預(yù)防保健與就醫(yī)診療

1、預(yù)防保健與就醫(yī)診療,臺(tái)灣家庭醫(yī)學(xué)醫(yī)學(xué)會(huì) 秘書長(zhǎng)李汝禮,前言：醫(yī)師是做什麼的？,醫(yī)生，古代稱大夫或郎中，指學(xué)習(xí)醫(yī)學(xué)或行醫(yī)的人，醫(yī)生也叫杏林，專指醫(yī)術(shù)精良，醫(yī)德高尚的醫(yī)家。,華 陀 Hippocrates,民眾的健康醫(yī)療照護(hù),就醫(yī)診療(disease treatment)預(yù)防保?。杭膊☆A(yù)防(disease prevention)健康促進(jìn)(health promotion)個(gè)人健康照護(hù)VS群體健康照護(hù),就

2、醫(yī)診療,S (Subjective Data）：自覺癥狀徵候，包括主訴、現(xiàn)在病史、過(guò)去病史及個(gè)人史…。O (Objective Data)：檢查發(fā)現(xiàn)，包括診療發(fā)現(xiàn)及各種檢查報(bào)告…。A (Assessment)：診斷評(píng)估，即診斷(Diagnosis)或臆斷(Impression) 。P (Plan)：治療計(jì)劃，包括各種處置、醫(yī)令或處方。,預(yù)防保健,篩檢screening群眾篩檢vs個(gè)人病例發(fā)現(xiàn)(case-finding)諮詢介入

3、(counseling intervention)疫苗接種(immunization)化學(xué)預(yù)防(chemoprophylaxis),預(yù)防性健康照護(hù)的實(shí)證依據(jù),美國(guó)預(yù)防服務(wù)工作小組 (U.S.Preventive services Task force,USPSTF)加拿大預(yù)防性健康照謢工作小組 (Canadian Task Force on Preventive Health Care, CTFPHC)社區(qū)工作小組 (Commu

4、nity Task Force, CTF),Overview of Process of Recommendation Development,AHRQ:the Agency for Healthcare Research and QualityUSPSTF:U.S. Preventive Services Task Force EPCs:Evidence-based Practice Centers,Procedures for

5、Developing a Recommendation Statement,Analytic Framework with Key Questions-1,Analytic Framework with Key Questions-2,1.Does screening for X reduce Morbidity and/or Mortality? 2.Can a group at high risk for X be identif

6、ied on clinical grounds? 3.Are there accurate (i.e., sensitive and specific) screening tests available? 4.Are treatments available that make a difference in intermediate outcomes when the disease is caught early, or de

7、tected by screening?,Analytic Framework with Key Questions-3,5.Are treatments available that make a difference in morbidity or mortality when the disease is caught early, or detected by screening? 6.How strong is the as

8、sociation between the intermediate outcomes and patient outcomes? 7.What are the harms of the screening test?8.What are the harms of the treatment?,Recommendation Grade Definitions,Grade Definitions After May 2007Gra

9、de Definitions Prior to May 2007,Grade Definitions After May 2007-1,Grade AThe USPSTF USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service,Grade Defi

10、nitions After May 2007-2,Grade BThe USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.Offer or provid

11、e this service,Grade Definitions After May 2007-3,Grade CThe USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is a

12、t least moderate certainty that the net benefit is small. Offer or provide this service only if other considerations support the offering or providing the service in an individual patient.,Grade Definitions After May 20

13、07-4,Grade DThe USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.,Grade Definiti

14、ons After May 2007-5,Grade I Statement The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and

15、 the balance of benefits and harms cannot be determined.Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balanc

16、e of benefits and harms.,Levels of Certainty Regarding Net Benefit-1,High：The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations.

17、 These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.,Levels of Certainty Regarding Net Benefit-2

18、,Moderate：The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: The number, size, or quality of ind

19、ividual studies. Inconsistency of findings across individual studies. Limited generalizability of findings to routine primary care practice. Lack of coherence in the chain of evidence. As more information becomes availab

20、le, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.,Levels of Certainty Regarding Net Benefit-3,Low：The available evidence is insufficient to

21、assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies. Important flaws in study design or methods. Inconsistency of findings across individual studies. Gaps in

22、the chain of evidence. Findings not generalizable to routine primary care practice. Lack of information on important health outcomes. More information may allow estimation of effects on health outcomes.,Grade Definiti

23、ons Prior to May 2007-1,A—Strongly Recommended: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outc

24、omes and concludes that benefits substantially outweigh harms.,Grade Definitions Prior to May 2007-2,B—Recommended:The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at le

25、ast fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.,Grade Definitions Prior to May 2007-3,C—No Recommendation:The USPSTF makes no recommendation for or aga

26、inst routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recom

27、mendation.,Grade Definitions Prior to May 2007-4,D—Not Recommended:The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is

28、ineffective or that harms outweigh benefits.,Grade Definitions Prior to May 2007-5,I—Insufficient Evidence to Make a Recommendation: The USPSTF concludes that the evidence is insufficient to recommend for or against rou

29、tinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.,Quality of Evidence-1,Good: Evidence inclu

30、des consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.,Quality of Evidence-2,Fair: Evidence is sufficient to determine effects on

31、 health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

32、,Quality of Evidence-3,Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or