1、決策制定與縱向分析Decision making & Vertical Analysis上海交通大學(xué)公共衛(wèi)生學(xué)院上海市全科醫(yī)學(xué)教育培訓(xùn)中心施 榕一、縱向分析（VA）的定義Definition of Vertical AnalysisA 縱向分析 vertical analysis, which is an analytical methodology to be applied to a health problem;A 縱向項(xiàng)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 縱向機(jī)構(gòu) vertical structure, which is a service or a structure that is specialised in the implementation of a (vertical) programme.縱向分析定義橫向方面的問題（“horizontal” approach） The concepts of health, health

3、 problem, care, health service and health care delivery structures. 縱向方面的問題（“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.縱向分析定義縱向分析

4、是對(duì)有關(guān)健康問題的識(shí)別、描述和系統(tǒng)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。縱向分析是主要分析方法是流行病學(xué) 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、縱向分析的基本步驟1. 問題描述 The problem concept2. 流行病學(xué)模型 The epidemiological system3. 列出可能的干預(yù)措施并選擇 Inventory of interventions selection4. 干預(yù)機(jī)構(gòu) Which services?5. 干預(yù)人員 Which pe

7、rsonnel?6. 干預(yù)措施的操作Operationalisation of selected activities7. 效果評(píng)價(jià) Evaluation of activities問題描述問題重要性的分析目的 Analysis of importance serves two main purpose.確定健康問題是否需要優(yōu)先解決 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).確定健康問題的重要程度例：結(jié)核病的縱向分析結(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)

9、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。描述在世界各個(gè)國(guó)家和地區(qū)觀察到的結(jié)核病流行趨勢(shì)上的異常現(xiàn)象TB報(bào)告率上升多耐藥結(jié)核病（MDR-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2百萬人口死于結(jié)核病每年有8百萬以上結(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

10、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（二）我國(guó)結(jié)核病的狀況我國(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) 每年150,000 TB 死亡 活動(dòng)性肺結(jié)核、涂陽肺結(jié)核和菌陽肺結(jié)核患病率 分別 為 367/105 , 122/105, and 160/105 肺結(jié)核死亡率為 8.8

11、/105 中國(guó)結(jié)核病現(xiàn)況(WHO, 2000)(全國(guó)第四次流調(diào)，2000)我國(guó)結(jié)核病流行現(xiàn)狀（1） 高感染率2000年感染率為44.5%全國(guó)約有5.5億人感染結(jié)核菌2000年全人群感染狀況45%55%感染未感染我國(guó)結(jié)核病流行現(xiàn)狀（2）疫情下降緩慢，傳染性病人幾乎沒有減少涂陽患病率(110萬)1990-2000年涂陽肺結(jié)核年遞降率為3.2%估算涂陽病人數(shù):1990年 151萬2000年 150萬我國(guó)結(jié)核病流行現(xiàn)狀（3）不同地區(qū)疫情差別較大農(nóng)村疫情高于城鎮(zhèn)近一倍19902000年衛(wèi)V項(xiàng)目地區(qū)的涂陽患病率下降了44.4%，而非衛(wèi)V項(xiàng)目地區(qū)患病率只下降了12.3%。我國(guó)結(jié)核病流行現(xiàn)狀（6） 結(jié)核病死亡

12、率仍然較高1999年死亡率為9.8/10萬，較1989年19.1/10萬下降了53.9%，目前每年約有12萬人死于結(jié)核病。（二）流行病學(xué)模型模型的基本要素 Elements of the model:根據(jù)疾病自然史，確定疾病發(fā)展的相關(guān)階段 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;取得某階段的靜態(tài)概率

13、和動(dòng)態(tài)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);描述疾病轉(zhuǎn)歸的相關(guān)因素 describe the elements that are relevant for transmission of the disease, if this is necessary and relevant;描述動(dòng)態(tài)轉(zhuǎn)

14、變的營(yíng)銷因素 describe the factors that can influence the dynamics within the system(co-factors, risk-factors, risk-markers)結(jié)核病流行病學(xué)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）影響感染的因素1年齡 2性別 3職業(yè) 4HIV感染和艾滋病 5其他因素 （三）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Inventory of interventions-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

16、解為以下二個(gè)問題）: 干預(yù)措施的有效性？ Is this intervention desirable? 干預(yù)措施的可行性？ Is this intervention feasible?2. 對(duì)預(yù)措施進(jìn)行系統(tǒng)分析 技術(shù)層面效能 Its technical efficacy 操作層面效能 Its operational efficacy ( or effectiveness) 成本（效率） Its cost (efficiency) 可行性 Its acceptability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)好治療原發(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Isolatin

17、g contagious patients重癥患者的康復(fù)對(duì)動(dòng)物傳染源的措施分析結(jié)果選擇三項(xiàng)措施檢測(cè)和治療肺結(jié)核檢測(cè)好治療原發(fā)或繼發(fā)感染BCG 接種（四）實(shí)施機(jī)構(gòu)Choices to be made here are situated in the following sets of oppositions:中央/集中性或非中心機(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

18、 專業(yè)技術(shù)人員或社區(qū)衛(wèi)生服務(wù)人員 One can, again, use the opposites specialized multi-functional, but also, more specifically, the necessary level of training or qualification.措施1：接種服務(wù)類型 centralized/decentralized multipurpose/specialized permanent / periodicBCG 接種結(jié)論: 唯一重要特征是強(qiáng)調(diào)非中心機(jī)構(gòu)的作用 -在社區(qū)衛(wèi)生服務(wù)中心 -通過流動(dòng)接種隊(duì)（專業(yè)、短期、非中心的機(jī)

19、構(gòu)）BCG 接種工作人員 專業(yè)人員或多功能人員 高資質(zhì)/ 不需高資質(zhì)評(píng)價(jià):從多個(gè)方面 技術(shù)層面 (生物學(xué)效果無必要性） 操作層面(覆蓋率?) 效應(yīng)(是否達(dá)到健康目標(biāo)?)BCG 接種-操作層面評(píng)價(jià)（覆蓋率）: 1)N vaccinated (1 week” 700 44“cough 2 weeks” 350 43Marginal cost or marginal return 350 exams 1 case（1）在一般就診中發(fā)現(xiàn)肺結(jié)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)在一般就診中發(fā)現(xiàn)肺結(jié)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) 痰涂片檢查 -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) 痰涂片檢查陽性者啟動(dòng)抗結(jié)核治療 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）持續(xù)進(jìn)行抗結(jié)核治療 -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） 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) 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: individual is still free of PTB Z: individual is cured of PTB = Attempt to visualise the patients health seeking and case management course 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）

26、 A: population of individuals still free of problem X = population for which the health service takes responsibility (1) PTB發(fā)病或患病情況: Incidence or prevalence (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患者痰涂片檢查陽性率: Sensitivity(6) 實(shí)驗(yàn)室檢測(cè)的一致性: Reliability

27、(7) 持續(xù)接受規(guī)則治療: Regularity(8) 治療的有效性: 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.四方面參數(shù):1.流行病學(xué) Epidemiology: Incidence(prevalence)2.參與性 Participation: Awareness x Motivation These patients want access to service3.診斷 Diagnosis: Examination