterminants?Whichelementsoftheproblemdowewanttoinfluenceorsolve?Howcanwebestinfluenceorsolvetheseelementsoftheproblem?縱向分析是主要分析方法是流行病學(xué)，包括定性分析和定量分析

Theanalyticalmodelisessentiallyepidemiological.Themaintoolthatisusedistheepidemiologicalunderstandingofhealthproblem.Quantificationisusedasmuchasnecessary.三、縱向分析的基本步驟1.問題描述Theproblemconcept2.流行病學(xué)模型Theepidemiologicalsystem3.列出可能的干預(yù)措施并選擇

Inventoryofinterventions–selection4.干預(yù)機(jī)構(gòu)Whichservices?5.干預(yù)人員Whichpersonnel?6.干預(yù)措施的操作Operationalisationofselectedactivities7.效果評(píng)價(jià)Evaluationofactivities（一）問題描述基本要素Elements嚴(yán)重性Severityoftheindividualproblem

incapacity/disability/“healthdeficit” lethality(“casefatality”) prematuremortality(YLL,HYLL,QALY,DALY)頻繁程度Frequency

prevalence，incidence，specificmortality(attributabletothisproblem)經(jīng)濟(jì)成本Economiccost

directcostindirectcost社會(huì)成本Socialcost問題描述問題重要性的分析目的Analysisof‘importance’servestwomainpurpose.確定健康問題的重要程度確定健康問題是否需要優(yōu)先解決

Decidingwhetherthehealthproblemcanbecalledapriorityornot(notonly‘theimportance’,butalso‘thevulnerability’,thepossibilitytodosomethingaboutit).例：結(jié)核病的縱向分析

（一）結(jié)核病的發(fā)生和發(fā)展結(jié)核菌首次侵入人體主要是通過呼吸道進(jìn)入肺泡并在此繁殖，稱為“原發(fā)感染”原發(fā)感染處形成原發(fā)病灶，結(jié)核菌從原發(fā)病灶中沿淋巴管進(jìn)入到血流中，叫做“血行播散”

結(jié)核菌通過血行播散進(jìn)入各臟器中，有的立即發(fā)病，發(fā)生嚴(yán)重的粟粒型結(jié)核病和結(jié)核性腦膜炎有的結(jié)核菌潛伏在各種器官內(nèi)，待機(jī)體免疫力下降時(shí)發(fā)病，稱為"繼發(fā)結(jié)核病"，也叫"內(nèi)源性發(fā)病"結(jié)核分枝桿菌1882年Koch首先由肺結(jié)核病人痰中發(fā)現(xiàn)了結(jié)核桿菌，并且證實(shí)結(jié)核病的病原是結(jié)核桿菌。結(jié)核菌為細(xì)長(zhǎng)桿菌，常有分枝傾向，具有抗酸脫色的性質(zhì)，可在肺結(jié)核病人痰中經(jīng)抗酸染色涂片發(fā)現(xiàn)結(jié)核桿菌根據(jù)致病性分為幾型，引起人結(jié)核病的主要病原體是人型和牛型結(jié)核桿菌。而牛型結(jié)核桿菌也能使牛、羊、家兔患結(jié)核病，所以，結(jié)核病也是一種人畜共患的疾病。（二）結(jié)核病流行趨勢(shì)上的異?，F(xiàn)象TB報(bào)告率上升多耐藥結(jié)核?。∕DR-TB）嚴(yán)重爆發(fā)HIV感染者中TB爆發(fā)，且病死率高初治TB病人中耐藥(23%)和多耐藥(7%)率高結(jié)核病控制的實(shí)施效果差：(e.g.在結(jié)核病治療中失敗率可高達(dá)89%)2000年接近2百萬(wàn)人口死于結(jié)核病每年有8百萬(wàn)以上結(jié)核病發(fā)病世界三分之一人口感染結(jié)核桿菌結(jié)核病導(dǎo)致青壯年死亡比其他任何傳染病都多每四秒即有一人患結(jié)核病每十秒即有一人死于結(jié)核病如果不治療,活動(dòng)性結(jié)核病人每年可感染10-15人結(jié)核病流行現(xiàn)狀

1980末：WHO僅兩位工作人員負(fù)責(zé)全球的TB控制普遍認(rèn)為結(jié)核病化療的發(fā)展決定了結(jié)核病很快就不再是公共衛(wèi)生的一個(gè)重要問題很少有人清醒地認(rèn)識(shí)到在發(fā)展中國(guó)家的貧困人群中TB仍具有重大公共衛(wèi)生意義中國(guó)結(jié)核病流行的狀況我國(guó)結(jié)核病的流行有以下三點(diǎn)特征：1．高感染率2．高死亡率3．高耐藥率

5億以上的人口感染菌核桿菌結(jié)核病負(fù)擔(dān)位居全球第二(140萬(wàn))

每年150,000TB死亡活動(dòng)性肺結(jié)核、涂陽(yáng)肺結(jié)核和菌陽(yáng)肺結(jié)核患病率分別為

367/105

,122/105,and160/105

肺結(jié)核死亡率為8.8/105

中國(guó)結(jié)核病現(xiàn)況(WHO,2000)(全國(guó)第四次流調(diào)，2000)建立優(yōu)先準(zhǔn)則的相互關(guān)系

MagnitudeoftheVulnerabilityproblemHealthseverityavailabilityservicesfrequencyapplicabilityPopulationperceptionacceptability（二）流行病學(xué)模型模型的基本要素Elementsofthemodel:根據(jù)疾病自然史，確定疾病發(fā)展的相關(guān)階段

Intheconstructionofsuchamodelwemakeuseofelementsofthenaturalhistoryofthedisease:therelevantstagesinsystemictermsand/orintermsofinterventions;確定各階段的靜態(tài)概率和動(dòng)態(tài)概率

Tothisareaddedthe“static”probabilities(intermsofprevalence)andthe“dynamic”ones(intermsofrisks,probabilitiestogofromonestageorstatustoanother);描述疾病轉(zhuǎn)歸的相關(guān)因素

describetheelementsthatarerelevantfortransmissionofthedisease,ifthisisnecessaryandrelevant;描述動(dòng)態(tài)轉(zhuǎn)變的影響因素

describethefactorsthatcaninfluencethedynamicswithinthesystem(‘co-factors’,‘risk-factors’,‘risk-markers’)結(jié)核病流行病學(xué)模型

Inf.Notres.Ill(1)Inf.Inf.Inf.NotInf.NotillResistIll(2)Notres.Notill“Resist”Thereappeartobe2differentdiseases:-type1isatypicalinfectious,transmittable,mono-factorial;-type2,thoughetiologicallyaninfectiousdisease,hasmoreofthecharacteristicsofachronicdisease,multi-factorial.影響感染的因素1．年齡2．性別3．職業(yè)4．HIV感染和艾滋病5．其他因素

影響流行的因素1．自然因素2．病原生物學(xué)因素3．社會(huì)因素

（三）列出可能的干預(yù)措施并進(jìn)行選擇Inventoryofinterventions-selection對(duì)每項(xiàng)干預(yù)措施進(jìn)行分析1.干預(yù)措施的關(guān)聯(lián)性分析（一般可分解為以下二個(gè)問題）:干預(yù)措施的有效性？

Isthisinterventiondesirable?干預(yù)措施的可行性？

Isthisinterventionfeasible?2.對(duì)預(yù)措施進(jìn)行系統(tǒng)分析

技術(shù)層面效能Itstechnicalefficacy操作層面效能Itsoperationalefficacy(or‘effectiveness’)成本（效率）Itscost(efficiency)可行性Itsacceptability

（三）結(jié)核病可能的干預(yù)措施檢測(cè)和治療肺結(jié)核檢測(cè)和治療原發(fā)或繼發(fā)感染BCG接種化學(xué)預(yù)防提高社會(huì)-經(jīng)濟(jì)狀況隔離病人重癥患者的康復(fù)對(duì)動(dòng)物傳染源的措施結(jié)核病可行的干預(yù)措施選擇三項(xiàng)措施檢測(cè)和治療肺結(jié)核檢測(cè)和治療原發(fā)或繼發(fā)感染BCG接種（四）實(shí)施機(jī)構(gòu)Choicestobemadeherearesituatedinthefollowingsetsofoppositions:綜合性、?？菩孕l(wèi)生服務(wù)機(jī)構(gòu)或社區(qū)衛(wèi)生服務(wù)機(jī)構(gòu)Centralized-decentralized永久性或階段性機(jī)構(gòu)Permanent-periodic多功能或?qū)I(yè)機(jī)構(gòu)

Multi-functional(versatile,polyvalent)-specialized（五）實(shí)施人員personnel

專業(yè)技術(shù)人員或社區(qū)衛(wèi)生服務(wù)人員

Onecan,again,usetheoppositesspecialized–multi-functional,butalso,morespecifically,thenecessaryleveloftrainingorqualification.操作性分析

OperationalisationofselectedactivitiesAnswerstothequestions:whodoeswhat,where,how,when,forwhom,whatwith?措施：檢測(cè)和治療肺結(jié)核患者問題:主動(dòng)或被動(dòng)檢測(cè)?主動(dòng)檢測(cè)目的:“todetectpeoplebeforetheyhavesymptoms,inordertoavoiddetectingthemwhentheyhavealreadycontaminatedtheirenvironment”措施：肺結(jié)核患者被動(dòng)檢測(cè)在普通就診中發(fā)現(xiàn)肺結(jié)核的可疑患者對(duì)可疑患者進(jìn)行對(duì)痰涂片檢查痰涂片檢查陽(yáng)性中啟動(dòng)足夠的治療持續(xù)對(duì)已啟動(dòng)治療的患者進(jìn)行治療被動(dòng)監(jiān)測(cè)(1)在一般就診中發(fā)現(xiàn)肺結(jié)核可疑患者-Whatweneed,therefore,isadiscriminatingsignatanearlystageofillness,andmoreover,onethatcaneasilybeoperationalised.DiscriminatingsignWorkload(examstobecarriedout)Result(sputumpositivedetected)“cough>1week”70044“cough>2weeks”

350

43Marginalcostormarginalreturn

350exams

1case(1)在一般就診中發(fā)現(xiàn)肺結(jié)核可疑患者Inthiscase,“cough>2weeks’appearstobethemostefficientscreeningsign.Othersign:-weightloss(well-nourishedpopulation)-nightsweat（1）在一般就診中發(fā)現(xiàn)肺結(jié)核可疑患者Inconclusion,adecentralizedandversatileserviceisnecessary.Permanencewillbeanasset,butratherasecondaryone.Quality

(2)痰涂片檢查-technicalcompetence:-trainingtoacquirethenecessaryskill-sufficientfrequencytomaintaintheskill-somekindofqualitycontrolsystem(supervision,qualitytesting)-decentralizedstructure(3)痰涂片檢查陽(yáng)性者啟動(dòng)抗結(jié)核治療commonsituation:patientsarediagnosedasPTBinthehospitalandthattreatmentisstartedinthehospital.After2or3monthsthesepatientsarereferredbacktotheHCforfurthercontinuationoftreatment.-theinitiationoftreatmentcanbestbeintegratedinthepackageofactivitiesofthesameservice(multipurposeanddecentralized).（4）持續(xù)進(jìn)行抗結(jié)核治療

-maintainingcontinuity:accessibility(decentralizedservice)-otherfactors(socialcontextandindividualtendency):sex,age,literacy,degreeofschooling.

-identifyingindividualcauseswiththepatients,byaskinghimwhyheisirregular.

-searchforsolutionswithpatients-acapacitytolistenandtohearthingsoutsideourown‘professional’logic-acapacityto‘empathize’操作性分析（OA）

(M.Piot’sModel)

1.定義

通過對(duì)衛(wèi)生服務(wù)功能進(jìn)行綜合分析，構(gòu)造模型識(shí)別實(shí)施特定健康問題干預(yù)時(shí)可能存在的問題。以定量分析為主。

2.方法(1)選擇某一健康問題，如結(jié)核病防治(2)描述已采用的策略（根據(jù)VA分析情況）ResultsoftheV.A.:

?Strategyofpassivedetection-treatmentatFLHS?Diagnosis=findingAAFBinsputum?Treatmentisstartedassoonasresultsareknow

(3)對(duì)各干預(yù)環(huán)節(jié)可能環(huán)節(jié)進(jìn)行分析（從起點(diǎn)到終點(diǎn)）A:individualisstillfreeofPTBZ:individualiscuredofPTB=>Attempttovisualisethepatient’shealthseekingandcasemanagementcourse

3.構(gòu)造分析模型

3.1識(shí)別干預(yù)過程的主要環(huán)節(jié)（每一環(huán)節(jié)的概率）

A:populationofindividualsstillfreeofproblemX=populationforwhichthehealthservicetakesresponsibility(1)PTB發(fā)病或患病情況:Incidence–orprevalence(2)對(duì)疾病的知曉率（根據(jù)癥狀）:

Awareness(3)知曉者接受衛(wèi)生服務(wù)的頻率:Motivation(4)就診者中接受痰涂片檢查的頻率:Examination(5)PTB患者痰涂片檢查陽(yáng)性率:Sensitivity(6)實(shí)驗(yàn)室檢測(cè)的一致性:Reliability(7)持續(xù)接受規(guī)則治療:Regularity(8)治療的有效性:EfficacyZ:TotalNofindividuals(timely)curedofPTB=NxIncidence(prevalence)xAwarenessxMotivationxExaminationxSensitivityxReadingReliabilityxRegularityxEfficacy.四方面參數(shù):1.流行病學(xué)Epidemiology:Incidence(prevalence)2.參與性Participation:

AwarenessxMotivationThesepatientswantaccesstoservice3.診斷Diagnosis:

ExaminationxSensitivityxReliabilityTheirstatushastobecorrectlyassessed.4.治療Treatment:RegularityxEfficacy

Table1:Modelof